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[ { "category": "ECG", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 262005, "text": "Sinus rhythm. Atrial ectopy. The P-R interval is prolonged. Compared to the\nprior tracing there is no significant change.\n\n" }, { "category": "ECG", "chartdate": "2147-09-02 00:00:00.000", "description": "Report", "row_id": 262006, "text": "Sinus rhythm with atrial premature beats. Left atrial abnormality. Modest\nnon-specific T wave changes. Since the previous tracing of sinus\nbradycardia is absent and atrial ectopy is seen.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 1288781, "text": " 4 ICU nursing admit/progress note:\n 82 y/o woman admitted from EW c/o headache, chest pressure, sobx3d and total body pain. Pt BP 200/110..hydralazine IV given with no change in BP, started on nipride gtt with quick decrease in bp, was stopped. Nipride restarted later and again drop in BP so was dc'd. Pt also had head CT..no evidence of bleeding. Sent to ICU for further monitoring.\n PMHX: Pt dc'd in of 07 with similar symptoms.\nHTN, CHF, Asthma, Diverticulosis, Chronic pain, Peptic ulcer disease\nSpinal stenosis, s/p AAA repair ''\n Allergies: KNDA\n Systems Review:\n HTN: Admitted to ICU with BP 170'/90..c/o HA HR 80-90 nsr with apc's. Given 100mgm po labataol and 5mgm oxycodone for pain. Bp slowly down to 130's-110/70-80. Stated she felt \"better\" Is on r/o MI protocol..enzymes wnl thus far.\n Respiratory: Pt not c/o of any sob..decreased BS..given 20mgm po lasix (pt dose at home) is on multiple inhalers and respiratory is following. 02 2l..(?use at home) sats 96-98%..r/a sat 95. rr 16\n Pain controll: c/o pain from back and head. Takes oxycodone at home..\nDoes seem to get some relief with this. Pt fell asleep for most of nite.\n Neuro: Is alert and orientated. Per family members.. pt is non-compliant with meds at home. Ran out of money for inhalers and ??forgets to take other meds. Found to be using an empty inhaler.\n GI: Pt has abdominal discomfort..??constipated d/t pain meds..On bowel regime.\n Lines: #18 left arm.\n Social: Lives with son who is a teacher. ?if pt has VNA services at home. Will need Case Manager/Social service follow-up.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 999224, "text": " 5:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with Alport's syndrome, ESRD failed 4 transplants, now on HD\n now with urosepsis. Pt with rhonchorous lungs on exam but without cough or\n fever.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate.\n ______________________________________________________________________________\n WET READ: AKSb FRI 8:41 PM\n Persistent mild pulmonary edema, increasing moderate bilateral effusions. In\n this setting, the retrocardiac opacity is like effusion/atelectasis, though\n infection cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Cough and fever.\n\n Portable AP chest radiograph compared to .\n\n The dialysis catheter tip is about 2.5 cm below the cavoatrial junction. The\n mild cardiomegaly is unchanged. Mediastinal contours are stable. The\n moderate pulmonary edema persists, accompanied by increased bilateral pleural\n effusions, left more than right, partially loculated.\n\n Diffuse dense appearance of the bones is unchanged dating back to , most\n likely due to known Alport syndrome.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-22 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 998928, "text": " 7:23 AM\n CT ABDOMEN W/O CONTRAST; -76 BY SAME PHYSICIAN # \n CT PELVIS W/O CONTRAST; -76 BY SAME PHYSICIAN\n : eval for ischemic gut\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with h/o mult renal transplants in ed with abd pain in rlq,\n initial ct done with min po constrast showing ?pneumotosis. pt drank more\n contrast while in ed.\n REASON FOR THIS EXAMINATION:\n eval for ischemic gut\n CONTRAINDICATIONS for IV CONTRAST:\n dye allergy\n ______________________________________________________________________________\n WET READ: 9:17 AM\n Study limited by motion. No definite free air, pneumatosis or ischemic bowel.\n Bilateral pleural effusions with atelectasis in lung bases. -ALee.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male with multiple renal transplants, now with right\n lower quadrant pain and question of pneumatosis on prior CT.\n\n COMPARISON: CT abdomen/pelvis performed on at 02:18.\n\n TECHNIQUE: MDCT axial imaging was performed through the abdomen and pelvis\n after administration of additional oral contrast since the study of six hours\n earlier. No IV contrast was administered given the patient's reported history\n of allergy. Multiplanar reformatted images were essential for study\n interpretation.\n\n CT ABDOMEN WITHOUT IV CONTRAST: The study is limited due to lack of IV\n contrast as well as patient motion despite repeating the study through the\n mid- to- lower abdomen. Bilateral moderate-sized pleural effusions are again\n noted with associated atelectasis. Calcifications of the coronary arteries are\n present. There is no pericardial effusion.\n\n The non-opacified liver, spleen, pancreas, and adrenal glands are\n unremarkable. The bilateral native kidneys are atrophic with calcifications.\n Oral contrast is seen within a dilated stomach as well as in loops of small\n bowel. There is no definite intra-abdominal free air, pneumatosis, or\n evidence of ischemic bowel. Vascular calcifications are noted throughout the\n abdominal aorta and the major arteries. Ascites and anasarca are again\n present.\n\n CT PELVIS WITHOUT IV CONTRAST: Evaluation of this region is limited due to\n patient motion. The patient is status post renal transplant with a left lower\n quadrant transplant kidney unchanged in appearance. Several hypodensities\n within the transplant kidney are too small to characterize and are unchanged.\n The bladder is decompressed with a Foley catheter in place. A small amount of\n air anteriorly likely represents air within the decompressed bladder. The\n rectosigmoid colon appears unremarkable except to note redundancy of the\n sigmoid colon. Extensive calcifications are noted in the iliac and femoral\n arteries. A 2.4-cm calcification in the right groin likely represents a\n (Over)\n\n 7:23 AM\n CT ABDOMEN W/O CONTRAST; -76 BY SAME PHYSICIAN # \n CT PELVIS W/O CONTRAST; -76 BY SAME PHYSICIAN\n : eval for ischemic gut\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n calcified aneurysm in the right common femoral artery, in the region of the\n superior anastomosis of a vascular graft. A central venous catheter is noted\n in a right femoral vein.\n\n OSSEOUS STRUCTURES: Again, diffuse osteosclerosis is noted likely relating to\n renal disease. Multiple foci of irregular hyperdensity in the left iliac\n muscle and in the hips bilaterally likely represent dystrophic calcifications.\n These findings are unchanged.\n\n IMPRESSION:\n 1. Study limited by motion, but no definite intra-abdominal free air,\n pneumatosis, or evidence of ischemic bowel.\n 2. Bilateral pleural effusions with atelectasis unchanged. Ascites and\n anasarca.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 998929, "text": " 7:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for worsening failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n assess for worsening failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male with hypoxia.\n\n COMPARISON: Chest radiograph performed on at 01:13. The lung bases\n are also visualized on CT abdomen and pelvis of the same day.\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: A single frontal view of the chest shows\n the right internal jugular dialysis catheter terminates in the right atrium.\n The heart size is normal. There is mild increase in prominence of\n the pulmonary vasculature with slight increase in perihilar and interstitial\n opacities. Bilateral pleural effusions are present as confirmed on CT images\n of the lung bases. The retrocardiac opacity likely represents pleural\n effusion with associated atelectasis. No free air is noted within the\n abdomen.\n\n Multiple osseous abnormalities are unchanged including deformity of the right\n humeral head with cerclage wire, scoliosis of the upper thoracic spine, and\n increased density of the vertebral bodies likely due to renal osteodystrophy.\n\n IMPRESSION: Mild increase in mild CHF with bilateral pleural effusions and\n associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-23 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 999112, "text": " 8:10 AM\n BILAT UP EXT VEINS US Clip # \n Reason: ASSESS FOR UPPER EXTREMITY VENOUS CLOTS, BIL UPPER EXT SWELLING\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with multiple medical problems including recent DVT. Has R\n upper extremity tunneled catheter line for hemodialysis. On exam, notable\n upper extremity swelling b/l concerning for clot.\n REASON FOR THIS EXAMINATION:\n Assess for upper extremity venous clots\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 46-year-old male with multiple medical problems including\n recent right lower extremity DVT. Patient with notable upper extremity\n swelling concerning for clot.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: -scale and Doppler son\n of bilateral internal jugular, subclavian, axillary, brachial, cephalic, and\n basilic veins were performed. Focal occulusive thrombus is identified within\n the left subclavian vein. The remainder of the upper extremity veins remain\n patent. Note is made of a 2.9 x 4.8 x 2.3 cm hemtoma in the region of the left\n subclavian vein.\n\n IMPRESSION: Deep venous thrombosis of the left subclavian vein. 2.9 x 4.8 x\n 2.3 cm hematoma in the region of the left subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-24 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 999364, "text": " 8:06 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: Please evaluate for graft rejection.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with Alports, s/p 4 renal transplants, now with abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please evaluate for graft rejection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old male with Alport syndrome, status post four renal\n transplants; now presenting with abdominal pain.\n\n COMPARISON: CT abdomen from ,; renal transplant ultrasound\n from .\n\n TRANSPLANT ULTRASOUND: The transplanted kidney is seen within the left lower\n quadrant measuring 11.4 cm in length, previously was 12.6 cm. There is normal\n renal corticomedullary differentiation. No hydronephrosis or perinephric\n fluid collection is identified. A small hypoechoic lesion in the mid-pole\n consistent with a cyst is without interval change. Resistive indices in the\n upper, mid-, and lower poles measure 0.76, 0.65 and 0.68, respectively, and\n are grossly unchanged from those of 0.81, 0.72 and 0.63, respectively on the\n previous study. The main renal artery and vein are patent with normal\n waveforms. The bladder is non-distended and poorly visualized.\n\n IMPRESSION: Normal renal transplant ultrasound. No evidence for\n hydronephrosis or perinephric fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-28 00:00:00.000", "description": "R ANKLE (AP, MORTISE & LAT) RIGHT", "row_id": 999991, "text": " 6:02 PM\n ANKLE (AP, MORTISE & LAT) RIGHT Clip # \n Reason: evaluate for osteoarthritis or other joint inflammation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with Alport's syndrome who presented with sepsis thought to be\n urosepsis with Pseudomonas UTI, currently on meropenem. Pt c/o persistent R\n ankle pain. R ankle edematous, tender on exam but no impressive.\n REASON FOR THIS EXAMINATION:\n evaluate for osteoarthritis or other joint inflammation\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: 46-year-old man with syndrome and has had prior renal\n transplant, and right ankle pain.\n\n FINDINGS: No prior studies of the ankle available for a direct comparison.\n\n There is a sclerotic lesion in the distal tibia which has peripheral\n calcification and is compatible with a bone infarct. There is no cortical\n destruction or pathologic fracture at this location. Additionally, there is\n an area of cystic change in the talar dome measuring 2.4 cm which extends to\n the joint surface. This likely represents sequela from avascular necrosis.\n There is no gross articular collapse at this time. However, imaging with MRI\n may better characterize this abnormality. The ankle mortise is preserved.\n There is no discrete fracture. There is some mild soft tissue swelling.\n\n IMPRESSION:\n\n 1. Cystic area within the talar dome, extending to the articular surface,\n likely due to avascular necrosis. This could be further evaluated with MRI\n imaging.\n\n 2. Bone infarct within the distal tibial metaphysis.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-01 00:00:00.000", "description": "L ANKLE (AP, MORTISE & LAT) LEFT", "row_id": 1000195, "text": " 7:05 PM\n ANKLE (AP, MORTISE & LAT) LEFT Clip # \n Reason: evaluate for osteoarthritis or other joint inflammation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with Alport's syndrome who presented with sepsis thought to be\n urosepsis with Pseudomonas UTI, currently on meropenem. Per dialysis team, pt\n persisently c/o L ankle pain (as well as R ankle pain). L ankle nonedematous,\n but tender on exam with minimal ROM.\n REASON FOR THIS EXAMINATION:\n evaluate for osteoarthritis or other joint inflammation\n ______________________________________________________________________________\n WET READ: 8:47 PM\n bone infarct in distal tibia. no comparison available. ahp\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left ankle, .\n\n HISTORY: 46-year-old man with Alport syndrome and status post renal\n transplant. Patient with left and right ankle pain. The left ankle was non-\n edematous, but tender.\n\n FINDINGS: Comparison is made to the previous study of the right ankle from\n .\n\n There is a well demarcated area of sclerosis in the distal left tibial\n metaphysis consistent with a bone infarct. There are no acute fractures. The\n talar dome is unremarkable. The ankle mortise is preserved. Vascular\n calcifications are present.\n\n IMPRESSION:\n\n Bone infarct in the distal left tibial metaphysis.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-02-23 00:00:00.000", "description": "Report", "row_id": 1633416, "text": "MICU NRSG ADMIT NOTE\n46yo with extensive pmhx. Briefly, he has ESRD s/p 4 renal xplant that have all failed, he is currently on HD. Also with (+) Hep C. Recently admitted to with polymicrobial bacteremia (MRSA, enterocoocu, ) who had c/o abd pain at rehab with fevers. Came to EW where he was found to be hypotensive requiring IVF and levophed. His WBC was slightly ^ with a lactate of 2.9. He had a CT scan that showed no definite intra-abd free air or evidence of ischemic bowel, following. His bilat pleural effusions with atelectasis are unchanged. While in ew levo was able to be weaned to off with no hypotension. He was transferred to MICU for further management.\n ID: Afebrile on multiple antibx.\n CV: Has remained hemodynamically stable with Hr in the 60-70's sr with no vea. Bp 100-110's, remains off all pressors and has not need any fluid boluses.\n Resp: Lungs with brochial aeration 1/3 up bilaterally with crackles but clear in upper airways. O2 at 3.5liters np with sats in the high 90's. CXR showed mild CHF with bilat pleural effusions.\n GI/GU: Abd soft denies pain when asked. Foley drng minimal urine, only a few cc's for shift. Has HD on M-W-F .\n MS: He is alert and oriented x but confused. Thinks at time that he is going to a wedding today. Saying things that make no sense at times yelling out. He is mostly cooperative and able to follow commands.\n Skin: Has pressure sore on his coccyx drng sm amt of serous fluid. Allevyn placed over site. Enc him to stay off his back. Was positioned multiple times but he does not stay on side. Upper extrems very , need to r/o clot and SVC syndrome. Skin tears weeping clear fluid. R leg also very edematous with (+) DVT (on coumadin, dose held due to supratherapuetic INR).\nA: septic intially requiring pressors but currently off\n need to r/o upper extrem clot/SVC syndrome\n coccyx pressure sore\nP: cont to follow hemodynamics\n titrate down O2 as possible\n enc to stay of back\n follow cx's\n" } ]

[ { "category": "Echo", "chartdate": "2182-03-14 00:00:00.000", "description": "Report", "row_id": 84990, "text": "PATIENT/TEST INFORMATION:\nIndication: Ascending aortic anuerysm\nHeight: (in) 67\nWeight (lb): 175\nBSA (m2): 1.91 m2\nStatus: Inpatient\nDate/Time: at 09:56\nTest: TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Dilated sinuses of Valsalva. Markedly dilated ascending aorta. Normal\naortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Bicuspid aortic valve. No AS. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. There is\nmild symmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). Right ventricular chamber size\nand free wall motion are normal. The sinuses of Valsalva are dilated. The\nascending aorta is markedly dilated The aortic valve is bicuspid. There is no\naortic valve stenosis. There is an eccentric aortic insuficiency jet c/w\nModerate to severe (3+) aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no pericardial\neffusion. Dr. was notified in person of the results on Nune in\nthe operating room before bypass\nPOST-BYPASS:\nPreservedbiventricular systolic function.\nAn intact graft is seen in the ascending aortic position with an intact\nmechanical valve c/w a composite graft. The residual peak and mean across the\nnew aortic prosthesis are 30 and 15 mm of Hg respectively. Thoracic aorta is\nintact. Mild TR.\n\n\n" }, { "category": "Echo", "chartdate": "2182-03-12 00:00:00.000", "description": "Report", "row_id": 84991, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Pericardial effusion.\nHeight: (in) 67\nWeight (lb): 175\nBSA (m2): 1.91 m2\nBP (mm Hg): 136/65\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 23:52\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith 35-50% decrease during respiration (estimated RAP (0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal\nregional LV systolic function. Overall normal LVEF (>55%). No resting LVOT\ngradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Markedly dilated aortic sinus. Markedly dilated ascending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. No AS. Moderate to severe (3+) AR.\nEccentric AR jet.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is\n0-10mmHg. Left ventricular wall thicknesses are normal. The left ventricular\ncavity is mildly dilated. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic root is markedly dilated at the sinus level with\nefffacement of the sinotubular juntion (suggestive of annuloaortic ectasia or\nMarfan's). The ascending aorta is markedly dilated The aortic valve is\nprobably bicuspid (not fully determined baed on limited study). There is no\naortic valve stenosis. Moderate to severe (3+) aortic regurgitation is seen.\nThe aortic regurgitation jet is eccentric. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The estimated pulmonary\nartery systolic pressure is normal. There is a small pericardial effusion.\nThere are no echocardiographic signs of tamponade.\n\nIMPRESSION: Large aortic root/ascending aortic aneurysm (Marfan appearance.)\nProbable bicuspid aortic valve with moderate to severe eccentric aortic\nregurgitation. Mildly dilated LV cavity size with preserved LVEF.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-03-13 00:00:00.000", "description": "Report", "row_id": 1651829, "text": "PROB: 15:00 HYPOTENSION\n\nO:PT TRANSPORTED TO XRAY VIA W/C FOR DENTAL X-RAYS. C/O LIGHTHEADNESS AND NAUSEA, BP 56/20 AT TIME, HR 60. PT TRANSFERRED TO STRETCHER, PT PUT FLAT WITH FLUIDS RUNNING, O2 AT 2L/NP-SAT 100%. BP 120/56 WITHIN SEVERAL MINUTES AND PT FELT MUCH BETTER WITHOUT SYMPTOMS OF NAUSEA OR LIGHTHEADNESS. IN XRAY TO PT.\nASSESSMENT: VAGAL EPISODE.\nPLAN: OR IN AM.\n\nPROB: DILATED AORTA, PRE-OP\n\nCV: LABETOLOL INCREASED TO 200MG PO Q 8HR, TOLERATING DOSE WELL. DIAZIDE GIVEN WITH GOOD EFFECT. PRE-OP BLOOD WORK DONE, T AND CM SENT TO LAB. U/A SENT. EKG DONE. HEALTH-CARE PROXY SIGNED. PRE-OP TEACHING DONE. DENTAL X-RAYS DONE-CLEARED BY DENTIST.\n\nRESP: LUNGS CLEAR.\n\nGU: DIAZIDE WITH GOOD RESPONE.\n\nGI: APPETITE GOOD. STOOL X2.\n\nNEURO: ALERT AND ORIENTED X3, APPROPRIATE.\n\nSOCIAL: FAMILY IN MMOST OF DAY.\n\nASSESSMENT: ANXIOUS TO GET SURGERY OVERWITH.\n\nPLAN: FIRST CASE IN AM.\nNPO AFTER MIDNOC.\nSURGICAL SCRUB TONOC.\nGOAL BP BELOW 120 SYS.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2182-03-14 00:00:00.000", "description": "Report", "row_id": 1651830, "text": " B: 7p-7a\nneuro: a+o x3, mae, pleasant, steady on feet w/ transfer chair to bed\n\ncv: sr 60-80, sbp 110-130, nibp equal bilat arms, labetalol 200mg po q8h, afeb, no cp overnoc\n\nresp: lungs cta, is teaching done, is to 2000ml, 02 sats>95% on RA\n\ngi: abdomen soft/non distended, npo since midnight\n\ngu: voids per urinal clear yellow urine\n\nlabs: no am labs per \n\nskin: chlorhexidine scrub completed overnoc\n\nassess: stable\n\nplan: to OR at 0730 (0630 pickup by anesthesia) for bental procedure\n" }, { "category": "Nursing/other", "chartdate": "2182-03-14 00:00:00.000", "description": "Report", "row_id": 1651831, "text": "~1236 PATIENT ADMITTED FROM OR S/P BENTAL. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. PSE SLUGGISH. OG IN PLACE, PATENT FOR BILIOUS. CT'S PATENT FOR MINIMAL SERO-SANG DRAINAGE. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW. PALPABLE PULSES.\nFAMILY IN, AWARE OF EVENTS AND PLANS EXPLAINED.\n" }, { "category": "Nursing/other", "chartdate": "2182-03-14 00:00:00.000", "description": "Report", "row_id": 1651832, "text": "NEURO: APPEARS INTACT, MAE, FOLLOWING COMMANDS.\n\nCARDIAC:HEART RATE NSR WITHOUT ECTOPY. PACER A DEMAND 60. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. IV NICARDIPINE AT 3.5 M/K/M TO KEEP S B/P ~100. CO/CI ACCEPTABLE BY CCO SWAN. PALPABLE PULSES.\n\nRESP: CS DIMINISHED IN BASES, EXTUBATED AT 1845. COOL MASK AT 50% WITH O2 SAT ^ 95%. DOING SPIROCARE, ABLE TO PULL TV'S 750. UNPRODUCTIVE COUGH.\n\nGI: OG PULLED WITH EXTUBATION. (-) BOWEL SOUNDS, TOLERATING ICE CHIPS.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT INFUSING, FOLLOWING PROTOCOL.\n\nPAIN: PATIENT DENIES, GIVING IM TORIDOL Q6H.\n\nFAMILY: AND FATHER HERE TILL ALMOST 2100. PLEASED WITH PROGRESS.\n\nPLAN: CONTINUE TO KEEP S B/P ~100 WITH NICARDIPINE: DRUG BE CHANGED IN AM. MONITOR HEMODYNAMICS, REPLEATE LAB WORK AS NEEDED, FOLLOW INSULIN PROTOCOL. ^ DIET AS TOLERATED. MEDICATE FOR PAIN AS NEEDED\n" }, { "category": "Nursing/other", "chartdate": "2182-03-13 00:00:00.000", "description": "Report", "row_id": 1651828, "text": "patient is 27 yo M developed cp ~2wks ago dc home with motrin. Schedule f/u echo showed bicuspid Ao valve and ^aorta. Admitted at OSH -CTA done showed dilated Ao with pericardial effusion. transfer to pt recieved labetol ivp for bp controlled.\n\nPt arrived via stretcher, walked to bed, parents at bedside. Pt a+ox3, conversing. no deficit. Apprehensive regard status/poc->reinforce by PA and Rn, support given, info provided for pt and parents. sleeping most of am.\n\nCV: afebrile. nsr, rare pacs. arrived with sbp ^130s, labetolol gtt started titrate effectively keeping sbp <120 per PA. started po labetolol this am. hct 40. denies cp/sob. EcHo done at bs. skin w/d. no edema. 3+pp\n\nRESP: ls cta. ra sat 98%.\nGEN: encourage ^fluid intake. belly soft. denies pain. patient voids. ua/urine cx sent. skin intact. Patient moves independently in bed.\npiv x3.\n\na/p: f/u echo/cxr/cta - eval by attending today. tight bp control keeping sbp <120. ?medical vs management. provide support.\n" }, { "category": "Nursing/other", "chartdate": "2182-03-15 00:00:00.000", "description": "Report", "row_id": 1651833, "text": "Neuro: pt alert oriented following commands.\nResp: pt weaned to 4l NP with O2 sats around 95% most ofnight. Pt coughing but not raising breath sounds clear. IS pulling 500-800.\nC/V: Heart rate 90 to 100 sinus rare pac's seen. BP 100-115 on nicardipine 3.5mcg pt given lopressor 5mg iv x 2 for elevated heart rate. this did briefly bring HR down to 88. SVO@ in the 80's with CO of 6.0-6.7 Temp up to 101 overnight. Down this am to 99. Pedal pulses palbable.\nGI: tolerating clear liquids will advance diet as tolerated\nEndo: Insulin gtt infusing at 1 u/hr lantus insulin given and regular sc will d/c drip in 1 hour.\nGU: Adaquate urine outputs.\nSkin: Dsgs intact no drainage.\nPain: pt complaines of pain sharp with movement. Medicated with percocet 2 tabsevery 4hours and tolrodol every 6 hurs with good effect.\nPlan: Deline start po antihypertensives possible transfer to floor later today\n" }, { "category": "Nursing/other", "chartdate": "2182-03-15 00:00:00.000", "description": "Report", "row_id": 1651834, "text": "Neuro: pt pleasant, dozing throughout day, maex4, no deficit.\nPain: gave percocet 1 tab prn, ketorolac ->effective with sternal incis pain control.\n\nid: pt receiving vanco post-op\n\nCV: NSR with no vea, Recieved on nicardipine gtt at 3.5mcg/kg/min-> started on labetolol, and doses increases throughoutday, captopril add to keep goal sbp <120, slow weaning down nicardipine gtt. ci>2, svo2 80s, d'c swan. MT c't d'c today as well, post cxr done. Peripheral gen edema, 3+pp, skin w/d\n\nresp: ls diminish bases, cta upper lobes, ox sat marginal 93% on 4lnc, need alot encouragement to use IS and dbc. sat improved to 95% after ambulation. no distress.\n\nGI: no difficulty swallowing, minimal intake, belly soft\nGU: diuresis fair with lasix, doses increases also to tid\nENDO: BS high 150s-160s, treat with RISS now. (pt recieved lantus in am).\nWOUND: sternal wound cdi. no apparent skin breakdown.\nCOMFORT: parents at bedside throughout day for support, family visit in pm. provide support and explaination to poc and status throughoutday\nACT: pt oob to chair x2, ambulate x1 with 2 assisted - well\nIV: R IJ introducer, piv x2 on left hand\n\na/p: KEep sbp <120, wean nicardipine gtt as tol. pulm toilet. ^act and diet. support. 6 tomorrow?\n" }, { "category": "Nursing/other", "chartdate": "2182-03-15 00:00:00.000", "description": "Report", "row_id": 1651835, "text": "add: pt also started on coumadin today\n" }, { "category": "Nursing/other", "chartdate": "2182-03-16 00:00:00.000", "description": "Report", "row_id": 1651836, "text": "NEURO: sleepy, awakes easily. oriented x3. steady on transfer from chair to bed. incisional pain with movement/coughing medicated with toradol and percocet 1 tab with good relief.\nCV: goal sbp <120. weaned off nicardipine gtt overnoc. captopril started tolerated well. lasix 20 mg with mild diuretic response. volume overloaded on exam. skin warm, pedal pulses palp. hypotensive this am sbp 90's, map 50's AM dose labetalol held. MD notified. A and V wires in place A captures at max mA, shut off d/t not sensing at max sensitivity.\nRESP: lungs diminished at bilat bases 4L nasal cannula with sats 93-95%. cooperative with I/S, coughing and deep breathing.\nGI/GU: abd soft distended +bowel sounds. ate approx 25% of dinner, , and potatoes. drinking well. foley with clear yellow urine mild diuresis with lasix.\nENDO: cvicu RISS\nID: vanco last dose today tmax 100.7\nA/P:continue to monitor, ?labetalol PO later this AM. ?transfer to floor this afternoon. OOB to chair, encourage PO diet, pulm hygiene.\n" }, { "category": "ECG", "chartdate": "2182-03-14 00:00:00.000", "description": "Report", "row_id": 215543, "text": "Sinus rhythm. RSR' pattern in leads V1-V2. Since the previous tracing\nof the rate is faster and QRS voltage has decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-03-13 00:00:00.000", "description": "Report", "row_id": 215544, "text": "Sinus rhythm. Q waves in leads I, aVL and V5-V6 with increased voltage,\nprobably normal for age. Since the previous tracing of probably no\nsignificant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2182-03-12 00:00:00.000", "description": "Report", "row_id": 215545, "text": "Sinus rhythm. Leftward axis. Increased QRS voltage, probably normal for age.\nLateral Q waves are non-diagnostic. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 595654, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n .\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Alert/oriented to self and sometimes place.\n Short term memory deficit apparent.\n Action:\n PO medications on schedule.\n Frequent redirection.\n Response:\n Intermittently successful.\n Plan:\n Continue with safety measures.\n Medication as scheduled.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission negative for PE but showing LLL pna and\n effusion.\n LS with wheezes at times.\n Desats on room air to low 80s. (baseline sats in 90s)\n Action:\n Aerosol mask titrated O2 delivery.\n Nebs on sched and prn\n Response:\n Sats 88-95%\n Plan:\n Goal sats mid 90s.\n Wean O2 as tolerated.\n ADDITIONAL INFORMATION:\n Did have episode of increased HR to 100s, SOB with some expiratory\n wheezes, desaturation down to low 80s, diaphoretic. Administered\n Albuterol neb and increase in O2 with eventual improvement.\n Urine output marginal.\n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 595640, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n .\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Alert/oriented to self and sometimes place.\n Short term memory deficit apparent.\n Action:\n PO medications on schedule.\n Frequent redirection.\n Response:\n Intermittently successful.\n Plan:\n Continue with safety measures.\n Medication as scheduled.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission negative for PE but showing LLL pna and\n effusion.\n LS with wheezes at times.\n Desats on room air to low 80s. (baseline sats in 90s)\n Action:\n Aerosol mask titrated O2 delivery.\n Nebs on sched and prn\n Response:\n Sats 88-95%\n Plan:\n Goal sats mid 90s.\n ADDITIONAL INFORMATION:\n Did have episode of increased HR to 100s, SOB with some expiratory\n wheezes, desaturation down to low 80s, diaphoretic. Administered\n Albuterol neb and increase in O2 with eventual improvement.\n Urine output marginal.\n" }, { "category": "General", "chartdate": "2110-09-18 00:00:00.000", "description": "ICU Event Note", "row_id": 595730, "text": "Clinician: Nurse\n Patient called out to medical floor with vital signs stable satting 95%\n on 3L NC, report given to nurse. Approx 5 minutes after transferring\n patient to floor, MICU resident called to assess patient for acute\n onset hypoxia. Patient transferred back to MICU, found to be in Afib\n with RVR and HR into 160s, satting in 80s on NRB. Cards consult was\n called by MICU resident, who felt the issue was severe aortic stenosis\n acutely c/b conversion into Afib. Multiple EKGs were checked, with\n collaboration with the CCU team, the patient was given lopressor for\n extreme tachycardia, diltiazem for Afib, morphine for pain, and\n zofran/reglan for nausea. At the time of lopressor and diltiazem\n administration, patient had BP in 130s-150s, but approx 5 minutes later\n was noted to have a systolic BP in the 60s. At that time, MICU resident\n spoke with the patient's HCP (her daughter ) to confirm that the\n patients code status was DNR/DNI, and this was confirmed, however the\n patient's daughter did express wishes for vasopressors. The patient was\n bolused with IVF for hypotension but lost a pulse and died before\n pressors could be initiated. Family was at bedside with patient at time\n of death.\n Total time spent: 60 minutes\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 595619, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yof dementia, COPD reportedly in USOH until\n Pt has had a cough for about 1 week and had been more fatigued. She\n has also been having constipation for several days and last night while\n having a BM began coughing. With this had tachypnea and coughing up\n bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n Patient admitted from: ER\n History obtained from Interpreter\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD, but no meds prescribed (apparently)\n CAD\n Dementia\n HTN\n RHEUMATIC HEART DISEASE, Mitral Regurg, Aortic Stenosis (mod-severe)\n HYPERCHOLESTEROLEMIA\n MACULAR DEGENERATION\n BLINDNESS, left eye\n OSTEOPOROSIS\n COPD, no home oxygen, sats 93-97% at her PCP, meds\n h/o TIA\n s/p CAE\n s/p bilateral cataract\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 120 (74 - 120) bpm\n BP: 92/70(75) {92/47(71) - 159/70(88)} mmHg\n RR: 35 (16 - 35) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 420 mL\n PO:\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 30 mL\n Urine:\n 130 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n -30 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 83%\n ABG: 7.34/43/236//-2\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Mild\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : left lower lung, posterior\n and anterior, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): \"Hospital\", Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 98 mg/dL\n 1.8\n 27\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Assessment and Plan\n RESPIRATORY DISTRESS --\n HYPOXEMIA --\n HEMOPTYSIS --\n RENAL INSUFFICIENCY -- chronic\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:29 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 595620, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yof dementia, COPD reportedly in USOH until\n Pt has had a cough for about 1 week and had been more fatigued. She\n has also been having constipation for several days and last night while\n having a BM began coughing. With this had tachypnea and coughing up\n bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n Patient admitted from: ER\n History obtained from Interpreter\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD, but no meds prescribed (apparently)\n CAD\n Dementia\n HTN\n RHEUMATIC HEART DISEASE, Mitral Regurg, Aortic Stenosis (mod-severe)\n HYPERCHOLESTEROLEMIA\n MACULAR DEGENERATION\n BLINDNESS, left eye\n OSTEOPOROSIS\n COPD, no home oxygen, sats 93-97% at her PCP, meds\n h/o TIA\n s/p CAE\n s/p bilateral cataract\n Unobtainable.\n Occupation: Retired\n Drugs: Denies\n Tobacco: Former smoker 1\n PPD for several years.\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 120 (74 - 120) bpm\n BP: 92/70(75) {92/47(71) - 159/70(88)} mmHg\n RR: 35 (16 - 35) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 420 mL\n PO:\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 30 mL\n Urine:\n 130 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n -30 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 83%\n ABG: 7.34/43/236//-2\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Mild\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : left lower lung, posterior\n and anterior, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): \"Hospital\", Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 98 mg/dL\n 1.8\n 27\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Assessment and Plan\n RESPIRATORY DISTRESS\n attributed to pneumonia (LLL); possible\n component of COPD exacerbation, although likely mild\n HYPOXEMIA --\n HEMOPTYSIS --\n ABNORMAL EKG\n RENAL INSUFFICIENCY\n chronic; creatinine at baseline.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:29 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 595621, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yof dementia, COPD reportedly in USOH until\n Pt has had a cough for about 1 week and had been more fatigued. She\n has also been having constipation for several days and last night while\n having a BM began coughing. With this had tachypnea and coughing up\n bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n Patient admitted from: ER\n History obtained from Interpreter\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD, but no meds prescribed (apparently)\n CAD\n Dementia\n HTN\n RHEUMATIC HEART DISEASE, Mitral Regurg, Aortic Stenosis (mod-severe)\n HYPERCHOLESTEROLEMIA\n MACULAR DEGENERATION\n BLINDNESS, left eye\n OSTEOPOROSIS\n COPD, no home oxygen, sats 93-97% at her PCP, meds\n h/o TIA\n s/p CAE\n s/p bilateral cataract\n Unobtainable.\n Occupation: Retired\n Drugs: Denies\n Tobacco: Former smoker 1\n PPD for several years.\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 120 (74 - 120) bpm\n BP: 92/70(75) {92/47(71) - 159/70(88)} mmHg\n RR: 35 (16 - 35) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 420 mL\n PO:\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 30 mL\n Urine:\n 130 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n -30 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 83%\n ABG: 7.34/43/236//-2\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Mild\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : left lower lung, posterior\n and anterior, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): \"Hospital\", Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 32.6\n 98 mg/dL\n 1.8\n 27\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Assessment and Plan\n RESPIRATORY DISTRESS\n attributed to pneumonia (LLL); possible\n component of COPD exacerbation, although likely mild\n HYPOXEMIA --\n HEMOPTYSIS --\n ABNORMAL EKG\n RENAL INSUFFICIENCY\n chronic; creatinine at baseline.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:29 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 595624, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yof dementia (advanced), COPD reportedly in USOH until approx. 1\n week PTA when developed cough (non-productive) and fatigue. On day of\n admission, experienced mild hemoptysis x2 (blood-streaked sputum)\n evaluated in PCP office, and noted tachypnea and SaO2= 85%\n ER\n for further evaluation.\n ER evaluation revealed T= 98.2 HR= 68 BP= 164/54, SaO2= 93%\n RA. Pt oriented to person. Experienced tachypnea and hypertension\n ECG revealed new lateral ST depression\n Cardiology consultation\n suggested demand ischemia\n ASA 325mg. CXR revealed LLL infiltrate.\n CT angio confirmed LLLinfiltrate, and without evidence for pulmonary\n embolism.\n Vanco. Ceftriaxone. BiPAP initiated and transferred to\n MICU for further evaluation and mangement.\n In MICU, HR= 63 BP= 133/46 RR= 19 SaO2= 100 BIPAP 15/5 FIO2 60%. Pt\n awake, interactive, attentive, but only oriented to person, and\nhospital\n. Denies pain.\n Patient admitted from: ER\n History obtained from Interpreter\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD, but no meds prescribed (apparently)\n CAD\n Dementia\n HTN\n RHEUMATIC HEART DISEASE, Mitral Regurg, Aortic Stenosis (mod-severe)\n HYPERCHOLESTEROLEMIA\n MACULAR DEGENERATION\n BLINDNESS, left eye\n OSTEOPOROSIS\n COPD, no home oxygen, sats 93-97% at her PCP, meds\n h/o TIA\n s/p CAE\n s/p bilateral cataract\n Unobtainable.\n Occupation: Retired\n Drugs: Denies\n Tobacco: Former smoker 1\n PPD for several years.\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 120 (74 - 120) bpm\n BP: 92/70(75) {92/47(71) - 159/70(88)} mmHg\n RR: 35 (16 - 35) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 420 mL\n PO:\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 30 mL\n Urine:\n 130 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n -30 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 83%\n ABG: 7.34/43/236//-2\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Mild\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : left lower lung, posterior\n and anterior, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): \"Hospital\", Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 32.6\n 98 mg/dL\n 1.8\n 27\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Assessment and Plan\n RESPIRATORY DISTRESS\n attributed to pneumonia (LLL); possible\n component of COPD exacerbation, although likely mild. Doubt CHF,\n although at risk in setting of Aortic stenosis and mitrial regurg.\n Monitor RR, provide supplimental oxygen, maintain SaO2 >90%.\n LLL INFILTRATE\n new on radiograph, likely represents pneumonia with\n parapneumonic effusion. No radiographic evidence for CHF. Plan\n continue empirical antimicrobials, await cultures of blood and sputum.\n F/u CXR.\n HYPOXEMIA\n attributed to LLL infiltrate. be contribution of COPD\n exacerbation, but mild. Doubt CHF. No evidence for pulmonary\n embolism.\n HEMOPTYSIS\n attributed to infection/pneumonia. Minimal. Monitor for\n evidence of escalation.\n ABNORMAL EKG\n concerning for ischemia (laterial). Doubt acute\n coronoary sydrome. Suspect reflects demand ischemia in setting of new\n LLL pneumonia, in setting of aortic stenosis and mitrial regurg.\n Complete r/o MI protocol (serial cardiac enzymes, ECG). Provide ASA.\n RENAL INSUFFICIENCY\n chronic; creatinine at baseline. Monitor renal\n function.\n COPD\n suspect mild exacerbation in setting of pneumonia. Provide\n b-agonist nebs, and maintain low threshold for steroids.\n FLUIDS\n hypovolemia. Provide /encourage PO. Monitor I/O. At risk\n for CHF (valvular heart disase).\n Other plans as outlined in MICU Resident\ns note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:29 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 595614, "text": ".H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Alert/oriented to self and sometimes place.\n Short term memory deficit apparent.\n Action:\n PO medications on schedule.\n Frequent redirection.\n Response:\n Intermittently successful.\n Plan:\n Continue with safety measures.\n Medication as scheduled.\n Pleural effusion, acute\n Assessment:\n Chest CT upon admission negative for PE but showing pleural effusion.\n LS with wheezes at times.\n Desats on room air to low 80s.\n Action:\n Aerosol mask .\n Nebs on sched and prn\n Response:\n Sats 88-95%\n Plan:\n Goal sats mid 90s.\n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 595615, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n .\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Alert/oriented to self and sometimes place.\n Short term memory deficit apparent.\n Action:\n PO medications on schedule.\n Frequent redirection.\n Response:\n Intermittently successful.\n Plan:\n Continue with safety measures.\n Medication as scheduled.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission negative for PE but showing LLL pna and\n effusion.\n LS with wheezes at times.\n Desats on room air to low 80s. (baseline sats in 90s)\n Action:\n Aerosol mask titrated O2 delivery.\n Nebs on sched and prn\n Response:\n Sats 88-95%\n Plan:\n Goal sats mid 90s.\n ADDITIONAL INFORMATION:\n Did have episode of increased HR to 100s, SOB with some expiratory\n wheezes, desaturation down to low 80s, diaphoretic. Administered\n Albuterol neb and increase in O2 with eventual improvement.\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 595616, "text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 yof dementia, COPD reportedly in USOH until\n Pt has had a cough for about 1 week and had been more fatigued. She\n has also been having constipation for several days and last night while\n having a BM began coughing. With this had tachypnea and coughing up\n bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n Patient admitted from: ER\n History obtained from Interpreter\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n Dementia\n RHEUMATIC HEART DISEASE, Mitral Regurg\n MACULAR DEGENERATION\n BLINDNESS, left eye\n OSTEOPOROSIS\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:01 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 120 (74 - 120) bpm\n BP: 92/70(75) {92/47(71) - 159/70(88)} mmHg\n RR: 35 (16 - 35) insp/min\n SpO2: 83%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 420 mL\n PO:\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 30 mL\n Urine:\n 130 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n -30 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 83%\n ABG: 7.34/43/236//-2\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Mild\n respiratory distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : left lower lung, posterior\n and anterior, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): \"Hospital\", Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 98 mg/dL\n 1.8\n 27\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Assessment and Plan\n RESPIRATORY DISTRESS --\n HYPOXEMIA --\n HEMOPTYSIS --\n RENAL INSUFFICIENCY -- chronic\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:29 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 595610, "text": "TITLE:\n Chief Complaint: Dyspnea and fatigue\n HPI:\n 85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n flet better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85 on RA, with\n a baseline of 96% with no oxygen at home. She was tachypneic to 40s.\n She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was sating 100%. She was changed to\n a nasal canula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN 180s. EKG showed larger ST\n depressions in lateral leads and STE in V1-V2. Cards thought this was\n still related to strain. CTA was done that showed no PE, but did show\n PNA in LLL and left effusion. She was started on BIPAP and transferred\n to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2 100 BIPAP 15/5\n FIO2 60%. Pt is DNR/DNI.\n .\n .\n ROS: (pt unable to answer most questions)\n + Fatigue\n - for chest pain, SOB, dysuria, diarrhea, abdominal pain, HA, rash\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Dementia\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n -Alendronate-D3 Qweek\n -Amlodipine 5mg \n -Aricept 10mg qday\n -Irbesartan 150mg qday\n -Lidocaine 5% patch\n -Penicillin 250mg \n -Simvastatin 40mg qday\n -Acetaminophen 325mg PRN pain\n -Aspirin 325mg QMWF\n -Tums\n -Capsaicin\n -Vitamin D2 400mg qday\n -Flaxseed Oil 1g Qday\n -MV Qday\n Past medical history:\n Family history:\n Social History:\n -COPD, no home oxygen, sats 93-97% at her PCP, meds\n -Gait instability\n -Dementia\n -Hypertension\n -Hypercholesterolemia\n -History of rheumatic fever- Moderate-severe AS (area 0.8-1.0cm2).\n Moderate (2+) AR, Mild [1+] TR. Mild PA systolic hypertension. Mild\n thickening of mitral valve chordae. Mild to moderate (+) MR. LV\n inflow pattern c/w impaired relaxation on echo \n -Osteoporosis\n -Carotid endarterectomy\n -Cataract surgery bilaterally\n -Hx of TIA\n -Blind in one eye due to retinal emboli, left eye\n -Macular degeneration\n -Decreased appetite\n -CAD hx\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She had quit smoking for a year and a half, but forgets this.\n Had smoked 1.5 ppd for many years. Lives mainly with her son, but\n travels during the week to other houses also providing 24\n hour care. She has been a housewife all her life. She enjoys gambling\n and also dancing. She has 6 children. She has no etoh use or drug hx.\n Unable to dress or bath herself. Has to be observed eating due to poor\n PO intake. Uses a rolling walker.\n Review of systems:\n Flowsheet Data as of 12:19 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 79 (74 - 79) bpm\n BP: 133/49(71) {133/47(71) - 159/70(88)} mmHg\n RR: 17 (16 - 35) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 300 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 0 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 170 mL\n 0 mL\n Respiratory\n SpO2: 93%\n ABG: 7.34/43/236//-2\n Physical Examination\n Vitals- T: 96.6 BP: 159/47 P: 75 R: 22 O2: 100% on NRB\n Gen- NAD, pleasantly confused\n HEENT- dry MM, no SI\n Neck- supple, no LAD\n CV- RRR, no M\n Pulm- crackles and rhonchi at left base with exp wheezes\n Abd- soft NT, ND, +BS\n Ext- no c/c/e, warm, thin\n Neuro- A&O to person and \"hospital\", CN 2-12 intact, strength 5/5\n Labs / Radiology\n 98 mg/dL\n 102 mEq/L\n 4.4 mEq/L\n 134 mEq/L\n [image002.jpg]\n \n 2:33 A9/16/ 08:38 PM\n \n 10:20 P9/16/ 09:39 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.07\n TC02\n 24\n Glucose\n 98\n Other labs: CK / CKMB / Troponin-T:58//0.07, Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: Lactate:2.0\n Trop-T: 0.07 MB: 5\n .\n 139 105 27\n -------------< 93\n 4.6 22 1.8\n .\n Ca: 9.8 Mg: 2.6 P: 3.7\n Alb: 4.3\n .\n WBC-10.2, plts- 332, hct 32.6\n N:85.8 L:8.6 M:4.4 E:0.8 Bas:0.4\n .\n PT: 11.8 PTT: 22.2 INR: 1.0\n Imaging: CTA chest\n No PE. Interlobular septal thickening c/w interstitial edema. Left\n lower lobe atelectasis/consolidation with small to moderate left\n pleural effusion and tiny right pleural effusion. COPD with multiple\n pulmonary nodules, including a 5 mm pulmonary nodule in left upper\n lobe. F/u CT in 6 months to assess for change\n Microbiology: Blood cx x 2 pnd\n Urine cx pnd\n ECG: EKG:\n IN ER during SOB: rate of 104, depressions in I and II, V4-V6 ST\n elevations in V1-V2, dynamic changes compared to initial EKG\n On FLOOR:\n NSR at 72, axis WNL, LVH, ST depressions in I, II,V4-V6 with some\n degree of resolution since prior, less STE in V1 and V2\n Assessment and Plan\n This is a 85 yo f with hx of COPD, Dementia, HTN, admitted from ER with\n dyspnea and hemoptysis in setting of new PNA and with EKG changes.\n # SOB/PNA/Hemoptysis: Has long hx of COPD, and now with worsening of\n cough, SOB, and hemoptysis. CXR with new left effusion and CTA with LLL\n consolidation likely representing PNA. CTA was negative for PE. At\n baseline as poor lung function with sats in PCPs office in low 90s, but\n not requiring home oxygen. Also likely has COPD flare.\n - sputum cx and blood cx\n - abx tx with ceftriaxone and azithro for CAP\n - oxygen to keep sats 92%\n - follow ABG\n - will wean off BIPAP\n - albuterol and ipratropium nebs\n - consider steroid burst if not improving\n - chest PT PRN\n - mucinex\n - will check CXR in AM\n .\n # ACS: Compared to prior EKG, pt has new ST depressions and elevations\n concerning for MI. Pt had a back ground of moderate aortic stenosis and\n mild MR. Pt had dynamic changes in ER with tachypnea and HTN episodes\n with changes in the lateral and percordial leads. This may have been\n related to cardiac strain per Cards fellow. Pt does have a hx of CAD\n per her daughter.\n - ASA 325mg\n - Continue statin\n - continue and CCB\n - Add low dose BB for BP and rate control if needed\n - Monitor on tele\n - Trend CEs\n - Follow EKGs\n - Echo to assess wall motion defects and valves (last echo )\n .\n # Hypertension: BP was elevated in ER during tachypnea\n - continue amlodipine\n - change home to Valsartan while admitted since on formulary\n .\n # Dementia: pt has chronic dementia, per family she is at baseline\n - A&O x 3\n - continue Aricept\n - fall precautions\n .\n # Chronic renal failure: Cr is at baseline 1.8. worsen in setting\n of having a CTA.\n - renally dose meds\n - monitor renal function\n .\n # Anemia: stable, chronic\n - monitor hct\n .\n # Lung Nodules: Seen on chest CTA, long hx of smoking concerning for\n cancer risk\n - will need out pt follow up\n .\n # Osteoporosis: chronic\n - continue Ca and Vitamin D\n - Fosamax weekly on Sundays\n .\n # FEN: replete electrolytes, will start diet once off BIPAP\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals\n .\n # Code: DNR/DNI, confirmed\n .\n # Communication: HCP is her daughter, copy of paperwork in chart\n .\n # Disposition: ICU for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 595698, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n felt better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85% on RA,\n with a baseline of 96% with no oxygen at home. She was tachypneic to\n 40s. She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was satting 100%. She was changed to\n a nasal cannula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN into the 180s. EKG showed\n larger ST depressions in lateral leads and STE in V1-V2. Cards again\n thought this was still related to strain. CTA was done that showed no\n PE, but did show PNA in LLL and left effusion. She was started on BIPAP\n and transferred to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2\n 100 BIPAP 15/5 FIO2 60%. Pt is DNR/DNI.\n CODE: DNR/DNI\n ACCESS: Rt and Lt #20G PIVs\n SOCIAL: (daughter) is HCP, cell phone # .\n Pt has total of 6 children, all of whom are involved in care.\n ROS:\n *Neuro- A&Ox1, pleasant/cooperative with care\n *CV- HR 70s-80s, SR; SBP ranging 120s-140s\n *Resp- satting 92-97% on 4L NC, LS clear/diminished @ bases with ronchi\n at times; pt also with cough productive of blood tinged sputem\n *GI/GU- tolerating sm portions of reg diet (eats minimal at baseline),\n denies N/V but did have loose brown/green stool x2 today; abd s/nt/nd;\n foley intact with minimal amts CYU as pt with h/o CRF\n *Act- able to stand and pivot to commode with minimal assist\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is A&Ox1 (person), very pleasant and cooperative with care but very\n poor short term memory.\n Action:\n Pt with frequent redirection/reorientation. Family at bedside entire\n day which is very helpful to her per her HCP. Pt receiving aricept at\n bedtime. Bed exit alarm on for safety.\n Response:\n Patient remains calm but continues with forgetfulness. Safety\n maintained.\n Plan:\n Continue aricept. Cont to redirect/reorient as necessary.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission showing LLL PNA and pleural effusion. Pt\n received on 40% aerosol cool mask with sats 97-100%. LS\n clear/diminished with intermittent ronchi.\n Action:\n O2 weaned to 4L NC. Pt receiving PO azithromycin and IV ceftriaxone.\n Nebs administered as ordered/PRN.\n Response:\n Sats maintained 92-97% on 4L NC.\n Plan:\n Cont with IV abx. Wean O2 as tolerated.\n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 595706, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n felt better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85% on RA,\n with a baseline of 96% with no oxygen at home. She was tachypneic to\n 40s. She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was satting 100%. She was changed to\n a nasal cannula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN into the 180s. EKG showed\n larger ST depressions in lateral leads and STE in V1-V2. Cards again\n thought this was still related to strain. CTA was done that showed no\n PE, but did show PNA in LLL and left effusion. She was started on BIPAP\n and transferred to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2\n 100 BIPAP 15/5 FIO2 60%. Pt is DNR/DNI.\n CODE: DNR/DNI\n ACCESS: Rt and Lt #20G PIVs\n SOCIAL: (daughter) is HCP, cell phone # .\n Pt has total of 6 children, all of whom are involved in care.\n ROS:\n *Neuro- A&Ox1, pleasant/cooperative with care\n *CV- HR 70s-80s, SR; SBP ranging 120s-140s\n *Resp- satting 92-97% on 4L NC, LS clear/diminished @ bases with ronchi\n at times; pt also with cough productive of blood tinged sputem\n *GI/GU- tolerating sm portions of reg diet (eats minimal at baseline),\n denies N/V but did have loose brown/green stool x2 today; abd s/nt/nd;\n foley intact with minimal amts CYU as pt with h/o CRF\n *Act- able to stand and pivot to commode with minimal assist\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is A&Ox1 (person), very pleasant and cooperative with care but very\n poor short term memory.\n Action:\n Pt with frequent redirection/reorientation. Family at bedside entire\n day which is very helpful to her per her HCP. Pt receiving aricept at\n bedtime. Bed exit alarm on for safety.\n Response:\n Patient remains calm but continues with forgetfulness. Safety\n maintained.\n Plan:\n Continue aricept. Cont to redirect/reorient as necessary.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission showing LLL PNA and pleural effusion. Pt\n received on 40% aerosol cool mask with sats 97-100%. LS\n clear/diminished with intermittent ronchi.\n Action:\n O2 weaned to 4L NC. Pt receiving PO azithromycin and IV ceftriaxone.\n Nebs administered as ordered/PRN.\n Response:\n Sats maintained 92-97% on 4L NC.\n Plan:\n Cont with IV abx. Wean O2 as tolerated.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Precautions:\n PMH: COPD, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: HTN, dementia, osteoarthritis, macular\n degeneration, Left eye visual deficit, reflux\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:39\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 530 mL\n 24h total out:\n 237 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:41 AM\n Potassium:\n 4.5 mEq/L\n 05:41 AM\n Chloride:\n 106 mEq/L\n 05:41 AM\n CO2:\n 22 mEq/L\n 05:41 AM\n BUN:\n 24 mg/dL\n 05:41 AM\n Creatinine:\n 1.8 mg/dL\n 05:41 AM\n Glucose:\n 94 mg/dL\n 05:41 AM\n Hematocrit:\n 29.5 %\n 05:41 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 788\n Transferred to: CC715\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 595707, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n felt better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85% on RA,\n with a baseline of 96% with no oxygen at home. She was tachypneic to\n 40s. She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was satting 100%. She was changed to\n a nasal cannula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN into the 180s. EKG showed\n larger ST depressions in lateral leads and STE in V1-V2. Cards again\n thought this was still related to strain. CTA was done that showed no\n PE, but did show PNA in LLL and left effusion. She was started on BIPAP\n and transferred to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2\n 100 BIPAP 15/5 FIO2 60%. Pt is DNR/DNI.\n CODE: DNR/DNI\n ACCESS: Rt and Lt #20G PIVs\n I/O: Total IN: , Total OUT:\n SOCIAL: (daughter) is HCP, cell phone # .\n Pt has total of 6 children, all of whom are involved in care.\n ROS:\n *Neuro- A&Ox1, pleasant/cooperative with care\n *CV- HR 70s-80s, SR; SBP ranging 120s-140s\n *Resp- satting 92-97% on 4L NC, LS clear/diminished @ bases with ronchi\n at times; pt also with cough productive of blood tinged sputem\n *GI/GU- tolerating sm portions of reg diet (eats minimal at baseline),\n denies N/V but did have loose brown/green stool x2 today; abd s/nt/nd;\n foley intact with minimal amts CYU as pt with h/o CRF\n *Act- able to stand and pivot to commode with minimal assist\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is A&Ox1 (person), very pleasant and cooperative with care but very\n poor short term memory.\n Action:\n Pt with frequent redirection/reorientation. Family at bedside entire\n day which is very helpful to her per her HCP. Pt receiving aricept at\n bedtime. Bed exit alarm on for safety.\n Response:\n Patient remains calm but continues with forgetfulness. Safety\n maintained.\n Plan:\n Continue aricept. Cont to redirect/reorient as necessary.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission showing LLL PNA and pleural effusion. Pt\n received on 40% aerosol cool mask with sats 97-100%. LS\n clear/diminished with intermittent ronchi.\n Action:\n O2 weaned to 4L NC. Pt receiving PO azithromycin and IV ceftriaxone.\n Nebs administered as ordered/PRN.\n Response:\n Sats maintained 92-97% on 4L NC.\n Plan:\n Cont with IV abx. Wean O2 as tolerated.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Precautions:\n PMH: COPD, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: HTN, dementia, osteoarthritis, macular\n degeneration, Left eye visual deficit, reflux\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:39\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 530 mL\n 24h total out:\n 237 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:41 AM\n Potassium:\n 4.5 mEq/L\n 05:41 AM\n Chloride:\n 106 mEq/L\n 05:41 AM\n CO2:\n 22 mEq/L\n 05:41 AM\n BUN:\n 24 mg/dL\n 05:41 AM\n Creatinine:\n 1.8 mg/dL\n 05:41 AM\n Glucose:\n 94 mg/dL\n 05:41 AM\n Hematocrit:\n 29.5 %\n 05:41 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 788\n Transferred to: CC715\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2110-09-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 595708, "text": "85 year old female with chief complaint of tachypnea and coughing-up\n blood. Pt has had a cough for about 1 week and had been more fatigued.\n She has also been having constipation for several days and last night\n while having a BM began coughing. With this had tachypnea and coughing\n up bright red blood last night (about a tsp mixed with mucus) and then\n felt better. She was going to her PCP this AM and had another episode\n of hemoptysis in the car. At her PCP, was hypoxic to 85% on RA,\n with a baseline of 96% with no oxygen at home. She was tachypneic to\n 40s. She was sent to the ER.\n .\n In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93 on RA.\n Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1 g IV.\n She had one episode of about a tsp of hemoptysis mixed with mucus. She\n was placed on a non-rebreather and was satting 100%. She was changed to\n a nasal cannula. She was at MS A&O x 1. She had an EKG that showed LVH,\n new V4-V6 ST depressions which cards thought was strain. She had a\n negative UA. CXR showed a new left effusion compared to . No nebs\n were given. Again became tachypneic with HTN into the 180s. EKG showed\n larger ST depressions in lateral leads and STE in V1-V2. Cards again\n thought this was still related to strain. CTA was done that showed no\n PE, but did show PNA in LLL and left effusion. She was started on BIPAP\n and transferred to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2\n 100 BIPAP 15/5 FIO2 60%. Pt is DNR/DNI.\n CODE: DNR/DNI\n ACCESS: Rt and Lt #20G PIVs\n I/O: Total IN: 530, Total OUT: 237 (ok per team, pt with CRF, Cr 1.8)\n SOCIAL: (daughter) is HCP, cell phone # .\n Pt has total of 6 children, all of whom are involved in care.\n ROS:\n *Neuro- A&Ox1, pleasant/cooperative with care\n *CV- HR 70s-80s, SR; SBP ranging 120s-140s\n *Resp- satting 92-97% on 4L NC, LS clear/diminished @ bases with ronchi\n at times; pt also with cough productive of blood tinged sputem\n *GI/GU- tolerating sm portions of reg diet (eats minimal at baseline),\n denies N/V but did have loose brown/green stool x2 today; abd s/nt/nd;\n foley intact with minimal amts CYU as pt with h/o CRF\n *Act- able to stand and pivot to commode with minimal assist\n .H/O dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt is A&Ox1 (person), very pleasant and cooperative with care but very\n poor short term memory.\n Action:\n Pt with frequent redirection/reorientation. Family at bedside entire\n day which is very helpful to her per her HCP. Pt receiving aricept at\n bedtime. Bed exit alarm on for safety.\n Response:\n Patient remains calm but continues with forgetfulness. Safety\n maintained.\n Plan:\n Continue aricept. Cont to redirect/reorient as necessary.\n Pneumonia/Pleural effusion, acute\n Assessment:\n Chest CT upon admission showing LLL PNA and pleural effusion. Pt\n received on 40% aerosol cool mask with sats 97-100%. LS\n clear/diminished with intermittent ronchi.\n Action:\n O2 weaned to 4L NC. Pt receiving PO azithromycin and IV ceftriaxone.\n Nebs administered as ordered/PRN.\n Response:\n Sats maintained 92-97% on 4L NC.\n Plan:\n Cont with IV abx. Wean O2 as tolerated.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 41 kg\n Daily weight:\n Allergies/Reactions:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Precautions:\n PMH: COPD, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: HTN, dementia, osteoarthritis, macular\n degeneration, Left eye visual deficit, reflux\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:39\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 0 %\n 24h total in:\n 530 mL\n 24h total out:\n 237 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:41 AM\n Potassium:\n 4.5 mEq/L\n 05:41 AM\n Chloride:\n 106 mEq/L\n 05:41 AM\n CO2:\n 22 mEq/L\n 05:41 AM\n BUN:\n 24 mg/dL\n 05:41 AM\n Creatinine:\n 1.8 mg/dL\n 05:41 AM\n Glucose:\n 94 mg/dL\n 05:41 AM\n Hematocrit:\n 29.5 %\n 05:41 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 788\n Transferred to: CC715\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 595687, "text": "Chief Complaint: Shortness of breath.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Stable overnight, cardiac markers remained flat x 3 checks.\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n colace, MVi, vitamin D, tums, asa 325, simvastain, PCN, potassium,\n donepzil, amlodipine , albuterol/atrovent nebs, azithromycin,\n losartan K 50mg. Ceftriaxone.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 79 (70 - 120) bpm\n BP: 134/43(67) {92/43(45) - 159/70(88)} mmHg\n RR: 29 (16 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 420 mL\n 480 mL\n PO:\n 120 mL\n 480 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 191 mL\n Urine:\n 130 mL\n 191 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n 289 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.34/43/236/22/-2\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilaterally, Diminished: left), kyphoscoliosis\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 295 K/uL\n 94 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.5 %\n 10.0 K/uL\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n 05:41 AM\n WBC\n 10.0\n Hct\n 29.5\n Plt\n 295\n Cr\n 1.8\n TropT\n 0.07\n 0.07\n TCO2\n 24\n Glucose\n 98\n 94\n Other labs: PT / PTT / INR:11.8/23.7/1.0, CK / CKMB /\n Troponin-T:52//0.07, Lactic Acid:1.1 mmol/L, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n Goals of care are management, if means arenon agressive. DNR, DNI.\n PLEURAL EFFUSION, Left:\n likely parapneumonia, small in size, continue therapy for severe CAP\n Ceftriaxone and azithro, cannot dteremine if effusion is acute or\n chornic.\n hemoptysis: likely to infection,cannot exclude malignancy given\n extensive smoking history.\n Ground glass opacities: c/w edema, vs infection, vs hemorrhage vs\n malignancy, will not prusue bronchoscopy as not consistent wiht goals\n of care, will treat for infction, including atypical infection and\n monitor for improvement of her symptoms. Will hold off on diuresis for\n now.\n Renal failure: at risk or contrast induced nephropathy\nCardiac: EKG changes c/w demand, continue to follow, repeat echo\n pending.\n ICU Care\n Nutrition: mechanical soft, with supervision.\n Glycemic Control: none\n Lines:\n 20 Gauge - 08:29 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2110-09-18 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 595690, "text": "Chief Complaint: Shortness of breath.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Stable overnight, cardiac markers remained flat x 3 checks.\n Allergies:\n Ergotamine\n made patient fe\n Hydralazine\n Confusion/Delir\n Paxil (Oral) (Paroxetine Hcl)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n colace, MVi, vitamin D, tums, asa 325, simvastain, PCN, potassium,\n donepzil, amlodipine , albuterol/atrovent nebs, azithromycin,\n losartan K 50mg. Ceftriaxone.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 79 (70 - 120) bpm\n BP: 134/43(67) {92/43(45) - 159/70(88)} mmHg\n RR: 29 (16 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 420 mL\n 480 mL\n PO:\n 120 mL\n 480 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 130 mL\n 191 mL\n Urine:\n 130 mL\n 191 mL\n NG:\n Stool:\n Drains:\n Balance:\n 290 mL\n 289 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.34/43/236/22/-2\n Physical Examination\n General Appearance: Thin, Anxious\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases bilaterally, Diminished: left), kyphoscoliosis\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 9.3 g/dL\n 295 K/uL\n 94 mg/dL\n 1.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 24 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.5 %\n 10.0 K/uL\n [image002.jpg]\n 08:38 PM\n 09:39 PM\n 05:41 AM\n WBC\n 10.0\n Hct\n 29.5\n Plt\n 295\n Cr\n 1.8\n TropT\n 0.07\n 0.07\n TCO2\n 24\n Glucose\n 98\n 94\n Other labs: PT / PTT / INR:11.8/23.7/1.0, CK / CKMB /\n Troponin-T:52//0.07, Lactic Acid:1.1 mmol/L, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n H/O DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n Goals of care are management, if means arenon agressive. DNR, DNI.\n PLEURAL EFFUSION, Left:\n likely parapneumonia, small in size, continue therapy for severe CAP\n Ceftriaxone and azithro, cannot dteremine if effusion is acute or\n chornic.\n hemoptysis: likely to infection,cannot exclude malignancy given\n extensive smoking history.\n Ground glass opacities: c/w edema, vs infection, vs hemorrhage vs\n malignancy, will not prusue bronchoscopy as not consistent wiht goals\n of care, will treat for infction, including atypical infection and\n monitor for improvement of her symptoms. Will hold off on diuresis for\n now.\n Renal failure: at risk or contrast induced nephropathy\nCardiac: EKG changes c/w demand, continue to follow, repeat echo\n pending.\n ICU Care\n Nutrition: mechanical soft, with supervision.\n Glycemic Control: none\n Lines:\n 20 Gauge - 08:29 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:06 ------\n" }, { "category": "Echo", "chartdate": "2110-09-18 00:00:00.000", "description": "Report", "row_id": 99873, "text": "PATIENT/TEST INFORMATION:\nIndication: patient with HTN, admitted with PNA. Concerns for ACS\nHeight: (in) 58\nWeight (lb): 109\nBSA (m2): 1.41 m2\nBP (mm Hg): 124/84\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 12:02\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Critical AS (area <0.8cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. There are three aortic valve leaflets. The aortic valve\nleaflets are severely thickened/deformed. There is critical aortic valve\nstenosis (valve area 0.7 cm2). Moderate (2+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation\nis seen. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Critical calcific aortic\nstenosis. Moderate aortic regurgitation. Moderate tricuspid regurgitation.\nMild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , aortic stenosis\nseverity has progressed. Tricuspid regurgitation is more prominent. The other\nfindings are similar.\n\n\n" }, { "category": "ECG", "chartdate": "2110-09-18 00:00:00.000", "description": "Report", "row_id": 284869, "text": "Atrial fibrillation, average ventricular rate 104. The previously noted\nST-T wave changes persist and are more prominent. Compared to the previous\ntracing #1 the increase in ST-T wave changes may be related to myocardial\nischemia due to the increased heart rate. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2110-09-18 00:00:00.000", "description": "Report", "row_id": 284870, "text": "Sinus tachycardia, rate 109. Some baseline artifact and absence of lead V5.\nLeft ventricular hypertrophy. There are marked ST-T wave changes in\nleads I, II, aVL and leads V2-V6. There are Q waves in leads V1-V2 and a tiny\nR wave in lead V3. Some of these changes may be related to left ventricular\nhypertrophy. Consider anteroseptal myocardial infarction of indeterminate age.\nLeft atrial abnormality. Compared to the previous tracing of the\nST-T wave changes are somewhat more prominent at this time.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2110-09-18 00:00:00.000", "description": "Report", "row_id": 284871, "text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave abnormalities.\nClinical correlation is suggested. Since the previous tracing of \nST-T wave changes appear slightly less prominent but there may be no\nsignificant change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2110-09-17 00:00:00.000", "description": "Report", "row_id": 284872, "text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave abnormalities. The\nST-T wave changes are diffuse. Clinical correlation is suggested. Since the\nprevious tracing of same date sinus tachycardia and atrial ectopy are absent.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2110-09-17 00:00:00.000", "description": "Report", "row_id": 284873, "text": "Sinus tachycardia with atrial premature beats. Left ventricular hypertrophy\nwith ST-T wave abnormalities. The ST-T wave changes are diffuse. Clinical\ncorrelation is suggested. Since the previous tracing of same date sinus\ntachycardia, atrial ectopy and further ST-T wave changes are now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2110-09-17 00:00:00.000", "description": "Report", "row_id": 284874, "text": "Sinus rhythm. Left ventricular hypertrophy with ST-T wave abnormalities. Since\nthe previous tracing of QRS voltage is more prominent and further\nST-T wave changes are present.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2110-09-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098240, "text": " 1:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 85 yo female woman with low 02 sat and SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with hx as above\n REASON FOR THIS EXAMINATION:\n 85 yo female woman with low 02 sat and SOB\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female, with low oxygen saturations and shortness of\n breath.\n\n COMPARISON: .\n\n CHEST, SINGLE AP VIEW The heart is mildly enlarged, with an atherosclerotic\n aortic arch. There is a new moderate-sized left pleural effusion, with\n associated left retrocardiac opacities, which are new from . The\n lungs are mildly hyperinflated suggestive of underlying COPD. No pneumothorax\n is identified. Again noted is a severe S- shaped scoliosis.\n\n IMPRESSION: New moderate-sized left pleural effusion, with associated\n retrocardiac opacities, which may reflect atelectasis. Underlying\n consolidation cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2110-09-17 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1098287, "text": " 5:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE, pt unstable, needs CT despite Cr 1.8\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with chest pain, SOB, tachypnea and small hemoptosis.\n REASON FOR THIS EXAMINATION:\n ? PE, pt unstable, needs CT despite Cr 1.8\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc WED 6:41 PM\n No PE. Interlobular septal thickening c/w interstitial edema. Left lower\n lobe atelectasis/consolidation with small to moderate left pleural effusion\n and tiny right pleural effusion. COPD with multiple pulmonary nodules,\n including a 5 mm pulmonary nodule in left upper lobe. F/u CT in 6 months to\n assess for change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with chest pain, shortness of breath, tachypnea,\n and small hemoptysis. Evaluate for pulmonary embolism.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n upper abdomen prior to and after administration of IV contrast. Coronal,\n sagittal, and oblique reformations were obtained.\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: Atherosclerotic calcifications\n of the coronary arteries are noted. The left atrium appears moderately\n dilated. Otherwise, the heart and pericardium are unremarkable, without\n pericardial effusion. Atherosclerotic calcifications of the aortic arch are\n noted. Otherwise, the great vessels are within normal limits, without\n evidence for pulmonary embolism. Few scattered mediastinal lymph nodes are\n seen, with a paratracheal node which measures approximately 9 mm in short\n axis, which may be reactive.\n\n There is diffuse intralobular septal thickening within the lungs bilaterally,\n with confluent ground-glass opacities seen within the upper lobes bilaterally.\n These findings are suggestive of pulmonary edema. Additionally, there is\n opacification of the left lower lobe, which may reflect atelectasis, with\n associated small-to-moderate pleural effusion. A tiny right pleural effusion\n is also noted. There is emphysema. Scattered within the lungs are small\n ground-glass and dense nodular opacities, with the largest in the left upper\n lobe (3:29) measuring approximately 5 mm. Another nodule also within the left\n upper lobe (3:51) measures 5 mm. A nodule within the right lower lobe (3:63)\n measures 5 mm.\n\n Limited views of the upper abdomen reveals a heterogeneous left adrenal\n lesion which measures grossly 3.6 cm x 1.8 cm, which is slightly increased in\n size from .\n\n OSSEOUS STRUCTURES: Multilevel degenerative changes are noted.\n (Over)\n\n 5:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE, pt unstable, needs CT despite Cr 1.8\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n 2. Cardiomegaly with pulmonary edema, bilateral pleural effusions, left >\n right, and left lower lobe atelectasis.\n 3. Emphysema with scattered bilateral pulmonary nodules (up to 5-mm). A\n followup chest CT in six months is recommended to assess for interval change.\n 4. Left adrenal mass, which is larger in size since ,\n incompletely characterized. Recommend further characterization with MRI.\n\n Findings were posted to the ED dashboard at the time of interpretation.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2110-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1098346, "text": " 2:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with COPD, admitted with PNA on LLL\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD with left lower lobe pneumonia.\n\n COMPARISON: CTA chest and multiple priors.\n\n SEMI-UPRIGHT CHEST: Retrocardiac opacity is largely due the left pleural\n effusion, in comparison to the recent CTA chest, with a small amount of\n associated atelectasis. Interstitial edema persists and the pulmonary\n vasculature is unchanged. No focal right lung consolidation is seen and there\n is no right pleural effusion or pneumothorax. Mild cardiac enlargement\n persists.\n\n Severe S-shaped scoliosis is again observed. Contrast persists within the\n left kidney and proximal renal collecting system.\n\n IMPRESSION:\n 1. Left effusion and atelectasis. No new focal consolidation.\n 2. Persistent moderate pulmonary edema.\n 3. Persistent left nephrogram is a nonspecific finding, but may represent\n underlying acute tubular necrosis.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-07-04 00:00:00.000", "description": "ART DUP EXT LO UNI;F/U", "row_id": 792402, "text": " 1:41 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: eval for ongoing femoral artery bleed or fistula\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD s/p cath this am c/b large hematoma\n REASON FOR THIS EXAMINATION:\n eval for ongoing femoral artery bleed or fistula\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Search for ongoing femoral artery bleed or arteriovenous (AV)\n fistula in a 68 year old man with coronary artery disease who underwent\n cardiac catheterization this morning and presents now with a large hematoma.\n\n TECHNIQUE & FINDINGS: scale, color and spectral Doppler examination of\n the arteries and veins of the right groin was performed.\n\n No pseudoaneurysm or AV fistula was detected. A non-circulating hematoma was\n found in the right groin, superficial to the common femoral vessels. Normal\n waveforms were found in the right common femoral artery and vein.\n\n CONCLUSION: No evidence of pseudoaneurysm or AV fistula in the right groin.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792789, "text": " 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p cabg and removal of chest tubes\n\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG and removal of chest tubes.\n\n PORTABLE AP CHEST, ONE VIEW: Comparison . Since the prior study, the\n ET tube and chest tubes have been removed. The patient is status post\n sternotomy. The cardiac and mediastinal silhouettes are stable. There is\n atelectasis at both bases and in the left midlung zone. I doubt the presence\n of underlying pneumonia. The right lateral thorax is not completely imaged.\n There is a probable small left effusion. There is no CHF. There is a right\n IJ Swan-Ganz catheter with tip curving towards the left main pulmonary artery.\n This is unchanged. There is no pneumothorax.\n\n IMPRESSION: Interval removal of ET tube and chest tubes. Otherwise no\n significant change from . No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-07-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792426, "text": " 5:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with new inf. ischemia / post. MI. High wedge pressures.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST FROM .\n\n INDICATION: Coronary ischemia.\n\n No priors.\n\n PORTABLE CHEST RADIOGRAPH: An IABP terminates 2 cm below the aortic arch. The\n lung volumes are low. The heart size is likely within normal limits. There is\n prominence of the central pulmonary vasculature on this supine radiograph. The\n left CPA is excluded from the study but there are no definite pleural\n effusions. There is no pneumothorax. There are no focal consolidations.\n\n IMPRESSION: No CHF or infiltrate on this supine radiograph. IABP 2 cm below\n aortic arch.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 793369, "text": " 9:07 AM\n CHEST (PA & LAT) Clip # \n Reason: Assess lead position and r/o PTx\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with CAD s/p IMI s/p CABG who had positive EPS now s/p ICD\n\n REASON FOR THIS EXAMINATION:\n Assess lead position and r/o PTx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ICD placement.\n\n PORTABLE CHEST: Comparison is made to prior film from three days earlier.\n Patient is status post median sternotomy. A new unipolar pacer is present,\n inserted via left subclavian vein, tip projecting over the right ventricle.\n There is no evidence of pneumothorax. Cardiac and mediastinal contours are\n stable. No acute change is seen within the lung parenchyma. There is no\n definite pleural effusion. Note that the lateral view is limited as patient\n did not raise his arms.\n\n IMPRESSION: New ICD tip in right ventricle; no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792631, "text": " 4:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o hemoptx\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o hemoptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post CABG. R/O hemothorax.\n\n Comparison is made to previous films from .\n\n FINDINGS: An ET tube is in good position. A Swan-Ganz catheter is seen with\n its tip in the main pulmonary artery. Bilateral chest tubes are seen. An\n intra-aortic balloon pump device is in stable position. An NG tube is seen\n within the esophagus, but its distal extent is not identified. Given low lung\n volumes, the pulmonary vasculature is within normal limits. Apparent\n increased width of the upper mediastinum is at least partially related to\n lower lung volumes. Retrocardiac opacity likely represents a left basilar\n atelectasis and a small left effusion is probable.\n\n IMPRESSION:\n\n 1. Satisfactory position of lines and tubes.\n 2. No pneumothorax of hemothorax appreciated.\n 3. Increased width of upper mediastinum likely related to lower lung volumes.\n However, hemomediastinum cannot be excluded. Please follow clinically and with\n followup exam.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 792671, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check iabp placement assess effusions\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p cabg\n\n REASON FOR THIS EXAMINATION:\n check iabp placement assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intra-aortic balloon pump placement. Assess\n effusions.\n\n Comparison is made to the prior examination of .\n\n FINDINGS: A Swan-Ganz catheter is slightly more advanced than previous, with\n now a slightly curved tip seen within the main pulmonary artery. The apparent\n intra-aortic balloon pump catheter appears to be within the proximal\n descending aorta. An ET tube is in good position. An NG tube is seen\n coursing through the esophagus, but its distal most extent cannot be\n visualized. Bilateral chest tubes are in stable position. There is no\n pneumothorax seen. The cardiomediastinal borders are unchanged, and again\n there are low lung volumes with bibasilar atelectasis and crowding of the\n pulmonary vasculature.\n\n IMPRESSION:\n\n 1. Stable appearance to the cardiomediastinal borders.\n\n 2. Continued low lung volumes with bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2186-07-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 793124, "text": " 10:42 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for CHF.\n\n Comparison is made with the chest radiograph from .\n\n PA AND LATERAL CHEST RADIOGRAPH: Again seen are sternal wires and clips from\n prior coronary artery bypass surgery. The heart size is enlarged with left\n ventricular configuration. The pulmonary vasculature is normal without upper\n lung zone redistribution. There is slight blunting of the left CP angle,\n which is likely related to scarring from prior surgery. Note is made of\n linear opacities in both lung bases which likely represent atelectasis. No\n pneumonic consolidations are present.\n\n IMPRESSION: No radiographic evidence of congestive heart failure.\n\n" }, { "category": "Nursing/other", "chartdate": "2186-07-05 00:00:00.000", "description": "Report", "row_id": 1575563, "text": "CCU progress note 7a-7p\nNEURO: A+Ox3. slept in naps early this morning from ativan 2mg given for anxiety at 7am. given back rubs for lwr back discomfort (chronic back pain - not cardiac - ekg done). this afternoon having L knee pain - given percocet 2 tabs w/ little effect. immobilizer to L leg taken off w/ little relief. HO aware. Family in visiting today.\n\nID: tmax 99.1. afebrile. no abx. ua + c/s sent pre-op.\n\nRESP: LS clear, dim. O2 2l n/c. sats >97%. RA sats 94%.\n\nCARDIAC: SR 80s - 1 episode this morning of 9 beats VT asymptomatic. started on amiodarone 400mg TID. RIJ ecchymotic/sore from old stick attempts at PA line last evening. R fem ecchymotic - no increase in hematoma. area marked. HCT stable. L fem IABP site D+I, no hematoma noted. palpable 2+ pulses. waveform dampened at times. fair augmentation. see careview for unloading numbers. MAPs 70-90s. no c/o CP or discomfort. CABG in am. K levels low today, repleated x 2. on Heparin gtt currently at 900u/hr. next ptt 11pm.\n\nGI/GU: foley patent, good urine output. abd large soft +BS. no bm. taking po well this afternoon. NPO after midnite for surgery in am.\nENDO: FS QID. RISS.\n\nPLAN: surgery 1st case CABG in am. NPO after midnite. hibicleanse scrub tonite. sleeping med tonite. emotional support. monitor for further bleeding at groin site. PTT check at 11pm. monitor K level.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-06 00:00:00.000", "description": "Report", "row_id": 1575564, "text": "CCU NSG PROGRESS NOTE.\nO:NEURO=APPROPRIATELY CONCERNED W PENDING CABG.\n PULM=O2 VIA NC 2L W SATS MID 90'S. BREATH SOUNDS=CLEAR/DEMISINSHED.\n CV=HEMODY STABLE THROUGHOUT NIGHT. PF. IABP 1:1 W GD AUGMENTATION & SYSTOLIC UNLOADING. PULSES 2+. R/L FEM SITES-WO CHG.\n GI=NPO AFTER MN.\n GU=FOLEY.ADEQUATE UO.\n ID=AFEBRILE.\n LABS=AM SENT.\n\nA:STABLE TROUGHOUT NIGHT. AWAITING AM CABG.\n\nP:SUPPORT AS INDICATED. CONTIN PRESENT MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-06 00:00:00.000", "description": "Report", "row_id": 1575565, "text": "POST OP\nWHITE MALE ADMITTED ~1525 FROM OR S/P CABG X 3, INTUBATED ON IV PROPOFOL, ESMOLOL, NEO, INSULIN AND PIT.\nCT' PATENT FOR SMALL AMT SERO-SANG. PACER OFF, TOLD NEVER USED IN OR. IABP IN PLACCE IN LT GROIN, SITE C/D, IABP 1:1, PALPABLE PULSES. RT GROIN LGE ECCYMOTIC AREA, LARGER THAN MARKED LINES, HO AWARE.\n\nNEURO: REMAINS SEDATED WITH IV PROPOFOL AND IV MS. RANDOMLY WITH STIMULATION AND TURNING. PSERL.\n\nCARDAIC: MP SR-ST WITHOUT ECTOPY. PACER SENSES AND PACING AS NEEDED, OFF AT PRESENT. IV NEO CONTINUES TO MAINTAIN SB/P ^ 100. ESMOLOL DC'D ~1800. PITRESSIN REMAINS ^, RATE NOW AT 4.8 U/HR. INITIAL HCT 15, GIVEN 3 UNIT CELLS WITH REPEAT 21, 2 MORE UNITS INFUSING. CT'S PATENT FOR SMALL AMT, NO ^ WITH TURNING.\n\nRESP: SUCTIONED FOR SMALL AMT WHITE, MODERATE ORALLY. PEEP AT 10 DUE TO OR ISSUES, SLOW O2 WEAN DUE TO LOW HCT, SAT 100%, WILL CONTINUE TO WEAN AS APPROPRIATE. NO PLANS TO WEAN TO EXTUBATE TONOC.\n\nGI: OG IN PLACE, PLACEMENT CHECKED X 2 WITHOUT DRAINAGE.\n\nGU: FOLEY IN PLACE, URINE ~40 QH CLEAR YELLOW.\n\nENDO : INSULIN GTT ^, FOLLOWING PROTOCOL.\n\nFAMILY IN, HAVE GONE HOME FOR THE NIGHT, AWARE OF EVENTS.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 1575560, "text": "CCU NPN 3-11PM\n68 yr old admitted from Cath lab with severe 3VD, high filling pressures, cath c/b R groin hematoma with sheath pulling in holding area, vagal episode with decrease BP, CP, requiring dopa, changed to Neo, IV fluids, taken back to cath for insertion of IABP, pressors weaned off fairly quickly. To CCU for further care. (see ICU adm sheet)\n\nCV: On IABP 1:1, with good augmentation, sys unloading of , diastolic unloading of , Mean 70-80's. Pulses palpable, feet warm. R groin hematoma marked, USA done at bedside showed no bleeding of fistula. L groin with IABP without hematoma. O hep gtt at 700U/hr, started without a bolus, stopped for cortis placement for swan. Having difficulty with cortis placement. Denies CP, pt has jaw pain ans angina. C/O R cheat pain, ECG done, no ischemic changes.\n\nResp: 3L NC sat 97%, LS clear, diminished, pt obese. No SOB.\n\nNeuro: A&Ox3\n\nGI: NPO for line placement, can eat after line in but needs to be NPO after MN for pot CABG tomorrow.\n\nGU: recieved lasix in cath lab, UO 200cc/hr.\n\nID: afebrile.\n\nEndo: on SS reg ins cov, BS 136 on arrival.\n\nSoc: wife, daughters(2) in this eve.\n\nA/P: monitor hemodynamics overnight, cont on IABP 1:1, obtain #'s after swan placed. Follow groin hematoma, HCT. Check coags on IV hep. CABG for Thurs, unless any indication to take sooner.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 1575561, "text": "CCU NPN 3-11PM\nAddendum: Attending in to help with line placement under ultrasound, unable to place line, will not cont. with line placement tonight. Will check hct with ck at 2300. No hematoma noted at R neck.\nCK back at 1839(presented at OSH with CK 200.)\nMg 1.3, given 4Gm MgSO4 IV, K+ 3.8, given 40 mEq KCL po.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-05 00:00:00.000", "description": "Report", "row_id": 1575562, "text": "CCU NPN 1900-0700\nS/O: pt. denies CP/jaw pain. no SOB.\nHR 69-75SR. no VEA. IABP 1:1. MAP 68-73. syst. unloading . diast. unloading 0-8pts. fair unloading/augmentaton.\n2300 HCT 30.3(32.2). heparin restarted at 0045 at 700u/hr.\nleft groin balloon site stable. C/D.\nright groin site hematoma stable. outline has not extended. echymosis extended laterally. pulses 2+ bilat. extrem warm.\n\nu/o 40-100cc/hr. (-) 2.3L for . currently (-) 200cc.\n\nCK 1391(1800).\n\nLS diminished bases. sats 96-99% on 3lnc. RA sat 93% .\n\npt. has spinal stenosis in lumbar, thorasic region. chronic pain at baseline. did not ask or require any pain meds. he stated that turning, moving makes pain worse and he prefers to stay on back in one position.\n\nslept all night, wakes easily but slightly disoriented, needing orientation to time mostly. pt. appearing mildly anxious at times, lots of questions/\nwife called and given update.\n\nA: stable post cath/IABP placement. HCT down 2pts following groin bleed/hematoma.\nP: f/u with AM labs (sent 0600).\n ck's trending down. contin. to follow\n pt. may benefit from benzo or other mild relaxant prior to .\n follow groin sites.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-09 00:00:00.000", "description": "Report", "row_id": 1575571, "text": "Shift Note\nPt is neurologically intact, MAE to command. Hemodynamically, vasopressin weaned to off, CO/CI improved after vasopressin off. Lungs are diminished at ther bases, pt encouraged to cough and deep breathe. U/O qs, lasix given for diuresis. Pt tolerating solid foods. Pt to remai in bed today so groin can further heal. Pt given dilaudid for pain with effect. See flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-10 00:00:00.000", "description": "Report", "row_id": 1575572, "text": "PT UPDATE\n PT IS S/P CABG X3 ON .\n\n NEURO: PT IS A&O X3. PLEASANT AND COOPERATIVE.\n\n RESP: BS MOSTLY CLEAR; SOMEWHAT DECREASED IN BASES. PT HAD SLIGHT EXP WHEEZE AFTER GETTING OOB-CHAIR-CLEARED WITH REST, COUGHING UP SOME SPUTUM AND USING I.S. STATES THIS IS HIS BASELINE AT HOME-OCCAS GETS WHEEZY. PT HAS GOOD STRONG COUGH-SM AMTS THICK WHITE SPUTUM. NEEDS ENCOURAGEMENT TO USE IS.\n\n\n CV: PT STARTED ON LOPRESSOR THIS AM-TOL WELL. SBP 105-120/50'S BY CUFF. ALINE/PA LINE D/C'D THIS AM.\n\n GU: WEIGHT DOWN 3 KG TODAY FROM YEST.; BUT REMAINS UP 17KG. CONT ON 40MG IV LASIX-EXCELLENT DIURESIS LAST NIGHT; LESS TODAY.\n\n GI: APPETITE IMPROVING. PASSING GAS-NO STOOL YET.\n\n LAB: RECEIVED PO KCL FOR K 3.6. HCT 25. BS WNL THIS AM; BUT UP TO 192THIS AFTERNOON-CONT TO RECEIVE SS REG COVERAGE.\n\n OTHER: PT ASSISTED FOR THE FIRST TIME SINCE SURGERY-DID WELL; STEADY ON FEET. SAT UP FOR 4 HRS; AND THEN AMB ALL AROUND UNIT WITH P.T. PT DID VERY WELL. VERY STEADY ON FEET-TOL ACTIVITY WELL. MED WITH PERCOCET FOR PAIN THIS AM WITH GOOD RELIEF. CONT TO HAVE SOME SORENESSS TO PT THAT PAIN MED WILL NOT ELIMINATE PAIN ALTOGETHER. PT HAVING SM AMT SEROSANG OOZING FROM STERNAL INCISION (ORIGINAL DSD REMOVED THIS AM). IN TO SEE-REMOVED STERISTRIPS; STERNUM IS STABLE-STERI STRIPS REPLACED AND BETADINE TO INCISION; COVERED WITH NEW DSD-TO LEAVE ON. SM INCISIONS ON RT LEG LOOK GOOD. PT WITH VERY LARGE HEMATOMAS RT AND LT GROIN AND RT ARM. PT NOT HAVING DISCOMFORT. NO FURTHER OOZING FROM EITHER GROIN-PRESSURE DSG REMOVED LT GROIN AS PER .\n\n PT'S DAUGHTER IN TO VISIT THIS AM-VERY PLEASED WITH PT'S PROGRESS. PT TO STAY IN CSRU FOR TONIGHT-?TRANSFER TO FLOOR TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-08 00:00:00.000", "description": "Report", "row_id": 1575569, "text": "7am-7pm update\nNeuro: Pt alert and orienated x3. MAE and able to follow commands. Anxious at times. pt continues to c/o blurry vision -> states \" I have trouble focusing\" -> vision somewhat improved with glasses on but \"still not 100%\"\n\nCV: pt remains NSR, rare PVC noted. HR 70-80's. SBP 110-120's. MAP 70-90. vasopressin decreased to 0.03 u/min (per team). IABP weaned to 1:3 -> 1:4 -> CI remained > 2.0. IABP dc'd by DR -> manual pressure held x 45 min and then pressure dressing applied. pt coughed approximately 1 1/2 hours later -> left grion site started bleeding -> Lg amount of bright red blood -> Dr into see pt -> C Clamp applied -> then pressure dressing applied. pressure dressing currently dry and intact. HCT this am 23.7 -> treated with 1 unit PRBC. repeat hct this afternoon 22.1 -> pt transfused with another unit PRBC. bil lower ext warm and normal in color. PT's palpable and DP's doppler\n\nresp: LS clear. pt with non productive cough. pt using IS 250-500. pt initally on 4 L nc -> weaned to 2 L nc. o2 sats 96-98%. CT's dc'd\n\ngi/gu: pt with + BS. + flatus. pt ate clears for breakfast and lunch. pt ate 50% of reg cardiac diet for dinner. foley draining clear yellow urine -> started on lasix\n\nendo: pt contines on insulin gtt -> titrated per protocol\n\nactivity/comfort: pt continues on bedrest. pt c/o of incisional pain this am -> treated with diluadid PO, MSO4 iv and started on torodol\n\nplan: continue vasopressin gtt at 0.03 u/min overnight, titrate insulin gtt per protocol, continue with grion and pulse checks, repeat HCT this evening, monitor lytes, pulm toleit, pain control\n" }, { "category": "Nursing/other", "chartdate": "2186-07-09 00:00:00.000", "description": "Report", "row_id": 1575570, "text": " 7P-7A CSRU SHIFT SUMMARY;\n\nNEURO; ALERT ORIENTED FOLLOWS COMMANDS AND MAE'S WELL. NO C/O'S OF BLURRED OR DOUBLE VISION THIS SHIFT.\n\nRESP; LUNGS COARSE C+R WITHOUT DIFFICULTY. 02 SAT'S AND RR WNL ON 2L N/C.\n\nCARDIOVAS; REMAINS ON VASOPRESSION GTT AT 0.03 SBP AND MAP WNL OVER NOC. CI>2.00. SR WITH RARE PVC AND OCCAS. PAC PT DID HAVE BRIEF SELF LIMITING BURST OF AFIB WITH PVC'S TX WITH MAGNISIUM SULFATE 2 GMS. DR AND LOOKED AT TELEMETRY STRIP. POTASSIUM AND CA REPLACED PER ORDERS. BILATERAL GROINS POSITIVE FOR LG HEMATOMA'S BUT NO FURTHER BLDING NOTED FROM THE LT. RT. GROIN VERY ECCYMOTIC ALONG WITH RT ARM\n\nGI; BS HYPOACTIVE. NO BM THIS SHIFT. TAKING AND TOLERATING PO'S WITH NO C/O NAUSEA\n\nGU; URINE OP WNL\n\nCOMFORT; MED WITH 4MG IVP MS04 X2 ALONG WITH TORADAL 15MG PER ORDERS WITH GOOD AFFECT.\n\nENDO; INITALLY ON INSULIN GTT BUT OFF FOR BLD SUGAR IN THE 80'S. THIS AM TX WITH SS FOR BLD SUGAR OF 133.\n\nPLAN; CONT TO MONITOR AND ASSESS. CONT BLD SUGARS AND WEAN SLOW VASOPRESSION WEAN TODAY.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-07-07 00:00:00.000", "description": "Report", "row_id": 1575566, "text": "NPN:\n\nNeuro: Sedated on propofol 30 overnight. Awakened in am-follows commands and MAE. Pt became very agitated-propofol restarted.\nCV: 90 AV paced via edicardial wires, Cont on vasopressin .08-decreased to .06 this am, CI-1.9-2.2, MVO2-62-52-59 this am. Neo .5-1.5. Pt remains labile. Transfused with 1u PRBC's for hct 25.5. K repleted. IABP 1:1 with good augmentation. Pedal pulses by doppler- feet cool.\nResp: Intubated- weaned to 40% O2, IMV 14,PS 5, PEEP 5. TV decreased to 800. Sats > 96%. Suctioned for sm amts white secretions. MT/CT to sxn with no airleak. Pleuravac changed r/t spillage.\nGU: Foley to gd with good uo>30cc/hr. Cr stable at 1.3.\nGI: Abd obese, soft, NT, ND, OGT to LCS- draining sm amts clear dng.\nEndo: On insulin gtt per CTS protocol. See carevue.\nIncisions: Sternum and ct/mt with DSD- D/i. R leg with ace wrap and JP intact.\nComfort: Medicated with 4 mg MSO4 q 2-3 hrs.\nActivity: Pt turned side to side with max assist .\nA: Marginal CI on vaso and neo withh IABP support..cont labile.\nP: Attempt to wean and extubated..but very agitated with awakening, Cont IABP-monitor pulses, Conts labile- wean meds as tol-may need more PRBC's.\n" }, { "category": "Nursing/other", "chartdate": "2186-07-07 00:00:00.000", "description": "Report", "row_id": 1575567, "text": "Neuro: alert and oriented - moves all extremeties, c/o blurred vision and double vision - Dr aware.\n\nCV: orginal paced - pacer set to back up, intrinsic rate 70-80 nsr with hemodynamics stable, pulses with doppler, able to wean neo and vasopressin, IABP weaned to 1:2 - tolerating well\n\nResp: lungs clear, extubated after improved ABG, post extubation gas good, is 250-750, able to take good deep breaths but unable to cough - clears throat. on cool mist 50% with sats 100%\n\nGI reglan given x2 bowel sounds now present tolerating clear liquids, passing flatus\n\nGU foley to gravity - lasix 20mg iv x2 with good diuresis\n\npain - multiple doses of morphine - tried iv dilaudid with better response - started on po dilaudid (percocet tried and he states he is not getting relief )\n\nFamily wife and 2 daughters in to visit, dr spoke with wife this pm.\n\nplan cont vasopressin at 0.04, titrate neo as needed, redose with lasix when urine output decreased, cont with pulmonary exercises, cont with IABP 1:2 goal to remove in am,\n" }, { "category": "Nursing/other", "chartdate": "2186-07-08 00:00:00.000", "description": "Report", "row_id": 1575568, "text": "Neuro: pt alert oriented, atimes seems to be having some slight hallucinations.\nResp: o2 sats 98% on 4l np. chest tubes patent draining small amounts of serous sangunious drainage.\nC/V: vss pt remains on vasopressin 0.4u/min, neo weaned off. Good hemodynamics.IABP on 1:2 overnight plan to d/c later this am. Good pulses by doppler.\nGI: tolerating liquids well npo this am for possible balloon removal.\nEndo: pt on insulin drip at 7u/hr most of night down to 4u this am.\nGU: urine output adequate 40cc/hr\nSkin: Dsg d&i no drainage noted.\nPain: pt c/o alot of chest incisional pain intermittently through night. States when ever he is awake he is having pain. Given Dilaudid 4mg po every 4hours and several doses of morphine 2mg iv. pt very anxious given ativan 1mg x2 with good effect Slept well for 3 1/2hours then awake and stated he has slept all night.\nPlan: D/C IABP, ?chest tubes wean vasopressin.\n" }, { "category": "Echo", "chartdate": "2186-07-13 00:00:00.000", "description": "Report", "row_id": 68535, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P Myocardial infarction.\nHeight: (in) 68\nWeight (lb): 288\nBSA (m2): 2.39 m2\nBP (mm Hg): 144/82\nStatus: Inpatient\nDate/Time: at 14:59\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. LV systolic function appears depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: There is borderline pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. LV systolic function\nappears depressed. Views were technically suboptimal for assessment of wall\nmotion. The septum appears severely hypokinetic/akinetic and the\ninferior/inferolateral wall appears hypokinetic akinetic; estimated ejection\nfraction ?30%. Right ventricular chamber size is normal; free wall motion may\nbe depressed but is not fully visualized. The interventricular septum appears\nflattened suggestive of right ventricular pressure/volume overload with phasic\nshifting. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2186-07-15 00:00:00.000", "description": "Report", "row_id": 149230, "text": "Atrial fibrillation\nPremature ventricular contractions or aberrant ventricular conduction\nOld inferior infarct\nLateral T wave changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince previous tracing of : ventricular premature complexes are new\n\n" }, { "category": "ECG", "chartdate": "2186-07-12 00:00:00.000", "description": "Report", "row_id": 149326, "text": "Sinus rhythm\nPremature atrial contractions\nOld inferior infarct\nLateral T wave changes are nonspecific\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2186-07-08 00:00:00.000", "description": "Report", "row_id": 149327, "text": "Sinus rhythm. Poor R wave progression. Old inferior myocardial infarction.\nMinor lateral ST segment elevation - repeat tracing if myocardial injury is\nsuspected. Since the previous tracing of lateral ST segment elevation\nis new.\n\n" }, { "category": "ECG", "chartdate": "2186-07-06 00:00:00.000", "description": "Report", "row_id": 149328, "text": "Sinus rhythm\nPoor R wave progression\nIntraventricular conduction defect\nOld inferior infarct\nLateral T wave changes are nonspecific\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2186-07-05 00:00:00.000", "description": "Report", "row_id": 149329, "text": "Sinus rhythm\nPoor R wave progression\nMarked left axis deviation\nOld inferior infarct\nLateral ST-T changes are nonspecific\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2186-07-05 00:00:00.000", "description": "Report", "row_id": 149330, "text": "Sinus rhythm\nMarked left axis deviation\nOld inferior infarct\nPoor R wave progression\nLateral ST-T changes are nonspecific\nBorderline intraventricular conduction delay\n\n" }, { "category": "ECG", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 149331, "text": "Sinus rhythm\nMarked left axis deviation\nOld inferior infarct\nPoor R wave progression\nBorderline intraventricular conduction delay\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 149332, "text": "Sinus rhythm\nOld inferior infarct\nLateral ST-T changes are nonspecific\nPoor R wave progression - possible old anteroseptal myocardial infarction\nIntraventricular conduction delay\nSince previous tracing, rhythm is sinus\n\n" }, { "category": "ECG", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 149333, "text": "Wide complex tachycardia\nIndeterminate frontal QRS axis\nIntraventricular conduction defect\nProbable acute inferior infarct\nMarked ant/septal STj depression is probably reciprocal to inferior infarct\nSince previous tracing of : rate and rhythm changes\n\n" }, { "category": "ECG", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 149334, "text": "Sinus rhythm\nmultifocal PVCs\nMarked left axis deviation\nIntraventricular conduction defect\nOld inferior infarct\nConsider old septal infarct\nSince previous tracing of : no significant change\n\n" }, { "category": "ECG", "chartdate": "2186-07-04 00:00:00.000", "description": "Report", "row_id": 149335, "text": "Sinus rhythm\nBorderline first degree A-V block, possible old anteroseptal myocardial infarct\nOld inferior infarct\nLow QRS voltages in limb leads\nNo previous tracing\n\n" } ]

[ { "category": "Echo", "chartdate": "2131-07-27 00:00:00.000", "description": "Report", "row_id": 95614, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Hypertension. Mitral valve disease. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 145\nBSA (m2): 1.69 m2\nBP (mm Hg): 100/60\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 10:17\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Moderate (2+) MR. [Due to acoustic shadowing, the severity\nof MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with inferior, inferolateral and basal inferoseptal hypokinesis.\nThe remaining segments contract normally (LVEF = 40-45%). Right ventricular\nchamber size and free wall motion are normal. The diameters of aorta at the\nsinus, ascending and arch levels are normal. The aortic valve leaflets (?#)\nare severely thickened/deformed. There is critical aortic valve stenosis\n(valve area 0.7 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The pulmonary artery systolic pressure could\nnot be determined. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Severe calcific aortic stenosis. Mild regional left ventricular\nsystolic dysfunction, c/w CAD. Moderate mitral regurgitation.\n\nCompared with the report of the prior study (images unavailable for review) of\n, regional LV systolic dysfunction appears new. Aortic stenosis has\nsignificantly progressed. The other findings appear similar.\n\nPreliminary findings discussed with Dr. at 1115 hours on the day of the\nstudy.\n\n\n" }, { "category": "Physician ", "chartdate": "2131-07-27 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 479098, "text": "DIVISION OF CARDIOLOGY CCU COMPREHENSIVE ADMISSION NOTE\n .\n .\n .\n OUTPATIENT CARDIOLOGIST: None\n .\n PCP: , MD\n .\n .\n REASON FOR CCU ADMISSION: AF with RVR\n HPI: 85F with severe AS ( 0.7cm^2, Peak Velocity 4.6 m/sec, Peak\n Gradient, 83 mm Hg),(EF 40-45%), moderate MR, LAD (Diffuse\n Irregularities without stenosus), LCx (OM1 50-60%, OM2 70%), RCA total\n occlusion, thats presenting to the CCU following cardiac\n catheterization.\n .\n The pt reported that she has had increased DOE over past month that and\n thus presented with dyspenea at rest on . One month ago the pt\n reported the ability to climb up to 2 flights of stairs without DOE. At\n 4am on the pt reported PND and the following morning presented to\n her PCP where she was noted to have crackles on exam and LE edema. The\n pt was subsequently sent to the ED.\n .\n While in the ED VS 98 108 126/75 18 100%@3L. EKG showed \n depression V4-V6. CXR noted b/l pleural effusion and pulmonary edema,\n calcified aorta (at the knob).The patient was given Lisinopril 20mg x1,\n Albuterol x1, Lasix 20mg IV x1, with reported improvement of symptoms\n of shortness of breath. She was admitted to service.\n .\n While on the service the pt was ruled out for MI and underwent\n repeat TTE which showed a decreased EF of 40-45% () from 55%\n () to now with severe AS. She was subseqeuntly referred to Cardiac\n Catheterization that revealed 2 vessel disease. They were unable to\n cross the AV. During the right heart catheterization the pt developed\n AF with RVR to the 150s. The pt was given Metoprolol 5mg x3 and\n Amiodarone 150mg IV. The pt remained in AF and was subsequrntly\n cardioverted back into NSR without complication. During the procedure\n the cath team noted thrombus while exchanging catheters through the\n arterial puncture site. Following the procedure the pt reported\n increase nausea while in the PACU but denies CP. Sheath pull was\n without complication.\n .\n Upon arrival to the floor the patients nausea had resolved. Denied\n chest pain, lightheadedness, back pain, leg pain or parasthesias.\n .\n Upon further review of symptoms the pt denies recent fevers, chills, +\n increased congestion and cough over the past 2 weeks. Denies CP,\n palpitations, n/v, diaphoresis. Denied prior PND. Uses 2 pillows per\n night to cough. The patient denies prior syncopal episodes.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n PAST MEDICAL HISTORY:\n 1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG:\n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD:\n 3. OTHER PAST MEDICAL HISTORY:\n s/p Fall in with left humerus and left superior ramus\n fracture\n .\n HOME MEDICATIONS:\n Lisinopril 20mg daily\n Simvastatin 20mg daily\n .\n ALLERGIES: NKDA\n .\n SOCIAL HISTORY\n -Tobacco history: 20 ppy, quit 11 years ago.\n -ETOH:\n -Illicit drugs:\n .\n .\n FAMILY HISTORY:\n Maternal uncle had MI in his 50s. Otherwise, no family history of early\n MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise\n non-contributory.\n .\n .\n PHYSICAL EXAMINATION:\n VS: T=98.7 BP= 106/64 HR 102 -> 97 RR 32 -> 24 98% 2L NC\n GENERAL: NAD. Elderly caucasian female. Oriented x3. Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 7 cm.\n CARDIAC: Tachycardic. mid-systolic ejection radiating to the\n carotids. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Clear anteriorly\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Trace bilateral bruits. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n .\n LABS/STUDIES\n EKG: NSR, Rate 92, Axis WNL, Biphasic P wave in V1, LVH, 0.5mm STD in\n V5-V6.\n .\n TTE: () The left atrium is moderately dilated. Left ventricular\n wall thicknesses and cavity size are normal. There is mild regional\n left ventricular systolic dysfunction with inferior, inferolateral and\n basal inferoseptal hypokinesis. The remaining segments contract\n normally (LVEF = 40-45%). Right ventricular chamber size and free wall\n motion are normal. The diameters of aorta at the sinus, ascending and\n arch levels are normal. The aortic valve leaflets (?#) are severely\n thickened/deformed. There is critical aortic valve stenosis (valve area\n 0.7 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve\n leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\n seen. [Due to acoustic shadowing, the severity of mitral regurgitation\n may be significantly UNDERestimated.] The pulmonary artery systolic\n pressure could not be determined. There is a trivial/physiologic\n pericardial effusion.\n IMPRESSION: Severe calcific aortic stenosis. Mild regional left\n ventricular systolic dysfunction, c/w CAD. Moderate mitral\n regurgitation.\n .\n CARDIAC CATH: ()\n LMCA: No significant stenosis\n LAD: Diffuse irregularities without stenosis\n LCx: OM1 50-60%, OM2 70% - Poor Target\n RCA: TO prox with R>R and L>R collaterals filing faintly; appears to be\n a diffuse distal disease.\n IMPRESSION:\n 2 Vessel CAD: Probably not good targets for CABG\n Moderate pulmonary HTN\n .\n LABORATORY DATA:\n See below.\n .\n .\n ASSESSMENT AND PLAN\n 85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization.\n .\n # RHYTHM: Pt with no known hx of AF and first episode during right\n heart cath this afternoon. Pt now back in NSR following cardioversion\n during cardiac cath. Etiology likely mechanical given correlation with\n procedure. Now resolved.\n - Cont to monitor on Tele\n - Holding off current antiarrhythmic therapy\n .\n # VALCULAR DISEASE: Pt with severe AF as evident by ( 0.7cm^2, Peak\n Velocity 4.6 m/sec, Peak Gradient, 83 mm Hg). Pt potentially to go for\n AVR\n - f/u CT Surgery Recs\n .\n # CORONARIES: 2 Vessel disease as above. Has ROMI. No signs of bleeding\n from groin site.\n - Cont ASA, Statin, B-Blocker\n - Post-Cath check\n - Repeat Hct at 9pm\n .\n # PUMP: SBP well controlled. Pt with dyspnea on arrival that improved\n with 20IV Lasix. EF of 45%. The pt had presented with exacerbation of\n systolic CHF now with resolved pulmonary edema, b/l leg edema.\n - Cont Lisinopril (now 10mg PO Daily)\n - Metoprolol 12.5mg PO BID\n - follow fluid status\n .\n # Nausea: Resolved prior to coming to the CCU\n - If continues to be , consider CT scan of brain.\n .\n # Hyperlipidemia\n - Continue outpatient Simvastatin\n .\n FEN: KVO/Replete PRN/Cardiac Diet\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with Heparin SC\n -Pain management with Tylenol PRN\n -Bowel regimen with Senna PRN, Colase\n Full Code\n DISPO: CCU for now, potential transfer back to service when\n stable.\n" }, { "category": "Nursing", "chartdate": "2131-07-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 479084, "text": "85 yr old pt with hx of Hyperlipidemia HTN, CAD, echo suggestive of\n previous mi. has month hx of increasing SOB to point of at rest.\n Came to ew and received lasix in ew with much relief. BNP >8000\n pulm edema, st depression with trop .06 at midnight and .04 at5 0600.\n went for cardiac cath today and had complications of afib.\n Aortic stenosis\n Assessment:\n At cardiac cath dev afib with rate 130-140, nausea and vomiting. Given\n Amioderone 150 mg and lopressor and was carioverted with 200 J to sinus\n rythym 80-90. bp dropped and received total 1150 cc iv to get bp up.\n Sheaths pulled and hemastasis complete 16:25. critical aortic\n stenosis, see caht report.\n Action:\n Transferred to ccu for monitoring rt groin site and doppler pulses\n checked q 15 min. taking po fluids,\n Response:\n Hr nsr 80-90, resp 22-33 cl ls. A&O x3. pos bs. Equal strength in\n extremities. Pulses in rt pedel are weaker than lt and rt foot is\n slightly cooler than lt. no bleeding or swelling noted at rt groin\n cath site.\n Plan:\n Bed rest flat to 15 degrees until 22:00. may take po . cont q1hr\n groin and pulse checks until 22:00 and then q 4hr. crti at 21:00.\n iv fluid at 75 cc/hr . monitor and eval for chf s/s. emotional support\n with discussions of poss . Pt wants to have md discuss with\n daughter needs and will confer with family. Pt is initially\n against \n" }, { "category": "Physician ", "chartdate": "2131-07-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479186, "text": "Chief Complaint:\n 24 Hour Events:\n No events overnight. Pt remained in NSR with occasional PACs\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Tachycardia\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 97 (92 - 105) bpm\n BP: 93/55(65) {93/49(32) - 122/70(78)} mmHg\n RR: 28 (20 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,940 mL\n 10 mL\n PO:\n 300 mL\n TF:\n IVF:\n 490 mL\n 10 mL\n Blood products:\n Total out:\n 510 mL\n 200 mL\n Urine:\n 130 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,430 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (Murmur: Systolic), Mid-peaking ejection murmur\n Heard at RUSB, Holosystolic SEM heard at left 5th intercostal\n space with radiation to axilla\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 28.0 %\n [image002.jpg]\n 09:18 PM\n Hct\n 28.0\n Assessment and Plan\n AORTIC STENOSIS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2131-07-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 479187, "text": "85 yr old pt with hx of Hyperlipidemia HTN, CAD, echo suggestive of\n previous mi. has month hx of increasing SOB to point of at rest.\n Came to ew and received lasix in ew with much relief. BNP >8000\n pulm edema, st depression with trop .06 at midnight and .04 at5 0600.\n went for cardiac cath today and had complications of afib.\n Aortic stenosis\n Assessment:\n s/p cardiac cath, right groin c&d, dopplerable pedal pulses. Denies\n c/o chest pain. Cont on o2 2l via nc. Crackles in upper airways,\n diminished at bases. Becomes sob with minimal exertion, ie getting to\n commode, turning in bed. HR 93-100 SR with occ pac\n Action:\n Seen by CT surgery for eval for valve replacement.\n Response:\n Pt. wishing to discuss possible surgery with family and surgical team.\n Plan:\n Cont to monitor labs, urine output, limit acitivity to small amts at a\n time .\n" }, { "category": "Physician ", "chartdate": "2131-07-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479190, "text": "Chief Complaint:\n 24 Hour Events:\n No events overnight. Pt remained in NSR with occasional PACs\n Post-Cath Check WNL\n Repeat Hct 28 from 30\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Tachycardia\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 97 (92 - 105) bpm\n BP: 93/55(65) {93/49(32) - 122/70(78)} mmHg\n RR: 28 (20 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,940 mL\n 10 mL\n PO:\n 300 mL\n TF:\n IVF:\n 490 mL\n 10 mL\n Blood products:\n Total out:\n 510 mL\n 200 mL\n Urine:\n 130 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,430 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (Murmur: Systolic), Mid-peaking ejection murmur\n Heard at RUSB, Holosystolic SEM heard at left 5th intercostal\n space with radiation to axilla\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 28.0 %\n [image002.jpg]\n 09:18 PM\n Hct\n 28.0\n Assessment and Plan\n 85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n .\n # RHYTHM: Pt remained in NSR overnight with PACs.\n - Cont to monitor on Tele\n - Holding off current antiarrhythmic therapy\n .\n # VALCULAR DISEASE: Severe AF as evident by ( 0.7cm^2, Peak Velocity\n 4.6 m/sec, Peak Gradient, 83 mm Hg). Pt potentially to go for AVR\n - f/u CT Surgery Recs\n .\n # CORONARIES: Groin check WNL without signs of hematoma, bruit. Hct\n slightly lower at 28 from 30.\n - Cont ASA, Statin, B-Blocker\n - Post-Cath check\n - Repeat Hct at 9pm\n .\n # PUMP: SBP well controlled. EF of 45%.\n - Cont Lisinopril (now 10mg PO Daily)\n - Metoprolol 12.5mg PO BID\n - follow fluid status\n .\n # Hyperlipidemia\n - Continue Simvastatin\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 20 Gauge - 05:37 PM\n Prophylaxis:\n DVT: HSQ\n Communication: Comments:\n Code status: Full code\n Disposition: CCU callout to 3 today\n" }, { "category": "Physician ", "chartdate": "2131-07-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479232, "text": "Chief Complaint:\n 24 Hour Events:\n No events overnight. Pt remained in NSR with occasional PACs\n Post-Cath Check WNL\n Repeat Hct 28 from 30\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Tachycardia\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 97 (92 - 105) bpm\n BP: 93/55(65) {93/49(32) - 122/70(78)} mmHg\n RR: 28 (20 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,940 mL\n 10 mL\n PO:\n 300 mL\n TF:\n IVF:\n 490 mL\n 10 mL\n Blood products:\n Total out:\n 510 mL\n 200 mL\n Urine:\n 130 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,430 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (Murmur: Systolic), Mid-peaking ejection murmur\n Heard at RUSB, Holosystolic SEM heard at left 5th intercostal\n space with radiation to axilla\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 28.0 %\n [image002.jpg]\n 09:18 PM\n Hct\n 28.0\n Assessment and Plan\n 85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n .\n # RHYTHM: Pt remained in NSR overnight with PACs.\n - Cont to monitor on Tele\n - Holding off current antiarrhythmic therapy\n .\n # VALCULAR DISEASE: Severe AF as evident by ( 0.7cm^2, Peak Velocity\n 4.6 m/sec, Peak Gradient, 83 mm Hg). Pt potentially to go for AVR\n - f/u CT Surgery Recs\n .\n # CORONARIES: Groin check WNL without signs of hematoma, bruit. Hct\n slightly lower at 28 from 30.\n - Cont ASA, Statin, B-Blocker\n - Post-Cath check wnl\n - Repeat Hct at 9pm slightly decreased from 30 to 28\n .\n # PUMP: SBP well controlled. EF of 45%.\n - Cont Lisinopril (now 10mg PO Daily)\n - Metoprolol 12.5mg PO BID\n - follow fluid status\n .\n # Hyperlipidemia\n - Continue Simvastatin\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 20 Gauge - 05:37 PM\n Prophylaxis:\n DVT: HSQ\n Communication: Comments:\n Code status: Full code\n Disposition: CCU callout to 3 today\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). ccu team from .\n I would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 60 minutes.\n ------ Protected Section Addendum Entered By: ,MD\n on: 10:13 ------\n" }, { "category": "Nursing", "chartdate": "2131-07-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 479243, "text": "85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n Aortic stenosis\n Assessment:\n Remains in NSR with HR\ns 90-110\ns, BP\ns 98/60-110\ns/60, with no CP.\n Angio-site D&I, with Doppler pulses bilat. Does become DOE, with\n activity, on 2L\ns NP with O2 sats 95-99%. L/S crackles @ bases. RR\n 24-30 with activity. involved concerning possibility of valve\n replacement, due to AS.\n Action:\n PO Lopressor held, due to low BP. OOB to chair slowly.\n Response:\n DOE, but did not desat.\n Plan:\n Monitor VS\ns , assess response to activity, transfer to floor whe bed\n is available.\n" }, { "category": "Nursing", "chartdate": "2131-07-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 479237, "text": "85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n Aortic stenosis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-07-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 479230, "text": "Chief Complaint:\n 24 Hour Events:\n No events overnight. Pt remained in NSR with occasional PACs\n Post-Cath Check WNL\n Repeat Hct 28 from 30\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Tachycardia\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.9\nC (98.4\n HR: 97 (92 - 105) bpm\n BP: 93/55(65) {93/49(32) - 122/70(78)} mmHg\n RR: 28 (20 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 1,940 mL\n 10 mL\n PO:\n 300 mL\n TF:\n IVF:\n 490 mL\n 10 mL\n Blood products:\n Total out:\n 510 mL\n 200 mL\n Urine:\n 130 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,430 mL\n -190 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (Murmur: Systolic), Mid-peaking ejection murmur\n Heard at RUSB, Holosystolic SEM heard at left 5th intercostal\n space with radiation to axilla\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 28.0 %\n [image002.jpg]\n 09:18 PM\n Hct\n 28.0\n Assessment and Plan\n 85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n .\n # RHYTHM: Pt remained in NSR overnight with PACs.\n - Cont to monitor on Tele\n - Holding off current antiarrhythmic therapy\n .\n # VALCULAR DISEASE: Severe AF as evident by ( 0.7cm^2, Peak Velocity\n 4.6 m/sec, Peak Gradient, 83 mm Hg). Pt potentially to go for AVR\n - f/u CT Surgery Recs\n .\n # CORONARIES: Groin check WNL without signs of hematoma, bruit. Hct\n slightly lower at 28 from 30.\n - Cont ASA, Statin, B-Blocker\n - Post-Cath check wnl\n - Repeat Hct at 9pm slightly decreased from 30 to 28\n .\n # PUMP: SBP well controlled. EF of 45%.\n - Cont Lisinopril (now 10mg PO Daily)\n - Metoprolol 12.5mg PO BID\n - follow fluid status\n .\n # Hyperlipidemia\n - Continue Simvastatin\n ICU Care\n Nutrition: Cardiac\n Glycemic Control:\n Lines:\n 20 Gauge - 05:37 PM\n Prophylaxis:\n DVT: HSQ\n Communication: Comments:\n Code status: Full code\n Disposition: CCU callout to 3 today\n" }, { "category": "Nursing", "chartdate": "2131-07-28 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 479272, "text": "85F Severe AS, moderate MR, HTN admitted to CCU following episode of AF\n with RVR during cardiac catherterization, remains in NSR and appearing\n comfortable.\n Aortic stenosis\n Assessment:\n Remains in NSR with HR\ns 90-110\ns, BP\ns 98/60-110\ns/60, with no CP.\n Angio-site D&I, with Doppler pulses bilat. Does become DOE, with\n activity, on 2L\ns NP with O2 sats 95-99%. L/S crackles @ bases. RR\n 24-30 with activity. involved concerning possibility of valve\n replacement, due to AS.\n Action:\n PO Lopressor held, due to low BP. OOB to chair slowly.\n Response:\n DOE, but did not desat.\n Plan:\n Monitor VS\ns , assess response to activity, transfer to floor whe bed\n is available.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n SHORTNESS OF BREATH\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 67.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CAD, CHF, Hypertension\n Additional history: high cholesterol, severe aortic stenosis and CAD\n Surgery / Procedure and date: cardiac cath \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:89\n D:44\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 10 mL\n 24h total out:\n 390 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 05:46 AM\n Potassium:\n 3.4 mEq/L\n 05:46 AM\n Chloride:\n 105 mEq/L\n 05:46 AM\n CO2:\n 25 mEq/L\n 05:46 AM\n BUN:\n 18 mg/dL\n 05:46 AM\n Creatinine:\n 0.8 mg/dL\n 05:46 AM\n Glucose:\n 113 mg/dL\n 05:46 AM\n Hematocrit:\n 26.6 %\n 05:46 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 309\n Date & time of Transfer: 1345\n" }, { "category": "ECG", "chartdate": "2131-07-26 00:00:00.000", "description": "Report", "row_id": 260512, "text": "Artifact is present. Sinus tachycardia. There is a late transition with\ntiny R waves in the anterior leads consistent with possible prior anterior\nmyocardial infarction. Non-specific ST-T wave changes. Compared to the\nprevious tracing ventricular ectopy is no longer present and the other findings\nare new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2131-07-27 00:00:00.000", "description": "Report", "row_id": 260509, "text": "Sinus rhythm. Poor R wave progression. Consider prior anteroseptal myocardial\ninfarction. Lateral ST-T wave changes may be due to myocardial hypertrophy\nand/or myocardial ischema. Clinical correlation is suggested. Compared to\ntracing #1 there is no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-07-27 00:00:00.000", "description": "Report", "row_id": 260510, "text": "Sinus rhythm. Prior septal myocardial infarction, age undetermined. Left\nventricular hypertrophy with secondary repolarization changes. Compared to the\nprevious tracing of the rate has decreased. Other findings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2131-07-26 00:00:00.000", "description": "Report", "row_id": 260511, "text": "Sinus tachycardia. Atrial ectopy. There is a late transition with tiny\nR waves in the anterior leads consistent with possible prior anterior\nmyocardial infarction. Non-specific ST-T wave changes. Compared to the\nprevious tracing atrial ectopy is new.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777646, "text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: improvement in CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 yo in ICU with CHF s/p acute MI.\n REASON FOR THIS EXAMINATION:\n improvement in CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Myocardial infarction and shortness of breath.\n\n ET tube is __ cm above carina. SG catheter is in right main pulmonary artery.\n NG tube is in proximal stomach. No pneumothorax. Heart size is borderline\n to enlarged for technique with persistent ill defined opacity in the right\n lower zone, consistent with consolidation. There is obscuration of the medial\n poortion of the left hemidiaphragm, consistent with atelectasis or\n consolidation in the left lower lobe. In addition, there could be bilateral\n layering pleural effusions in the supine film. There are biapical nodular\n densities and upward retraction of the hila, especially on the left,\n consistent with granulomatous disease as previously demonstrated. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777396, "text": " 6:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusions/p line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with\n REASON FOR THIS EXAMINATION:\n effusions/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Effusions, status post line placement.\n\n Comparison is made to previous films from , 2-1/2 hours earlier.\n\n PORTABLE AP CHEST: An endotracheal tube has been inserted and lies in\n satisfactory position with the tip several cm above the carina. A left\n subclavian approach Swan-Ganz catheter is demonstrated with the tip in the\n main pulmonary artery. A feeding tube is again demonstrated, with the tip\n below the diaphragm, but not visualized on this study. The heart size and\n mediastinal contours are stable in appearance. The aorta is tortuous. There\n is increasing opacity within the right lung parenchyma consistent with\n aspiration or pneumonia. There is fibronodular thickening within both apices,\n which is likely secondary to a prior granulomatous disease. Due to the\n somewhat nodular appearance, comparison with prior films is recommended to\n document stability. Mild left ventricular failure is present.\n\n IMPRESSION:\n\n 1. Mild left ventricular failure.\n 2. Aspiration or pneumonia within the right lung.\n 3. Bilateral fibronodular apical thickening, likely secondary to prior\n granulomatous disease, but comparison with prior studies is recommended to\n document stability.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-03 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 777490, "text": " 11:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: FEVER, CHOLECYSTITIS, ABD PAIN - ? ETIOLOGY\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with abdominal pain and septic parameters, now in ARF,\n enlarged GB from CT scan obtained at outside hospital\n REASON FOR THIS EXAMINATION:\n please perform CT ABD/PELVIS and place percutaneous cholecystostomy tube,\n drainage for C+S\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, septic parameters, now with acute renal failure\n and enlarged gallbladder.\n\n TECHNIQUE: Noncontrast helically acquired contiguous axial images were\n obtained from the lung bases to the pubic symphysis.\n\n CONTRAST: Contrast was withheld due to elevated creatinine measuring 3.6.\n\n CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There are bibasilar pleural\n effusions. There are bilateral posterior lower lobe consolidations. The\n evaluation of the intra-abdominal solid organs is somewhat limited due to the\n lack of intravenous contrast. There are multiple low density lesions\n throughout the liver which are unable to be characterized on this noncontrast\n examination but likely represent simple liver cysts. At the fundus of the\n gallbladder there is a rim of hyperdensity. There is hyperdense material\n layering at the neck of the gallbladder. There is no pericholecystic fluid.\n At the inferior portion of the right lobe of the liver anteriorly there is a\n small area of hyperdensity. Given the recent percutaneous gallbladder\n drainage, this may represent a small area of hemorrhage. The spleen appears\n slightly enlarged. The pancreas appears unremarkable. The adrenal glands are\n unremarkable. In the perirenal fat posterior to the left kidney there is\n evidence of stranding. The left kidney appears to be displaced somewhat\n anteriorly. The contours of the kidneys are unremarkable. There is no\n evidence of hydronephrosis or nephrolithiasis. There are multiple small lymph\n nodes throughout the retroperitoneum. None of these meet CT criteria for\n pathologic enlargement. The abdominal bowel loops are unremarkable. There is\n no free fluid within the abdomen. There is no free air.\n\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: There is a Foley catheter\n within the urinary bladder. The rectum and sigmoid colon are collapsed. Note\n is made of multiple sigmoid diverticula without evidence of diverticulitis.\n There is a small amount of low density fluid within the right paracolic gutter\n inferiorly.\n\n Note is made of a right femoral compression screw. The osseous structures are\n otherwise unremarkable. Surgical clips are noted along the right anterior\n abdominal wall, inferiorly.\n\n (Over)\n\n 11:50 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: FEVER, CHOLECYSTITIS, ABD PAIN - ? ETIOLOGY\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. There is high density material layering at the gallbladder neck. There is\n a small rim of high density at the gallbladder fundus. Note is also made of a\n small area of high density within the right lobe of the liver adjacent to the\n gallbladder fossa. The conglomeration of these findings may be due to\n hemorrhage given the recent percutaneous gallbladder drainage.\n 2. There are multiple small areas of low density throughout the liver which\n are unable to be characterized on this noncontrast examination and may\n represent simple liver cysts. If clinically indicated and U/S examination can\n be performed for further evaluation.\n 3. There are small bilateral pleural effusions and bibasilar consolidations.\n 4. The left kidney appears displaced anteriorly and within the left perirenal\n fat there is evidence of stranding. This may be due to perinephric changes\n from renal failure. However, an acute infectious or inflammatory cause cannot\n be excluded. There is no hydronephrosis.\n\n 5. There is a small amount of low density fluid within the right hemipelvis\n of uncertain etiology.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777492, "text": " 1:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute desaturation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with\n\n REASON FOR THIS EXAMINATION:\n acute desaturation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute desaturation.\n\n Comparison is made to the prior study from .\n\n SUPINE AP CHEST RADIOGRAPH: Again demonstrated are ETT and Swan-Ganz catheter.\n The Swan-Ganz catheter has been advanced, the tip lies in the right pulmonary\n artery. A feeding tube is present with the tip below the diaphragm, but not\n included on this study. There is increased opacity of the left lung, with\n stable opacity of the right lung. There is increased cardiomegaly. These\n findings are consistent with increasing left ventricular failure with\n superimposed pneumonia or aspiration. The osseous structures are stable in\n appearance.\n\n IMPRESSION: Increasing left ventricular failure with superimposed pneumonia or\n aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-03 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 777476, "text": " 5:32 PM\n US ABD LIMIT, SINGLE ORGAN; GUIDANCE PERC TRANS BIL DRAINAGE US Clip # \n Reason: R/O INFECTED BILE\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Septic patient, distended gallbladder on recent CT scan.\n Please rule out infected bile.\n\n Ultrasound guided gallbladder drainage:\n\n Using sterile technique, ultrasound guidance, and an 18-gauge needle, a single\n puncture gallbladder drain was performed puncturing the gallbladder through\n the liver. Approximately 150 cc of thin, simple-appearing bile was aspirated.\n Son assessment post-drainage demonstrates marked decrease in size of\n the gallbladder with no evidence of pericholecystic fluid.\n\n No complications were encountered. Dr. , attending radiologist, was\n present for the entire procedure. 1% Xylocaine was used as local analgesia.\n The procedure was performed portably in the ICU.\n\n A portion of the sample was given to the referring clinician for submission to\n the lab for analysis.\n\n IMPRESSION: Successful single-puncture aspiration of the gallbladder under\n ultrasound guidance.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777593, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for volume overload/CHF; intubated pt with recent MI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n\n REASON FOR THIS EXAMINATION:\n Assess for volume overload/CHF; intubated pt with recent MI and renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated patient with recent MI and renal failure.\n\n AP, SUPINE, PORTABLE CHEST:\n\n Exam was compared to a study of at 1:30 am. ET tube, Swan-Ganz catheter\n adn nasogastric tube are again noted in place. ET tube remains in position\n approximately 3 to 4 cm above the . Swan-Ganz catheter has been pulled\n back slightly and appears to be in the main pulmonary artery. Nasogastric tube\n tip is seen to be in the region of the upper stomach. There is haziness to\n both lower lung fields and loss of definition of the left hemidiaphragm. On\n this supine study, there may be a small pleural effusion contributing to this\n density. No definite air bronchogramming is seen.\n\n Pulmonary vascularity is upper limits of normal but unchanged from prior exam.\n No edema is seen. Lower lung haziness persists, unchanged\n from a study one day earlier, although air bronchogramming is not\n appreciated.\n\n IMPRESSION: Allowing for slightly increased lung expansion there is no\n significant change from study one day earlier of the lungs. Findings suggest\n a possibility of a small bilateral pleural effusions. Superimposed\n infiltrates cannot be exclused at the bases. Swan-Ganz catheter has been\n pulled back somewhat and is now in the main pulmonary outflow tract.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-03 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 777389, "text": " 3:38 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: assess for free air (get left lateral decub as well)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with abdominal pain\n REASON FOR THIS EXAMINATION:\n assess for free air (get left lateral decub as well)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for free air.\n\n AP SUPINE ABDOMINAL RADIOGRAPH:Normal bowel gas pattern. A small amount of\n dense contrast material is seen overlying the sacrum. Note is made of a right\n femoral compression screw. An NG tube is present. The osseous structures are\n unremarkable.\n\n IMPRESSION: no evidence of obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 777388, "text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for free air, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with sob\n REASON FOR THIS EXAMINATION:\n assess for free air, pna\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Assess for free air or pneumonia in patient with shortness of\n breath.\n\n An NG tube is present with the tip within the stomach. The cardiomediastinal\n contours are normal. The aorta is tortuous. There are no definite pleural\n effusions. Note is made of biapical pleural thickening and patchy upper lobe\n parenchymal opacities, right greater than left. There is consolidation of the\n right lower lobe. The pulmonary vasculature is normal.\n\n IMPRESSION: Bilateral, right greater than left apical densities\n possibly secondary to prior granulomatous disease, but in absence of prior\n films acute versus chronic nature undetermined. There is a right lower lobe\n consolidation. Compare with outside prior films if available. Further\n evaluation by short term follow is recommended to re-evaluate.\n\n\n" }, { "category": "ECG", "chartdate": "2118-01-06 00:00:00.000", "description": "Report", "row_id": 170929, "text": "Sinus rhythm\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of : voltage appears less\n\n" }, { "category": "ECG", "chartdate": "2118-01-03 00:00:00.000", "description": "Report", "row_id": 170930, "text": "Sinus tachycardia\nModest nonspecific ST-T wave changes\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2118-01-03 00:00:00.000", "description": "Report", "row_id": 1283262, "text": "NPN\n81 yr old males admitted awake alert able to follow commands , but unable to tell me where he was.\nCV BP 160-190/90-100 hr 80 nsr, pulse palp, feet cool to touch, pt started on nitro drip to maintain spb<160, pt now on 6.6 mcgs.kg/min\npt had aline and swan placed.\nResp see flow sheet for abg, pt repeat able was poor decreaseing mental status, pt was intubated and place in imv 100/650/14/5,\nLungs decreased breths sounds in bases, noted when pt being intubated pt was suctions for bloody secreations. sats 100 % abg pending\nGI abd firm distended and tender when palp, ngt to lws, passing dark brown secreations.\nGU foly in place pt boluses with lr 500 ccx1 with no u/o second bolus up,\npt oozing fom all line that were placed , pt on heperin drip at 100u hr. nitro 6.6 mcg /kg/min d5w via cordic at kvo. not hx on family althought befor pt was intubated he stated he did have family but was unable to give any more information.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-03 00:00:00.000", "description": "Report", "row_id": 1283263, "text": "Nursing note\nPt alert this am, followed commands, was calm, cooperative, anxious and twitchy at times. Progressively became more restless, as abg's were more acidotic. Is now on iv Cistracurium at .2mcg/kg/hr to keep paralyzed. Had Fentanyl and ativan today for pain and restlessness. PERL 3/br. Equal strength to all extrems. Appeared appropriate and was frequently reoriented and reassured.\nRESP: Orally intubated, #7.5 secure to rt lip at 23cm, bbs scatt rhonchi ul's, crackles to bases, more noted at this time, following freq fluid boluses. O2 sats 95-98%. Vent on simv 20, occais breathes over, high as 29/min. (reason for sedation). Peep 7.5, fi02 .50, . sx'd for lg amnts bloody tan secrt.\nCV: HR SR rare pvc's, sbp 150-180, on iv Ntg at .67mcg/kg/min. Lt scv PA cath secure at 65cm, site oozing blood, was stiched at site by resident. Still oozing. Palp pulses, color pale, rt rad aline, piv to both fa's d/i no s/s infiltration.\nGI/GU: Ngt to lws, dk burgandy d/c this am, more bilious now. Abd is semisoft, tender to touch this am. Fentanyl for pain. BS hypo, npo.\nno stool.\nPt recve 4u ffp, 2l ns, LR 1L. NS cont at 100cc/hr. U/S of gallbladder done, approx 160 cc off, to be sent for c&s. Awaiting CT of abd. Continues on IV Unasyn and Flagyl for abx. Mag repleted today w/ 2gms iv.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-04 00:00:00.000", "description": "Report", "row_id": 1283264, "text": "micu/sicu boarder npn\n patient having u/s guided ttap of gallbladder last eve yielding ~160cc of dk fluid sent for cx and gram stain. transported o/n to ct w/o incident for abd ct for r/o ishemic bowel, prelim results showing distention and more fluid collect of the gb. no other information reported.\nsystems review--\n\nneuro- at begin of shift, pt was just begun on 0.2 mg/kg/hr of cisatrucurium, still breathing above vent. pt was begun on fentanyl gtt, bolused w/ativan, then bolused w/cisat per protocol and re-started at .2 mg/kg/hr. pt was increased after short time to .3mg/kg/hr d/t spontanous efforts, ceasing w/ increase in dose. pt adequately paralysed at present.\n\ncv- swan to l subclavian. #'s this am include sv 82-106, ci 3.56-4.4, wedge 15 svr 5-600 c.o 6.7-8.3. svr decreasing over the night and c.o steadily increasing. (on paralytic)hr mid 70's, nsr w/o ectopy, bp 105-1teens/50's. am lopressor dose held at 4am. ntg gtt off during night as pt began to get hypotensive.\n\nresp- cisat off during night at request of anasthesia/sicu resident. pt began to double trigger vent, rr 10-15 over set rate of 20. abg 7.18/38/68. lasix 40 mg ivp w/ no result. cisat restarted per dr. w/pt immediately back in synch w/vent, sats 97-100%, abg pndg.\ncurrent vent settings are imv500x20, 50% fio2, peep10, ps5.\ngi/gu- pt w/few bs heard. ngt conts to lcs. rusty colored/barocat sm amts out. no bm and no u/o still o/n. pt receiving several liters in bolus' then lasix also yielding no urine.\n\nendo- bs down to 50, insulin gtt off most of night.\n\nheme- hct last eve 23.2, pt has received 3 units of rbc's, hct after 1.5 units in was 28.3. coags this am much improved inr 2.2 pt/ptt 18.3/44.4.\n\nplan to continue ventillitory support/sedatives/paralytics as needed to ventillate. f/u w/ am cxr. ?? reason for profound met acidosis. f/u w/ ct results in am. cont to support.\nsocial- pt's daughter called and updated several x's o/ supportive.\n\nfull code\n" }, { "category": "Nursing/other", "chartdate": "2118-01-04 00:00:00.000", "description": "Report", "row_id": 1283265, "text": "review of system:\n\nNeuro: pt paralytic was D/C'd @ 12 noon, pt remains on fentanyl gtt @ 100 mcg/hr. pt will respond to painful stim with purposful movement but does not follow any simple commands. pt has sudden full body twitches since paralytic was turned off Pt MAE. pt \n\nResp: pt remains on vent SIMV 500/50/20/10/5. pt has since started to take a few spont breaths with TV of 200-250. pt requires q 2-4 hour suctioning for small amount of tan thick secreations. pt sao2 > 95% on current settings.\n\nCV: pt BP has been WNL, pt BP has started to drop a small amount pt to recieve a 500 cc NS bolus. pt BP is currently 104/53. pt has not needed any vasopressors. Pt HCT has remaied stable. PT has a SWAN cath in with the cco monitor. pt CO has slightly dropped with BP see careview for all current #s\n\nGI/GU: pt still has not had any UO py recived 200 mg of lasix. pt has not had any BM.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-05 00:00:00.000", "description": "Report", "row_id": 1283266, "text": "NURSING PROGRESS NOTE:\nPT CONT TO BE INTUB/VENT INITIALLY ON SIMV 500 X 20 50% +10PEEP, O2SAT'S 96-98% WITH SV02 67-71%. LUNG SOUNDS COARSE TO CLEAR WITH CRACKLES AT THE BASES. PT SX FOR MOD AMT'S OF THICK TAN SECRETIONS.\nPT SEDATED ON FENTANYL DRIP AT 100MCQ/HR UNTIL 0400 PT DROPPED BP AND FENTANYL TURNED OFF. ABG AT THIS TIME 7.22 AND PO2 62 AND O2 SAT'S DROPPING TO THE LOW 90'S. VENT MODE CHG'D TO AC WITH AN INC IN FIO2 TO 70% FROM 50%. O2 SAT'S UP TO 98% WITH THIS CHG.\nNEURO: PT CONT ON FENTANYL DRIP ALL NIGHT UNTIL PT BECAME HYPOTENSIVE. DRIP OFF UNTIL BP MORE STABLE. PT IS HAVING MOVEMENTS OF ARMS AND LEGS. DOES NOT MOVE TO COMMAND. PT ABLE TO LIFT ARMS BUT THEN FALL BACK TO THE BED. NOT MOVING LOWER EXTREMETIES VERY MUCH BUT IS ABLE. PT SEEMS TO UNDERSTAND WHAT YOU ARE SAYING TO HIM.\nHAV\nCV: HR IN NSR NO ECTOPY, 80-90. BP STABILE UNTIL 0400 AFTER TURNING PT FOR AM CARE PT'S BP DID NOT COME UP ON IT'S OWN. PT RECEIVING 2 500CC FLUID BOLUS FOR BP THAT DROPPED TO THE UPPER 70'S. FENTANYL DRIP OFF AT THIS TIME TILL BP COMES BACK UP. PT PRESENTLY RESPONDING WELL TO 2ND 500CC BOLUS. HAVE NOT STARTED PRESSORS YET. SEE FLOWSHEET FOR FURTHER HEMODYNAM INFO.\nGI: NGT TO LCS DRAINING SM AMT'S OF BILIOUS MATERIAL. GUAIAC POS.\nPT HAS POS BOWEL SOUNDS. NO STOOL AT THIS TIME.\nGU: PT NOT MAKING ANY URINE DURING THIS SHIFT. FOLEY CATH IS PATENT.\nPT'S ARMS BECOMING VERY EDEMATOUS. OTHERWISE SKIN INTACT.\nPT DOES NOT TOLERATE ANY MOVEMENT WELL. PT RESISTS TURNING AND ATTEMPTS TO PUSH HIMSELF BACK.\nPT SWITCHED TO MICU TEAM. PT HAS STARTED ON VANCO AS WELL AS OTHER\n\n ANTIBX. LOPRESSOR RESTARTED BUT UNABLE TO GIVE AT THIS TIME. HAVE NO HEARD FROM FAMILY OVERNIGHT. PT REMAINS FULL CODE AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-05 00:00:00.000", "description": "Report", "row_id": 1283267, "text": "ADDENDUM:\nPT'S BP RESPONSE TO FLUID BOLUS WAS VERY TEMPORARY, DOBUTAMINE STARTED AND BP DROPPED EVEN FURTHER INTO THE 60'S. DOBUTAMINE D/C'D AND WAS STARTED ON LEVOPHED. PT'S BP RESPONDED IMMEDIATELY ON LOW DOSE. WILL TITRATE TO KEEP MAP GREATER THAN 65. FENTANYL DRIP OFF AT PRESENT AND WILL TURN BACK ON FOR SEDATION AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-06 00:00:00.000", "description": "Report", "row_id": 1283270, "text": "FOCUS: NURSING PROGRESS NOTE.\nREVIEW OF SYSTEMS-\nNEURO- PATIENT IS UNAROUSABLE. DOES NOT RESPOND TO PAINFUL STIMULI. PEARL. SEDATED ON FENTANYL,MSO4 AND ATIVAN DRIPS AS PER FLOW SHEET.\nRESP- INTUBATED ON A/C OF 20,TV 500, PEEP 10 AND FIO2 OF 60%. AT 0700 AFTER SURGIACAL TEAM HAD EXAMED PATIENT AND HE WAS VERY AGGITATED. WITH AGONAL RESP ON THE VENT. HIS SATS DROPPED TO 85%. THEY DID NOT REPOND TO AMBUING OR INCREASING TO 100% FIO2. PEEP EVENTUALLY INCREASED TO 15 AND ABG WAS 7.17/37/223/14. NO VENT CHANGES WERE MADE FOR THIS ABG AS WE FELT WE WERE MOVING TOWARDS COMFORT CARE WITH THIS PATIENT DUE TO HIS MULTISYSTEM FAILURE. HIS SATS AFTER THIS ABG WERE 91-93% . HIS SATS HAVE GONE UP TO 98% SO HIS FIO2 IS BEING WEANED DOWN. HE HAS BEEN SUCTIONED FOR SMALL TO SCANT AMOUNTS OF THICK TAN SPUTUM.\nCARDIAC- SBP INITIALLY UP TO 200 THIS AM AFTER HE WAS EXAMED SO LEVOPHED AND PITRESSIN WERE DC'D. LATER HIS SBP DROPPED TO THE LOW 80'S. PITRESSIN AND LEVOPHED WERE TURNED ON AND TITRATED UP. HE WAS ON A MAX OF 0.076MCGS/KG/MIN OF LEVOPHED AND 0.04U/MIN OF PITRESSIN. THEY WERE LATER WEANED OF WITH SBP OF 120-140'S. SBP NOW IN THE 80'S. DR AWARE. PRESSORS NOT TO BE RESTARTED AS PATIENT IS A DNR WITH THE GOAL OF OUR TREATMENT BEING COMFORT. HR HAS BEEN 80-90'S NSR W/O ECTOPI. CARDIAC #'S AS PER FLOW SHEET. 1 L NS GIVEN THIS AM TO INCREASE FILLING PRESSURES WITH THE HOPE OF INCREASING CO. HE WAS LATER MADE DNR WITH COMFORT OUR PRIMARY GOAL SO NO FURTHER BOLUSES WERE GIVEN. K WAS 5.7 THIS AM WITH A REPEAT OF 6.2. HE WAS TREATED FOR THIS WITH 60GMS OF KAYXELATE .\nGI- ABD REMAINS SOFT DISTENDED WITH HYPOACTIVE BS. ABD TENDER TO PALPATION EARLY IN DAY CAUSING INCREASED BP TO 200 WHEN SURGEONS EXAMED IT. HE IS PRESENTLY ON MSO4 AT 8MG/HR TO KEEP HIM COMFORTABLE. NG TO LWS DRAINGING BROWN DRAINAGE THAT IS GASTRO POS AND PH . LFT'S REMAINS ELEVATED DUE TO SHOCK LIVER.\nGU- UO 2-5CC OF BROWN SLUDGE. FOLEY PATENT. CREAT UP O 5.6 TODAY.\nID- WBC UP TO 23.4 TODAY. TEMP MAX 99.1. CONTINUES ON LEVOFLOXACIN, FLAGYL AND RENAL DOSED VANCO.\nSOCIAL- DAUGHTER CALLED THIS AM AND WAS TO COME IN. CALLED LATER FROM RTE 93 WHERE SHE HAD ALMSOT HAD AN ACCIDENT. SHE WAS VERY UPSET. SHE WAS UPDATED ON THE FACT THAT HER DAD WAS NOT DOING WELL. SHE WAS TOLD THAT DR WANTED TO GET IN TOUCH WITH HER TO TALK ABOUT HOW AGRESSIVE WE WANTED TO BE TO WHICH SHE MADE THE STATEMENT \" I WOULD NOT BEING DOING RIGHT BY MY FATHER IF I KEPT CONTINUING THIS. LATER DR TALKED WITH HER ON THE PHONE. HE WAS MADE A DNR WITH THE PRIMARY GOAL OF KEEPING HIM COMFORTABLE. A MSO4 DRIP WAS STARTED AT THIS TIME AND INCREASED TO 8MG/HR TO KEEP HIM COMFORTALBE. THE DAUGHTER IS ATTENDING HER FIANCES FATHER'S WAKE TODAY.\nDISPO- PATIENT REMAINS IN THE MCIU A DNR WITH THE PRIMARY GOAL OF TREATMENT KEEPING HIM COMFORTALBE.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-07 00:00:00.000", "description": "Report", "row_id": 1283271, "text": "NURSING NOTE: 7P-7A\nNEURO- REMAINS SEDATED ON ATIVAN AT 1MG/H, FENTANYL AT 200MCG/H AND MORPHINE AT 8MG/H. APPEARS COMFORTABLE. NO RESPONSE TO STIMULI. NO SPONTANEOUS MOVEMENTS.\n\nRESP- REMAINS INTUBATED ON A/C 20X500 305 PEEP 15.\n\nCV- HR 90'S SR RARE ECTOPY. SBP REMAINS 60-70.\n\nGI- ABD SOFT DISTENDED, LARGE MUCOID STOOL S/P KAYEXALATE. NPO. NGT TO LCS WITH SMALL AMOUNT OF BROWN-GREEN DRAINAGE.\n\nGU- VERY SCANT AMOUNTS OF BROWN U/O . LESS THAN 30CC FOR SHIFT.\n\nSOCIAL- NO CONTACT WITH DAUGHTER.\n\nDISPO/PLAN- REMAINS IN MICU, DNR, PRIMARY GOAL OF CARE IS COMFORT. ? WITHDRAWAL OF VENTILATOR SUPPORT TODAY. CONTINUE TO SUPPORT DAUGHTER AND KEEP PT COMFORTABLE.\n" }, { "category": "Nursing/other", "chartdate": "2118-01-07 00:00:00.000", "description": "Report", "row_id": 1283272, "text": "FOCUS; EXPIRATION.\nPATIENT CMO. OFF ALL MEDS AND PRESSORS. ON ATIVAN, MSO4 AND FENTANYL FOR COMFORT. EXTUBATED THIS AFTERNOON AND EXPIRED SHORTLY AFTER. HE WAS PRONOUNCED AT 1342 BY DR . A POST IS TO BE DONE. POSTMORTEM CARE DONE. HE IS TO BE TRANSPORTED TO THE MORGUE. THE FAMILY WAS NOTIFIED BY DR .\n" }, { "category": "Nursing/other", "chartdate": "2118-01-05 00:00:00.000", "description": "Report", "row_id": 1283268, "text": "REVIEW OF SYSTEMS:\n\nNEURO: PT GTT WAS TURNED OFF OVER NIGHT DUE TO PTS LOW BP,\nAT 11AM AFTER TEAM ROUNDED ON PT, PT BECAME VERY AGGITATED WITH S/S OF HAVING ALOT OF PAIN, GTT TURNED BACK ON TO HELP CONTROL PTS PAIN. PT IS CURRENTLY SEDATED ON 100MCG/HR OF FENTANYL. PT TOLERATING GTT WELL. PT DOES NOT FOLLW ANY COMMANDS, PT MOVES ALL EXT U>L. PT BECOMES VERY AGGITATED WHEN MOVED/TURNED. PT HAS A VERY WEAK COUGH AND GAG. PT \n\nRESP: PT REMAINS ON VENT, CURRENT VENT SETTING ARE AC/60/500/20/10. PT TOLERATING CURRENT SETTING, SAO2 > 96%. DURING EPISODE OF PT STARTED TO DROP SAT AND REQUIRED AN INCREASE IN FIO2, ABG AFTER INCREASED SHOWED IMPORVED PO2, FIO2 DROPPED TO 60 BASED ON PTS O2%. PT REQUIRES Q 4HOUR SUCTIONING FOR SCANT THICK TAN SECREATIONS. PTS PH STILL ACIDODIC DUE TO A METABOLIC ACIDOSIS HO AWARE.\n\nCV: PT WAS STARTED ON LEVOPHED LAST NIGHT AND REQUIRED ME TO TITRATE GTT UP DUE TO A DROP IN BP, PT ALSO ON A VASSOPRESSIN GTT SET\n@ .04 UNITS/MIN. SINCE VASSOPRESSIN STARTED LEVO GTT HAS BEEN WEAND DOWN TO .03 MCG/KG/MIN CURRENTLY BP IS 107/60 WITH NO ECTOPY NOTED. PT HAD A FEW PVC'S EARLY ON DURING DAY. WILL CONTINUE TO TITRATE PRESSORS AS TOLERATED.\n\nGI/GI: PT REMAINS ANURIC, 6CC OF DARK CLOUDY URINE OUT ALL DAY. PT CREAT UP TO 5.0 HO AWARE. PT HAS STARTED TO HAVE BM TODAY PT HAD 4 MUCIOD STOOLS TODAY, MUSHROOM CATH PLACED TO HELP COLLECT STOOL.\n\nID: PT HAS A LOW GRADE FEVER AND CONTINUES ON LEVO, VANCO, AND FLAGYL.\n\nDISPO: FAMILY AND PT MADE A DNR/DNI\n" }, { "category": "Nursing/other", "chartdate": "2118-01-06 00:00:00.000", "description": "Report", "row_id": 1283269, "text": "NURSING PROGRESS NOTE:\nPT REMAINS /VENTED ON A/C 500X 20 60% AND 10PEEP. PT'S O2SAT'S DOING WELL ON THESE SETTINGS. WILL DESAT SOME WITH AGITATION DUE TO ANY STIMULATION. OC PT WOULD HAVE AGONAL TYPE BREATHING BUT WOULD SETTLE DOWN AFTER A WHILE AND BREATHING WOULD APPEAR LESS LABORED.LUNG SOUNDS COARSE AND WILL CLEAR WIHT SX. VERY DIMINISHED AT THE BASES. CONT TO HAVE METABOLIC ACIDOSIS AND TCO2 WAS 12 LAST EVENING. PT HAS AMT OF ORAL SECRETIONS FROM THE BACK OF THROAT, ?SINUSITIS.\nCV: PT CONT TO REQUIRE PRESSORS AND HAVE BEEN TITRATED UP AND DOWN THROUGHOUT THE NIGHT, CURRENTLY THIS AM ABLE TO TITRATED DOWNWARD SEE FLOWSHEET FOR DATA. HEART RATE SINUS 80'S TO 100 DEPENDING ON RATE OF PRESSORS. SVO2 STOPPED WORKING AFTER GENERATORS WENT DOWN AND THIS RN UNABLE TO RECALIBRATE MACHINE. C.O. CONT TO RANGE BETWEEN 5 AND 6.\nGI: PT NOT PASSING ANY STOOL THIS EVE, MUSHROOM CATHETER REMOVED DUE TO THICKENING CONSISTENCY OF STOOL. NGT TO LCS, DRAINING SM AMT'S OF BILIOUS MATERIAL. HYPOACTIVE BOWEL SOUNDS.\nGU: PT CONT TO BE ANURIC BUT HAS PASSED APPROX 25CC OF DK OLD BLOODY URINE. FOLEY IS PATENT.\nSKIN CONT TO BE INTACT ALTHOUGH VERY EDEMATOUS AND BECOMING COOL AND CLAMMY AT TIMES. DIFFICULT TO PT'S POSITION DUE TO LEVEL OF AGITATION AND RESULTING DESATURATION.\nFAMILY CALLED OVERNIGHT TO GET UPDATE. PT REMAINS DNR/DNI.\n" } ]

[ { "category": "Radiology", "chartdate": "2172-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 860478, "text": " 6:27 PM\n CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: REPEAT FILM PER RADIOLOGIST\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 55-year-old woman with tracheal stenosis, status post\n bronchoscopy. Please assess for pneumothorax, atelectasis.\n\n Portable AP view of the chest dated at 18:25 is compared with the\n same examination done 1.25 hours earlier. The lungs apices are now\n visualized. There is no pneumothorax. Otherwise, there has been no change\n since the prior exam.\n\n" }, { "category": "Radiology", "chartdate": "2172-03-26 00:00:00.000", "description": "CT TRACHEA W&W/O C & RECONS", "row_id": 860320, "text": " 4:33 PM\n CT TRACHEA W&W/O C & RECONS Clip # \n Reason: please assess airway for tracheobronchomalacia\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with tracheal stenosis\n REASON FOR THIS EXAMINATION:\n please assess airway for tracheobronchomalacia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Tracheal stenosis. Evaluate for tracheal bronchomalacia.\n\n No prior scans for comparison.\n\n Helical CT of the trachea was performed according to the CT trachea protocol.\n This involves initial imaging at end inspiration using a standard dose\n technique. Subsequently, a sequence is performed using a low-dose technique,\n during dynamic expiratory phase of respiration to evaluate for malacia. The\n axial CT data was subsequently used to create a series of multiplanar and 3-D\n images, which will be reviewed in conjunction with the axial images.\n\n Per the CT trachea protocol, please note that the scan extends to a few\n centimeters below the carina but does not include the entirety of the thorax.\n\n Assessment of the airways demonstrates the presence of a subglottic stenosis\n extending to the level of the cervicothoracic junction. The maximal narrowing\n of the airway is 5 mm in the coronal dimension and 9 mm in the AP dimension.\n This appears to be due to circumferential wall thickening, which appears\n somewhat nodular. Below this level, the intrathoracic trachea is normal in\n caliber and contour. However, note is made of multiple intraluminal polypoid\n opacities, which are predominantly dependent in position and involved both the\n trachea and the right main stem bronchus as well as the bronchus intermedius.\n Similar opacity is also seen in the left lower lobe bronchus. Some of these\n opacities are associated with areas of linear stranding.\n\n Images obtained during dynamic expiratory phase of respiration demonstrate\n expiratory changes within the trachea and main stem bronchi that are within\n the range of normal.\n\n Multiplanar and 3-D reconstruction images confirm the presence of a focal\n subglottic stenosis and also demonstrate a regular, nodular contours of the\n wall thickening, particularly along the anterior aspect of the airway,\n consistent with a complex stenosis. The craniocaudad extent of the airway\n abnormality is approximately 2 cm.\n\n Soft tissue structures of the imaged portion of the thorax demonstrates no\n significant mediastinal or hilar lymphadenopathy. There is left-sided focal\n pleural thickening adjacent to healed rib fractures. Skeletal structures\n reveal numerous rib fractures in the left hemithorax with associated marked\n chest wall deformity. There are also several right-sided rib fractures as\n well as a healed fracture of the left clavicle.\n (Over)\n\n 4:33 PM\n CT TRACHEA W&W/O C & RECONS Clip # \n Reason: please assess airway for tracheobronchomalacia\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Assessment of the lungs demonstrates nonspecific scarring at the lung apices\n as well as scattered band-like areas of opacity, some of which are associated\n with traction bronchiectasis in the posterior aspects of the upper lobe and\n superior aspects of the lower lobes, also likely due to areas of scarring.\n\n\n IMPRESSION:\n\n 1) High-grade complex subglottic stenosis with airway narrowed to 5 mm in\n transverse dimension. The craniocaudad extent of the stenosis is\n approximately 2 cm.\n\n 2) No evidence of tracheobronchomalacia.\n\n 3) Multiple polypoid filling defects within the trachea and bronchi, with an\n appearance most suggestive of retained secretions. If the patient is\n scheduled for bronchoscopy, this could be confirmed bronchoscopically. If\n such a procedure is not planned, then it would be recommended for the patient\n to return for additional prone imaging after coughing to ensure clearing and\n to fully exclude a fixed endobronchial lesion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2172-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 860221, "text": " 10:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, congestion\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with tracheal stenosis pre op\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, congestion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop repair of tracheal stenosis.\n\n FINDINGS: No prior comparisons. The left ventricle appears mildly enlarged.\n No CHF or definite consolidating infiltrates.\n\n There is blunting of the left costophrenic angle and what appears to be\n pleural thickening or loculated fluid tracking up along the left lateral chest\n wall. There are healing rib fractures/thoracotomy defects in the adjacent\n left 5th and 6th ribs.\n\n There is an ovoid opacity projecting at the left lung base overlying the heart\n shadow. This may represent some focal atelectasis or scarring, mitral annulus\n calcification, or a pulmonary lesion. Please correlate with outside films\n and/or reports and/or followup films.\n\n" }, { "category": "Radiology", "chartdate": "2172-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 860467, "text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for pneumothorax, atelectasis, tracheomalacia\n Admitting Diagnosis: TRACHEAL STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with tracheal stenosis s/p bronchoscopy/ stent placement\n REASON FOR THIS EXAMINATION:\n please assess for pneumothorax, atelectasis, tracheomalacia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with tracheal stenosis, status post\n bronchoscopy and stent placement. Please assess for pneumothorax or\n atelectasis.\n\n Portable AP view of the chest dated , is compared with the same\n examination from . The lung apices are excluded from the film.\n Given this limitation, no pneumothorax is identified. There is mild left\n hemidiaphragm elevation which is associated with some compressive effect at\n the left lung base. The left costophrenic angle appears blunted, which is\n unchanged. The remaining left lung and the right lung are grossly clear. The\n previously identified opacity at the left lung base is not seen. Note is made\n of several left lateral rib fractures, one of which is displaced, which appear\n subacute in nature.\n\n IMPRESSION: Limited examination with apices cut off the film. However, no\n pneumothorax is identified. No opacities to suggest consolidation or\n atelectasis. Subacute left lateral rib fractures, one of which is displaced.\n\n" }, { "category": "ECG", "chartdate": "2172-03-26 00:00:00.000", "description": "Report", "row_id": 192875, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-03-27 00:00:00.000", "description": "Report", "row_id": 1451409, "text": "7a-7p\npt to OR today, flexable bronchoscopy done under LMA anesthesia, ballon dilitation & mytomycin C application(prevents scarring), unable to pass rigid bronch, unable to debride scar tissue\n\ncv: hr nsr-st(90-120), no ectopy, sbp stable(129-143), on iv lopressor\n\nresp: on 4 l np & 4 l heliox this am, heliox dc'd post , now only 4 l np, sat 98-100, rr 16-20, no resp distress noted post procedure, bs+ all lobes & clear, diminished to bases, non-productive cough\n\ngi: + gag reflex noted post procedure & cl lix taken well, advanced to DAT, tol well, no nausea, vomiting or stool, iv protonix\n\ngu: foley patent, clear yellow urine, good uo\n\nneuro: AA&Ox3, follows commands, moving all extremities, pt very depressed, social worker up to speek with pt, HO aware, pt to have psych consult\n\nother: am K+ & MG+ repleated, iv fluids dc'd after tolerating po\n\nsocial: husband in most of day & updated on pt's condition, DR. down to speek with husband & pt\n\nplan: monitor resp status in icu overnoc, support pt, possible trach, tracheal reconstruction surgery in future\n\n" }, { "category": "Nursing/other", "chartdate": "2172-03-28 00:00:00.000", "description": "Report", "row_id": 1451410, "text": "NEURO ALERT ORIENTED WITHDRAWN DOES NOT ANSWERS MANY QUESTIONS ASKED NO NEURO DEFECITS EQUAL STRENGTHS ANSWERS QUESTIONS REGARDING NEEDS WITH \"WHAT DIFFERENCE DOES IN MAKE\" STATES SHE IS NOT GOING TO DO ANYTHING AND DOES NOT NEED TO BE WATCHED PT OBSERVED AS PRECAUTION UNTIL EVAL BY PSYCH TODAY BENADRYL X2 WITH NO EFFECT PER PATIENT AMBIENT GIVEN WITH EFFECT X2-3 HOURS SLEEPING REQUESTING SECOND AMBIEN 530 AM\n\nC/V NSR ST B/P STABLE LOPRESSOR IV CONT TOL WELL PALP PULSES\n\nRESP NC 4L SATS 99% LUNGS CLEAR NO RESP DISTRESS OR STRIDOR NOTED\n\nGU/GI ABD SOFT BOWEL SOUNDS HEARD ADEQUATE URINE OUT TOL PO WELL\n\nSKIN SKIN INTACT MOVES WELL IN BED REQUEST PATIENT CHANGE POSITION TO SIDE COCCYX PINK PATIENT REFUSED TO CHANGE POSITION FROM SUPINE STATES MY BOTTOM HAS BEEN SORE BEFORE CONTINUED TO ENCOURAGE POSITION CHANGES\n\nPLAN CONTINUE TO MONITOR MENTAL STATUS MAINTAIN PATENT AIRWAY\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-03-26 00:00:00.000", "description": "Report", "row_id": 1451405, "text": "ADMISSION NOTE\nPT IS A 55 Y.O. FEMALE SUBSTITUTE HIGHSCHOOL TEACHER FROM N.Y. PMH UNREMARKABLE UNTIL WHEN PT INVOLVED IN MVA REQUIRING REPAIR OF RUPTURED DIAPHRAGM, SPLENECTOMY. PT ALSO SUFFERED MULT PELVIC FX, HEMOTHORAX, AFIB AND WAS TX FOR LUE DVT W/ COUMADIN. SHE WAS INTUBATED FOR 10 DAYS DURING INITIAL ADMISSION AND IN EARLY (POST-D/C) PT DEVELOPED STRIDOR. W/U REVEALED TRACHEAL STENOSIS FOR WHICH SHE UNDERWENT DILATATION . SHE PRESENTED (EARLY) FOR PLANNED REPEAT DILATATION DUE TO INCREASED SOB AND COUGH. BRONCH WAS DONE BUT DILATATION DEFERRED DUE TO EXTENT OF SCARRING AND INCREASED NARROWING. PT REFERRED TO FOR FURTHER W/U AND TX OF TRACHEAL STENOSIS.\n\nNEURO: PT ADM A&O, APPEARING SOMEWHAT APPREHENSIVE. DENIED PAIN. STATES SHE HAS JUST STARTED WALKING AGAIN WITH HELP OF WALKER AND IS STILL UNSTEADY.\n\nRESP: IN NAD ON ARR ON HELIOX AND O2 BY FM. RR ~20, SPO2 98%. LUNGS CLEAR W/ MILD STRIDOR AND PT COUGHING FREQUENTLY. HELIOX FLOW INCREASED AND O2 FLOW DECREASED FOLLOWED BY LESS COUGHING, RR IN TEENS, SPO2 ~95% AND RESOLUTION OF STRIDOR. AWOKE FROM SOUND SLEEP X1 TONIGHT AND FELT UNABLE TO BREATHE/DESPERATE, SPO2 91%. CALMED DOWN W/ REASSURANCE AND SITTING UP IN BED.\n\nCV: ST 110'S ON ARR W/SBP 130'S. HR DOWN TO 80'S W/ SBP 120'S AFTER 5MG IV LOPRESSOR, NO ECTOPY. FEET COOL, PALPABLE PULSES. 20 GA R HAND IV PRESENT ON ARR; FLUSHED/PATENT, SITE WNL. MAINT IVF STARTED FOR HYDRATION.\n\nG.I.: PT NPO SINCE TUES. STATES SHE WAS HAVING NO TROUBLE SWALLOWING PRIOR TO ADM.\n\nG.U.: WEARING DIAPER WHICH WAS URINE-SOAKED ON ARR. PT REPORTS RECENT INCREASE IN STRESS INCONTINENCE DUE TO FREQ COUGHING. FOLEY CATH PLACED W/ 400ML OUT IMMED.\n\nSOCIAL: HUSBAND(PROXY) FOLLOWED AMBULANCE IN CAR FROM N.Y. AND IS STAYING IN LOCAL HOTEL.\n\nLABS: LABS DRAWN. OF NOTE PLT COUNT>600K. INR 1.2(REPORTEDLY NO COUMADIN X 3 WKS.) UA/CX SENT AS WELL AS T&S.\n\nA/P: RESP STATUS COMFORTABLE/STABLE ON CURRENT HELIOX/02. PT AND HUSBAND SPOKE W/ AND ABOUT MED PLAN. REMAINS NPO FOR PLANNED BRONCH IN A.M. W/ DECISION ON STENT VS SURGERY TO FOLLOW. MONITOR RESP STATUS CLOSELY; GOAL SPO2 ON HELIOX >90% PER R.T. HYDRATE. SC HEPARIN FOR DVT PROPHYLAXIS. REASSURE PT PRN.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-03-26 00:00:00.000", "description": "Report", "row_id": 1451406, "text": "Resp Care,\nPt. transferred from OSH on heliox due to tracheal-stenosis. Placed on scoop mask 8L heliox and 2L O2. Appears comfortable. Sat 97%. Plan stent.\n" }, { "category": "Nursing/other", "chartdate": "2172-03-26 00:00:00.000", "description": "Report", "row_id": 1451407, "text": "NEURO ALERT ORIENTED NO NEURO DEFECITS NOTED\n\nC/V NSR/ST LOPRESSOR WITH GOOD HR CONTROL B/P STABLE\n\nRESP LUNGS CLEAR SATS 97% WITH 4L NC O2 4L HELIOX MIX RR 18 NONPRODUCTIVE COUGH AT TIMES TO INTERVENTIONAL PULMONOLOGY IN AM FOR BRONCH TOL WELL RETURN TO AWAKE ALERT NO SOB OR RESP DISTRESS\n\nGU/GI NPO IN AM GAG REFLEX RETURN 1300 TOL SIPS H2O ADVANCE TO SOFT TOL WELL SWALLOWING WELL WITHOUT DIFFICULTY ADEQUATE URINE OUT ABD SOFT\n\nPLAN CONTINUE CLOSELY MONITOR AIRWAY PATENCY AND RESP EFFORT TO OR IN AM FOR ? DILUTATION AND SCAR TISSUE REMOVAL\n" }, { "category": "Nursing/other", "chartdate": "2172-03-27 00:00:00.000", "description": "Report", "row_id": 1451408, "text": "Neuro: alert and oriented x 3, mae, following commands correctly, denies pain.\n\nCardiac: nsr no ectopy noted, palpible pedial pulses, skin warm dry and intact, afebrile.\n\nResp: continues oxy-helox at 4 liters and 4liters face mask and is satting at 98%, lungs are clear.\n\nGi/Gu: tolerating po's, has been npo since mdnight for or today, abd soft round and nontender with good bowel sounds, not on riss, making good u/o with maintance fluids.\n\nPlan: keep npo, monitor o2 sats and resperatoy condition.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2121-11-22 00:00:00.000", "description": "Report", "row_id": 1711556, "text": "NPN 7a7p\n\n\nSepsis\nInfant on 48 hr R/O of amp and gent. No growth in clt yet.\nInfant doing well no additional S&S of infection presently.\nCont to monitor for infection and treat with abx.\nResp\nInfant in RA with adeq sats. RR 50-60s. LSC. I/C S/C rtxs.\nNot on caffiene. No bradys or desats. Monitor and support\nresp status.\nFEN\nInfant on TF 100 cc/k/d. Started feed this eve. BM or SC at\n10 cc/k/d, PG. IV of PND10 with IL started today as well. DS\n58 prior to adding IL and feed this eve. Abd soft, flat. BS\nheard with last cares. Voiding. No stool today. No loops.\nInfant just starting feeds. Monitor tolerance, exam and\nweight.\nG/D\nInfant in servo isolette with stable temps. A/A for cares.\nSettles well between. MAEs. FS&F. HUS friday. AGA. Support\nG/D.\nParenting\nBoth parents in today. Mom held for first time. Dad\nencouraged to participate in cares and did well. Needs extra\nsetup to be able to reach infant. Both parents very\nappropiate. Extensive family support. Mom has been primary\ncaregiver for recently injured FOB. Appears to be doing well\nbut might benifit from additional support. SW involved.\nSupport and educate parents.\nBili\nInfant jaundice/ruddy. Placed under single light this am.\nLabs to be drawn in am. Monitor color activty amd labs.\nProvide lights as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-06 00:00:00.000", "description": "Report", "row_id": 1711621, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level;; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds; umbilicus healed\nGU: testes descending; normal phallus\nExt: moving all\nNeuro: appropriate and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2121-12-06 00:00:00.000", "description": "Report", "row_id": 1711622, "text": "2. remains in RA, sats 92-100, RR30-50's, mild ic/sc\nretractions, BBs clear, equal, no spells(please refer to\nflow sheet)-on caffeine.\n3. TF 150cc/k/d BM/SC28 with promod 37cc q4h pg over 1h, no\nspits, minimal aspirates, abd soft, active bowel sounds, no\nloops, voiding and passing guiac neg stool.\n4. temp stable in servo isolette, nested in sheepskin with\nboundaries, active and alert with cares, sucks on pacifier.\n5. no contact from family so far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-07 00:00:00.000", "description": "Report", "row_id": 1711623, "text": "NICU nursing note\n\n\n2. Resp=O/Stable in room air. No spells so far this shift.\nCont on caffeine. (Please refer to flowsheet for resp\nassessment.) A/stable in room air. P/cont to monitor for\nresp distress.\n\n3. FEN=O/TF cont at 150cc/k/d of BM/SC28PM gavaged over\n60min. Abd benign. (Please refer to flowsheet for\nassessment.) Sm spit x1. Voiding/stooling, heme (-). Cont\non Vit E and iron. A/tolerating current regime. P/Cont to\nmonitor for feeding intolerance.\n\n4. G&D=O/Temp stable now swaddled in air isolette. Alert\nand active with cares. Sleeping well between feeds. MAE.\nFont S/F. A/Alt in G&D. P/Cont to monitor and support G&D.\n\n5. =O/No contact with so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-07 00:00:00.000", "description": "Report", "row_id": 1711624, "text": "Attending Progress Note\nDOL # 16\nCGA 31 wk\n\nOn RA with RR 30-70\nNo spells in 24 hrs\nOn caffeine\n\nNo murmur\nBP mean 49\n\nWt 1515 (up 45 gm)\nOn 150 cc/kg BM/SC 28 with promod\nTolerating feeds\n\nStable infant\n- Continue on current feeding regimen\n- Continue caffeine\n- Nutrition labs this week\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711720, "text": "#2Resp\nLungs clear. Mild sc retractions. RR 30-60's. Oxymeter\nD/C'd. No spells\nP. Cont to monitor.\n#3FEN\n Wt 2.345 up 20g. Baby cont to receive BM/SC 28 with promod\nat 140 or 55cc q4. Baby bottled half feed at 2100 and then\ntired. At 0130, sleepy and feed gavaged. Abd soft, active\nbowel sounds. Void, but no stool.\nNo spits. Min asp.\nA. feed and gaining weight\nP. Cont to monitor.\n#4Dev\nTemp stable in an open crib. Active and alert with cares.\nLearning to bottle.\n#5Parent\nNo contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711721, "text": "Attending Note\nday of life 38 CGA 34 0/7\n in room air RR 30-50 no spells\nlast spell 1/4\nHR 140-170 72/38 mean 43\nweight 2345 up 20 on 140 cc/kg/day of BM 28 cal/oz with promod\ntook two whole feeds in a row po\nvoiding but no stool overnight\nno spits\n\nImp-stable currently\nwill continue to encouare po feeds\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711722, "text": "Nursing Progress Note:\n\nResp:\nO: Infant respiratory rate 30-40's, with occasional mild\nsubcostal retractions. Infant shows no signs of grunting or\nnasal flaring. Lung sounds clear and equal. Infant pink and\nwell perfused.\nA: No signs of respiratory distress.\nP: Continue to monitor with cares.\n\nNutrition:\nO: Infant recieving 140cc/kg of BM 28 with promod, (55cc),\nalternating po/pg, every 4 hours. Po feed successful this\nam, as infant took 56cc. Infant well coordinated once he\ngets started. This afternoon gavaged full feed. No spits\nnoted as of today. Max aspirate of 2.4cc; non-billious.\nAbdominal exam benign. Infant voiding and passing heme\nnegative stool.\nA: Infant tolerating feeds well.\nP: Continue to advance po feeds as tolerated.\n\nDevelopment:\nO: Infant temperature stable, as he is swaddled, in an open\nair crib. Alert and active with cares. within normal\nlimits. Infant reaches hands to face, and enjoys sucking on\nhis pacifier for comfort.\nA: Appropriate behavior for gestational age.\nP: Continue to support development.\n\nParenting:\nO: not in yet this shift. Due in at 5pm.\nA: Unable to assess at this time.\nP: Continue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711723, "text": "NPN \n\n\n\n I have examined this infant and am in agreement w/above\nnote and assessment by PCA .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711724, "text": "Neonatology NP Note\nPLease refer to attending ote for details of evaluation and plan.\n\nPE: growing preemie nestled in open crib.\n, eyes clear, ng in place, MMMP\nChest is clear wuthe equal bs, comfortable resp patter\nCV: RRR, no murmu, pulses+2=\nAbd: soft, active bs, NTND\nGU: testes in scrotum\nEXT: MAE, WWP\nNeuro: appropraite and activity for CGA\n" }, { "category": "Nursing/other", "chartdate": "2121-12-29 00:00:00.000", "description": "Report", "row_id": 1711725, "text": "NICU Lactation Note\n\nMet with during a breastfeeding session. Mom using a small nipple shield. She demonstrates correct positioning and latch on technique in cradle hold. The infant latches and nurses in immature suck/swallow breath pattern for ~ 10 minutes with milk transfer.\n\nShe will continue breastfeeding every day.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-07 00:00:00.000", "description": "Report", "row_id": 1711625, "text": "2. remains in RA, color pink, BBS clear, equal,\nRR30-60's, sc retractions, no bradys so far this\nshift(please see flow sheet) but had one desat to 62, color\ndusky, given BBO2, on caffeine.\n3. TF150cc/k/d BM/SC28 with promod 38cc q4h pg over 75min,\nabd soft, no spits, minimal aspirates, voiding and passing\nsm stool.\n4. temp stable swaddled in off isolette, nested in sheepskin\nwith boundaries, active and alert with cares, sucks on\npacifier.\n5. in to visit with family and friends, updated, Mom\nheld , pumping breast milk.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-07 00:00:00.000", "description": "Report", "row_id": 1711626, "text": "NNP ON-Call\nPhysical Exam\nGeneral: infant in isolette, room air\nSkin: warm and dry color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV:RRR, no murmur appreciated; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds umbilicus healed\nGU: normal preterm male; testes undescended, palpable in canals bilaterally\nExt: moving all; normal \nNeuro: appropriate reflexes for gestational age\n" }, { "category": "Nursing/other", "chartdate": "2121-12-27 00:00:00.000", "description": "Report", "row_id": 1711713, "text": "I agree with above note and by ,PCA and have examened the infant.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-27 00:00:00.000", "description": "Report", "row_id": 1711714, "text": "Neonatology Attending Progress Note:\nDOl #36\nHR=160's, BP mean=60\nwt=2275g (inc 40g), TF=140cc/kg/d BM/SC 28 calories with promod\nsome po feeds\nvoiding stooling\nImp/Plan: premie doing well, learning to po feed\n--encourage po feeds, monitor weight\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-27 00:00:00.000", "description": "Report", "row_id": 1711715, "text": "Neonatology-NNP Progress Note\n\nPE: remains in his open crib, in room air bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afso, gavage in place\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-27 00:00:00.000", "description": "Report", "row_id": 1711716, "text": "NICU PCA progress note\n\n\n2. Resp: O/Cont. with RA. No spells or desats so far this\nshift. (Please refer to flowsheet for respiratory\nassessment.) A/Stable in RA. P/Cont. to monitor resp.\ndistress.\n\n3. FEN: O/TF cont. at 140cc/k/d of BM\\SC28PM po/pg.\nBottled x1. Abd. benign. (Please refer to flow sheet for\nassessment and PO volume.) Moderate spit x1. Voiding. No\nstool. Continues on vitamin E and iron. A/PO x1/shift.\nBottle fed very well. P: Continue with current regime.\n\n4. DEV: O/Temp stable. Swaddled in open crib. Alert and\nactive with cares. Sleeps well between feeds. MAE. Font\nS/F. A/Alt in growth and development. P/Continue to\nmonitor and support growth and development.\n\n5. PARENT: O/ called x1. Updated by RN. Will be in\nto visit tomorrow. A/Appropriate and actively involved.\nP/Cont. to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-28 00:00:00.000", "description": "Report", "row_id": 1711717, "text": "#5 PARENT\ns/o: No contact this shift.\n#4 DEV\ns/o: Temp stable in open crib. good. Awake and\ndemanding x2 consecutive feeds--taking 35-40cc well - then\ntires. A: CGA- 34-2/7. Behaviors AGA. P: Cont dev supp care\n#3 FEN\ns/o: WT up 50 gms tonight to 2325gms.Lots of flatus tonight.\nCOnt with 28 cal BM/sc with pm. Abd girth stable. A: Gaining\non 28 cal/oz feeds. P: Cont to mtr tolerance, daily wt and\nreport changes.\n#2 RESP\ns/o: No spells this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711551, "text": "NPNOte\n\n1 Infant with Potential Sepsis\n2 Alt In Resp due to prematurity\n3 Alt in Fluid/elect/nutrition\n4 Developmental\n5 Parenting\n6 Hemodynamics\n\n#1. Alert,active with care,CBC with def results team\naware.blood culture results pending. A; asymptomatic; P;\ncont to monitor for s/s of sepsis.\n\n#2.Received on cpap of 6cm, aBG 7.22/62/75/27/-3, intubated\nrate20/mt,19/5, fio2 21%, surf x1, chest xray done, CBG at\n12.30 7.32/46, extubated to CPAP of 5cm at 5pm.BBS clear,\nequal, mild subcostal retractions present, no spells thus\nfar this shift,no desats.A; stable on CPAP.P; cont to Resp\nsupport as needed.\n\n#3. TF=80cc/kg/day, NPO, IVF starter PN connected ~1pm,\ninfusing at PIV, BS+, soft loops noted, NGT passed,\naspirated 8cc air, voided, stooled, mecx1. D'stix\n71.54,151,75.A; NPO, maintained d'stix P; cont current\nnutritional plan.\n\n#4, alert,active with care, temp atble on a warmer bed, mae,\nnested in sheepskin, caput+, bruised left hand little\nfinger,A; AGA P; cont dev support.\n\n#5. Parents visited, asking app questions, Dad is\n,on wheelchair, family meeting held in mothers\nroom with fellow, A; loving, concerned. P; cont update and\nteaching,\n\n#6. BP means 25-27,started on Dopamine with D10at 10am, PIV,\nconcentration changed with Nsaline at 12.45pm, infusing at\nPIV, area blanched surrounding the vein,seen by Attending.\nCurrently at 5mcg to miantain BP means >33.ruddy well\nperfused,A; required dopamine to maintain BP means besides 2\nNSaline bolus P; cont to maintain BP means >33.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt In Resp due to prematurity; added\n Start date: \n 3 Alt in Fluid/elect/nutrition; added\n Start date: \n 4 Developmental; added\n Start date: \n 5 Parenting; added\n Start date: \n 6 Hemodynamics; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-22 00:00:00.000", "description": "Report", "row_id": 1711552, "text": "RESPIRATORY CARE NOTE\nBaby received on Prong CPAP 5 FiO2 21%. At hrs baby was taken off CPAP and placed in room air. RR 30-40's breath sounds are clear. Baby looks very comfortable off CPAP cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-22 00:00:00.000", "description": "Report", "row_id": 1711553, "text": "NPN\n\n\n#1-O; ampi given as ordered, remains on ampi and genta\npending culture results. no signs or symptoms of sepsis at\nthis time. cont to monitor.\n\n#2-O; CPAP dc'd at , has been in RA for 10 hrs, no\ndrifts or spells thus far. CLear and equal RR 30's-50'.very\ncomfortable, cont to monitor, ? load w/ caffeine.\n\n#3-O; tf currently at 80cc/k/d, NPO at this time, PIV PN D8\ninfusing well, h/l left foot, patent. NG tube in , no\naspirates, no air. Abd flat soft, BS hypoactive at times.\nD/S 72-79. Voiding 5cc/k/hr this shift. 24 hr. lytes and\nbili pending. wt down 40 gms to 1.320 kg.\n\n#4-O; placed in isolette from warmer earlier in shift, noted\nto have some temp instability but isolette discovered not to\nbe heating appropriately. Changed isolettes , temps better.\n, , alert and active, irritable at times. cont to\nassess\n\n#5-O; no contact this shift.\n\n#6-O: received baby on 4 mcgs Dopamine, weaned and dc's at\n2300. b/p MAPS 32-38. no murmur, pink/ruddy , well\nperfused. pulses WNL cont to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-28 00:00:00.000", "description": "Report", "row_id": 1711718, "text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable appearing.\n\nWt 2325 up 50. Tolerating feeds at 140 cc/k/d of 28 cal.. Abdomen benign. Bottling reasonably well.Still req gavage.\n\nTemp stable.\n\nActive alert. Moving all 4. Neuro non-focal.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-28 00:00:00.000", "description": "Report", "row_id": 1711719, "text": "NICU nursing note\n\n\n2. Resp=O/Cont in room air. No spells so far this shift.\nOximeter d/c'd at 1400 per team. (PLease refer to flowsheet\nfor resp assessment.) A/Stable in room air. P/Cont to\nmonitor for resp distress.\n\n3. FEN=O/TF cont at 140cc/k/d of BM/SC28PM po/pg. Bottled\nx1 by mom at 1300. Abd benign. (Please refer to flowsheet\nfor assessment and po vol.) Sm spit x1. Voiding. No\nstool. Cont on Vit E and iron. A/Alt po/pg. Bottlefed\nvery well for mom. P/cont to offer po's when awake and\nalert.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert and\nactive with cares. Sleeping well in between. MAE. Font\nS/F. A/Alt in G&D. P/cont to monitor and support G&D.\n\n5. =O/Mom and dad in to visit. Updated by this\nnurse. Mom bottled baby for first time. Both participating\nin cares. A/appropriate and actively involved. P/Cont to\nsupport and educate .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711616, "text": "Neonatology Attending Progress Note\n\nPMA 31 \nRA 30-60's 2 spells 1 with stimulation\nHR 130-170 BP mean=52\n1440 (inc 45)\nTF=150 BM/SC 26 on Iron and Vit E\nservo isollette\nImp/Plan: x-29 week infant doing well with AOP, on caffeine, advancing on calories\n--increase to 28 calories\n--monitor spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711617, "text": "Progress Note\nPE: Gen: A, NAD, in a servo isolette\nHEENT: \nLungs: CTA bilaterally\nCVS: RRR NS1S2, no murmor\nAbd: NT ND, NBS\next: pink well perfused\nNeuro: appropriate for age\n\nA/P: 31 wk old premie, former 29 wk old, that is cardovascular and respiratory stable. Is gaining weight and increasing on calories. Will continue to monitor for any changes\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711618, "text": "NICU nursing note\n\n\n2. Resp=O/cont in room air. Spell x1 so far this shift.\nCont on caffeine. (Please refer to flowsheet for resp\nassessment and details of brady.) A/stable in room air.\nP/Cont to monitor for resp distress.\n\n3. FEN=O/TF cont at 150cc/k/d of now BM/SC28PM gavaged over\n60min. Abd benign. (Please refer to flowsheet for\nassessment.) Sm spit x2. Voiding/stooling, heme (-). Cont\non Vit E and iron. A/tolerating current regime. P/Cont to\nmonitor for feeding intolerance.\n\n4. G&D=O/Temp stable nested in servo isolette. Alert and\nactive with cares. Sleeping well between feeds. Kangarooed\nwith mom for 60min- well. MAE. Font S/F. A/alt in G&D.\nP/Cont to monitor and support G&D.\n\n5. =O/Mom and dad in to visit. Updated by this\nnurse. Both participating in all cares. A/appropriate and\nactively involved. P/Cont to support and educate .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-06 00:00:00.000", "description": "Report", "row_id": 1711619, "text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:REMAINS IN RA WITH SATS 93-99%. BS CLEAR. RESP RATE 40-54\nWITH MILD IC/SC RETRACTIONS. SOME PERIODIC BREATHING NOTED,\nNO SPELLS.\nA:STABLE\nP:CONTINUE TO MONITOR\n\n#3F/E/N\nO:TF AT 150CC/KG. BM28/SCF28 36CC Q4HR GAVAGE OVER ONE HOUR.\nABDOMEN SOFT, ROUND WITH GOOD BS. NO SPITS. AG 22.5-23.5CM.\nNO ASPIRATES. VOIDING WELL; NO STOOL. WT UP 30GM\nA:TOLERATING FEEDS WELL; GAINING WT\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS AND WT GAIN\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATURE.\nACTIVE/MAE WIHT CARES; SLEEPING WELL BETWEEN. FONTANEL SOFT\nAND FLAT; SUTURES SL OVERRIDING. NESTED ON SHEEPSKIN\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO:NO CONTACT THUS FAR\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-06 00:00:00.000", "description": "Report", "row_id": 1711620, "text": "Neonatology Attending\n\nDOL 15 CGA 31 2/7 weeks\n\nStable in RA. 2 A/B. On caffeine.\n\nNo murmur.\n\nOn BM/SC 28 with promod at 150 ml/kg/d pg. Voiding. Stooling (heme neg). Wt 1470 grams (up 30).\n\n in and up to date. Mother having some issues with milk supply. Has met with lactation consult.\n\nA: Stable. Minor spells on caffeine. Tolerating feeds.\n\nP: Monitor\n Continue current regimen\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711579, "text": "Neonatology Attending Progress Note:\nDOl 37\nPMA 31 \nback to RA from NC 13 cc\nno spells this morning, yesterday some bradys and apnea\ncaffeine\nBP mean=51, HR=140's\nseptic eval last night due to brady's and temp instability\n6.5 WBC (59p12b2metas)\nblood culture\nbili=5.9/0.3\n137/5/105/23\non vanc and gent\nHUS normal today\nwt=1305g (inc 45g), on 150cc/kg/d feeds at 110cc/kg/d SC 20\nvoiding, stooling\nservo-isolette, temps now stable\niv infiltrate in left arm\n\nImp/Plan: premie with concern for sepsis--now on antibiotics, physiologic jaundice, AOP, advancing on feeds\n--monitor bili on phototherapy\n--continue vanc and gent pending clinical course and blood culture results\n--continue advance feeds, monitor for intolerance\n--monitor spells on caffeine\n--continue to keep family updated\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711580, "text": "PE: well appearing, , normal S1S2, no murmur, bretah sounds clear, badomen soft, nontender, nondistended, ext well perfused. aga\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711581, "text": "Progress Note\nPE: Gen: NAD\nCVS: RRR, N S1S2, no murmor\nResp: Lungs CTA Bilaterally\nAbd: ND, NBS\nskin: pink well perfused\n\nA/P: This is a 30 wk premie, former 29 wk with some respiratory distress on caffeine and is being evaluated for sepsis. Was restarted on antibiotics. Advancing enteral feeds. Had a HUS today which was normal. Is still receving phototherapy, will re-evaluate bili in 2 days.\n\n MS IV\n" }, { "category": "Nursing/other", "chartdate": "2121-12-26 00:00:00.000", "description": "Report", "row_id": 1711707, "text": "NPNOte\n\n\n#2.Remains in R air, BBs clear, equal, mild subcostal\nretractions present, nos pells thus far this shift,\noccassional desats to high70's QSR. A; no spells. P; cont to\nmonitor for desats/spells.\n\n#3.Todays weight=2235, up60gms,Tf=140cc/kg/day,SC28 with\npromod,MBM28 with promod, pg fed tolerated, BS+, no loops,\nvoided, stooled, guaic negative. A; Feeds tolerated.P;\nencourage po skills.\n\n#4. alert,active with care, temp stable in a open crib,\nswaddled with blanket, mae. bath given. A; AGA P; cont dev\nsupport.\n\n#5.No contact from thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-26 00:00:00.000", "description": "Report", "row_id": 1711708, "text": "Attending Note\nDay of life 35 CGA 34 \nRR 20-60 in room air\nlast spell on the \nHR 140-170's BP 64/24 mean 40\nweight 2235 up 60 on 140 cc/kg/day BM 28 cal/oz with promod po once a shift and mom putting him on breast pg the remainder\nvoiding and stooling\ns/p hep B\n\nImp-stable currently\nwill continue monitor growth\n" }, { "category": "Nursing/other", "chartdate": "2121-12-26 00:00:00.000", "description": "Report", "row_id": 1711709, "text": "Neonatology NP Note\nPE\nswaddled in isolette\n, sutures opposed\nvery mild subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good \n" }, { "category": "Nursing/other", "chartdate": "2121-12-26 00:00:00.000", "description": "Report", "row_id": 1711710, "text": "NICU nursing note\n\n\n2. Resp=O/Cont in room air. No spells/desats so far this\nshift. (Please refer to flowsheet for resp distress.)\nA/STable in room air. P/cont to monitor for resp distress.\n\n3. FEN=O/TF cont at 140cc/k/d of BM/SC28PM po/pg. Ng feeds\ngavaged over 90min. Abd benign. (Please refer to flowsheet\nfor assessment.) Voiding/stooling, heme (-). Cont on Vit E\nand iron. A/tolerating current regime. Will BF when mom\nvisits at 1700. P/Cont to monitor for feeding intolerance.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. A/Alt in G&D. P/cont to monitor and support G&D.\n\n5. =O/NO contact with so far this shift.\nP/Cont to support and educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-26 00:00:00.000", "description": "Report", "row_id": 1711711, "text": "NICU Lactation Note\n\nMet with during breastfeeding session.\nGave mom a small size nipple shield, infant latched on with the nipple shield, nursed for 10minutes with milk transfer. Mom demonstrates excellent positioning techniques in cradle hold and ability to insert nipple with mouth wide open.\n\nMom reports that her nipples are not sore. Her milk production is not adequate. She will consider Reglan at a later date, she is hesitant d/t the concern for depression.\n\nI will meet with the again on at 1 pm.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-27 00:00:00.000", "description": "Report", "row_id": 1711712, "text": "PCA NOTE\n\n\nRESP: No spells or desats noted. Drifting with PO attempt.\nResolved quickly with bottle removed. Stable in RA.\nP-Continue to monitor.\n\nFEN: Current weight 2.275, ^ 40gm. TF 140cc/k/d of BM/SC 28\nw/ promod. PG. PO x1 this shift. Took 25 cc' is\nvoiding, trace stool. Active bowel sounds. Abdomen is\nunremarkable. Minimal residuals. No spits. Tolerating feeds.\nP-Continue to follow current regimen as ordered.\n\nDEV: Temp stable in OAC. Waking for feeds. Alert and active.\nSleeps peacefully. MAE. AF-flat. Sucking on pacifier.\nCurious disposition. AGA. P-Continue to support\ndevelopmental milestones.\n\n: No contact over night.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711582, "text": "NPN 7a7p\n\n\nResp\nInfant recieved on NC this am, 13 cc. Trialed off at 9 am\nand has had adeq sats since. No bradys today. Some shallow\nbreathing but no apnea noted. On caffiene. LSC. S/C I/C\nrtxs. RR 30-50s. Monitor and support resp status.\nFen\nInfant on TF 150 cc/k/d BM or SC 20 gavaged over 45 mins.\nFeeds presently at 120 cc/k and increasing by 10 cc/k/.\nD10 presently at 30 cc/k/d via PIV. DS 75 today. Abd soft\nwith active BS. Max asp 2.2 cc, benign. Mixed mod stool and\nvoiding. Infant tolerating increase in feeds. Monitor weight\nand exam.\nG/D\nInfant in servo isolette with stable temps today. A/A for\ncares although still somewhat mellow compared to 2 days ago.\nAppropiate. Sleeping well between. Comfortable prone with\nhands at face. MAEs. FS&F. Had HUS this am WNL per team.\nLeft arm with firm area at IV infiltrate site from\nyesterday, skin intact, slightly reddened, not warm. AGA.\nMonitor and support G/D.\nParenting\nBoth in for visit and cares. Mom did cares\nindependently. FOB kangarooed infant. Both appeared to enjoy\nthe experience. Asking appropiate questions. FOB struggling\nwith mobility issues, his fears of being able to keep his\ninfant safe. Reassured he is doing great and he has lots of\nsupports. Support and educate parentds.\nHyperbili\nInfant under single light. Slighty ruddy. Repeat bili to be\nobtained tomorrow with a vanco level. On feeds, stooling,\nactive. Monitor color, labs and activity.\nSepsis\nInfant on vanco and gent. No growth in BLD clt. CBC in\ncareview. No temps instability today, no bradys and\nincreased activity. No additional S&S of infection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-16 00:00:00.000", "description": "Report", "row_id": 1711662, "text": "#2Resp\nLungs clear. Mild retractions. RR 40-60's. Sat in mid 90's.\nNo spells. Pale pink.\nA. Ra\nP. Cont tomonitor.\n#3FEN\nWt 1.825 up 40g. baby cont to receive feed of BM/SC28 with\npromod by gavage over 90 min. No spits Min asp. Void and\nstooling, heme neg.\nA. Feed and gaining weight\nP. Cont to monitor.\n#4Dev\nTemp stable in an open crib. Slept well bvetween cares.\nAwake and alert ieh cares.\nP. HUS on Thursday.\nParent\nhere at change of shift. No further contact.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-16 00:00:00.000", "description": "Report", "row_id": 1711663, "text": "Neonatology Attending Note\nDOL #25, CGA 32 wks.\n\nCVR: Remains in RA, RR 30-60s, mild intermittent retractions. One brady with feeds, several brief self-resolved desaturations. Caffeine discontinued yesterday. Hemodynamically stable.\n\nFEN: Wt 1825, up 40. TF 140 cc/kg/day, BM/SC 28 w/PM, all PG. No aspirates/spits. Voiding/stooling.\n\nNEURO: Due for HUS this week.\n\nPE: see note NP Buck.;\n\nIMP: Overall stable growing premature infant. Respiratory status stable. Minimal apnea of prematurity off of caffeine. Tolerating feeds, gaining weight.\n\nPLANS:\n- Continue current management.\n- Monitor for spells.\n- Continue 28 cals, monitor weight gain.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-16 00:00:00.000", "description": "Report", "row_id": 1711664, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR without murmur; normal S1 S2; pulses +2\nABd: soft; no masses; umbilicus healed; + bowel sounds\nGU: normal male; testes descended\nExt: moving all\nNeuro: appropriate and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711547, "text": "Clinical Nutrition:\nO:\n29 week gestational age BB, AGA, now on DOL 0.\nBWT: 1360g(~75th %ile)\nHC @ birth: 26.5cm(25-50 %ile)\nLN @ birth: 40.5cm(~75th %ile)\nNutrition: TF @ 80cc/kg/day. NPO. D10 w/3%AA starter PN w/dopa infusing via PIV until PN is initiated later today. Projected intake for next 24hrs from PN ~26kcal/kg/day & ~1.5g pro/kg/day. Glucose infusion rate from PN ~4.1mg/kg/min.\nGI: Abd w/some loops.\n\nA/Goals:\nRemains NPO. Starter PN w/dopa as above. Plan to start PN later today Via PIV. Initial goal for PN ~90-110kcal/kg/day, ~3-3.5g pro/kg/day & ~3g fat/kg/day. Advancing per protocol. Limitations may preclude being able to deliver adequate nutrition from PN via PIV. When able to start EN feeds, initial goals are ~150cc/kg/day SC/BM 24, providing ~120kcal/kg/day & ~3.2-3.3g pro/kg/day. Further advances in EN feeds as per growth & tolerance. Appropriate to start Fe & Vit.E when EN feeds reach initial goal. Growth goals after initial diuresis are ~15-20g/kg/day for WT gain, ~0.5-1cm/wk for HC gain & ~1cm/wk for LN gain. Will follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711548, "text": "Respiratory Care\nPt extubated and placed on +5cm H2O prong CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711549, "text": "Respiratory Care\nPt extubated and placed on +5cm H2O prong CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-27 00:00:00.000", "description": "Report", "row_id": 1711575, "text": "NPN 7a7p\n\n\nResp\nInfant in RA with adeq sats. No bradys today thus far.\nLoaded with caffiene yesterday. LSC. S/C I/C rtxs. RR\n30-60s. Admin maint caffiene. Monitor for bradys.\nFEN\nInfant on TF 150 cc/k/d of PND10 via PIV and Entral feeds.\nFeeds increasing by 10 cc and are presently @ 90 cc/k.\nBM or SC20 gavaged. Abd soft. active BS. Voiding. DS 75\ntoday. Min asps, no spits. Monitor tolerance to feeds.\nMonitor weight and exam.\nG/D\nInfant in servo isolette. A/A for cares. Quiet and settles\nnicely between. MAES. FS&F. HUS planned for Friday. AGA.\nMonitor and support G/D.\nParenting\nNo contact yet today.\nHyperbili\nInfant under single light. Mildly ruddy. Active, feeding and\nstooling. Bili to be obtained tonight. Monitor activity,\ncolor and labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-27 00:00:00.000", "description": "Report", "row_id": 1711576, "text": "NPN add 7a7p\nResp\nInfant has had 3 bradys this afternoon. Having some drifts to the 70s as well. Apenic and color changes. Needed BBo2 x 2. Recieved maint dose of caffiene. LSC and no change in WOB. alert NNP.\nSepsis\nInfant cool with last cares, despite no change in servo temp or skin temp. Isolette increased and infants temp now 98.2. Infant sleepy with cares. alert NNP.\nSleepy, cool and bradys. Monitor. Obtain bld clts if necessary.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-16 00:00:00.000", "description": "Report", "row_id": 1711665, "text": "Nursing Progress Note\n\n\n#2-O/A- Received infant in RA. Infant remains in RA. No\nresp distress. Occas drifts. P- Cont to assess for resp\nneeds.\n#3-O/A- TF=140cc/kg/d of BM/sc28w/ProMod via NGT. Abd exam\nbenign. Voiding and stooling. feeds. P- Cont to\nassess for FEN needs.\n#4-O/A- cont to be awake and active with cluster cares\nq4hrs. Sleeps well between cares. Temp stable in open\ncrib. P- Cont to assess for G&D needs.\n#5-O/A- in to visit with updates given. \nheld infant. Loving and involved. P- Cont to enc parental\ncalls and visits.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-17 00:00:00.000", "description": "Report", "row_id": 1711666, "text": "PCA NOTE\n\n\nRESP: In RA. Breathing 40-60's. Sats > 96%. No spells noted.\nOne desat noted. Occasional drifts into the 80's. Self\nresolved. Off caffeine. P-Continue to monitor.\n\nFEN: Curret weight 1.850, ^ 25gm. TF 140cc/k/d of BM/SC 28.\nPG/90 mins. is voiding and stooling. Hem neg. Active\nbowel sounds. Girth is stable. Abdomen is unremarkable.\nMinimal residuals. No spits. Tolerating feeds. P-Continue\ncurrent regimen as ordered.\n\nDEV: Temp stable in OAC. Waking for feeds. Alert and active.\nSleeps peacefully. Sucking on pacifier. AGA. P-Continue to\nsupport developmental milestones.\n\n: No contact over night.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-17 00:00:00.000", "description": "Report", "row_id": 1711667, "text": "Agree with above note ny coworker .\n" }, { "category": "Nursing/other", "chartdate": "2122-01-05 00:00:00.000", "description": "Report", "row_id": 1711760, "text": "PCA NOTE\n\n\nFEN: Current weight 2.685, ^ 80gm. TF 140cc/k/d of SC/BM 26.\nPO/PG. Doing better bottling this shift. See flowsheet. \nis voiding, no stool. Active bowel sounds. Benign abdomen.\nMinimal residuals. No spits. Tolerating feeds. P-Continue to\nencourage PO intake.\n\nDEV: Temp stable in OAC. Wakes for feeds. Alert and active.\nSleeps peacefully. MAE. AF-flat. Sucking on pacifier. Sweet\ndisposition. Eye exam today. AGA. P-Continue to support\ndevelopmental milestones.\n\n: No contact over night.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-05 00:00:00.000", "description": "Report", "row_id": 1711761, "text": "NPN 1900-0700\nAgree with above assessment by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-05 00:00:00.000", "description": "Report", "row_id": 1711762, "text": "Neonatology Attending Progress Note\n\nNow day of life 44, CA 3/7 weeks in RA with RR 40-50s\nNo apnea and bradycardia.\nHR 140-150s BP 75/38 53\n\nWt. 2685gm up 80gm on 140ml/kg/d of SSC or MM26 kcal/oz po/pg\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress for this premature infant.\nWill decrease to 24kcal/oz.\nEye exam today.\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-05 00:00:00.000", "description": "Report", "row_id": 1711763, "text": "NNP Physical Exam\nPE: pink, , sutures apposed, breath sounds clear/equal with comfortable WOB, RRR with soft murmur LSB, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711550, "text": "Respiratory Care\nPt admitted to NICU for prematurity. Initially req CPAP, but progressed to intubation following abg 7.22/62. Pt was intubated and rec'd 1 dose survanta. Tol. both procedures well. ETT pulled back 0.5cm following cxr. Currrently on settings 16/5, f 16. Fio2 .21, bs clear, rr 40-60. cbg on 18/5, f 20: 7.32/46. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-04 00:00:00.000", "description": "Report", "row_id": 1711609, "text": "Neonatology Attending Progress Note:\nDOl #13\nRR=40-60's, sats over 96%, occasional drifts to 80's\nno spells, no murmur, HR=140-160's\nBP mean=38\nremains on caffeine, no phototherapy\n1415g (inc 30g), TF=150cc/kg/d BM 26 over 1 hour without spits\nvoiding, stooling heme negative\nImp/Plan: x-29 week infant with AOP--on caffeine, s/p r/o sepsis, advancing on feeds.\n--add promod, monitor weight\n--monitor spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-04 00:00:00.000", "description": "Report", "row_id": 1711610, "text": "Progress Note\nPE: Gen: A, NAD, in servo isolette\nHEENT: \nLungs: CTA bilaterally\nCVS: RRR NS1S2, no murmor\nAbd: ND, NBS\nExt: pink well perfused\n\nA/P: 31 wk old premie, former 29 wk old is doing well from a cardiac and respiratory stand point. Is gaining weight and plan to add promod today to BM today.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-04 00:00:00.000", "description": "Report", "row_id": 1711611, "text": "Nursing note\n\n\n#2 RESP O: Child remains on room air. RR as noted. Breath\nsounds are clear and equal. Occasional desats this am to the\nlow 80s that were qsr. None this afternoon. Mild inter and\nsubcosatal retractions noted. Child remains on caffeine. P:\nwill continue to monitor and will continue with caffeine.\n#3 FEN O: Child remains on 150cc/k of bm26. Today added\npromod to his feed as ordered. Tolerating feeds without\nspits or aspirates. Abdomen is benign. No loops noted. Good\nbowel sounds heard. NG secure and placement verified. Child\nvoiding and stooling well. Remains on vit e and iron. P:\nWill continue to gavage over 1 hour and monitor weight gain.\n#4 DEV O: Child remains in isolette on servo temp. Temp\nremains WNL. Child nested with raised HOB. Child sleeps\nbetween cares. Alert and active with cares. P: Will continue\nto support the child's coping skills.\n#5 Parenting O: Mom and Dad in to visit for the 1700 cares.\nMom did diaper and Dad kangarooed the child. Both\ngiven updates by NSG and MD. Both interact well with the\nchild. P: Will continue to support and inform .\n also talked with SW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711612, "text": "NPN 1900-0730\n\n\nResp: Infant in RA, RR 30-60s. Lung sounds clear, equal.\nMild IC/SC retractions noted. O2 Sats remain above 96%. One\nA&B spell with HR to 71, Sat to 83%, requiring mild stim.\nSee flowsheet for further details. No further desats or A&B\nspells thus far this shift. Continue to monitor respiratory\nstatus.\n\nFEN: Infant wt. 1440g^25g. TF=150/k/day BM26 w/PM= 36cc's\nq4h gavaged over 1 hour. Abd benign. No spits. Max aspirate\n2cc's partially digested breastmilk, nonbilious. Voiding.\nMed heme neg stool x1. Continue to monitor tolerance to\nfeeds.\n\nDevelopment: Stable temp in servo isolette. Nested with\nsheepskin. Alert and active when woken for cares. Continue\nto promote development.\n\nParenting: No contact from thus far this shift.\nUpdate and support as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711613, "text": "NPN 1900-0730\nSmall nodule on left antecube still present. No redness or drainage noted.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711577, "text": "NPN/1900-0700\n\n\n#2 RESP: Infant remains in 100%O2 NC, weaned from 50cc to\n13cc this shift. Sats >98%, however when trialed to ra had\nnumerous apneic episodes with desats. No bradys thus far.\nRR 20-40's. LSC. Mild retractions. On Caffeine. Cont. to\nmonitor.\n#3 FEN: WT 1305, ^45gms. TF=150cc/k/d. Enteral feeds of\nBM20 at 100cc/k/d and IVF of D10 infusing at 50cc/k/d.\nTolerating feeds over 40 min; no spits or aspirates. Abd.\nbenign. Girths=19-20.5cm. V/S. DS=88. AM\nlytes=137/5.0/105/23. Plan to advance feeds 10cc/k as\ntolerated. Cont. to monitor.\n#4 DEVELOPMENT: Nested on sheepskin in servo mode isolette.\nTemps WNL. Quiet, sleepy with cares. . Monitor and\nsupport developmental needs.\n#5 : No parental contact this shift.\n#7 BILI: Remains under single phototx w/ eye shields in\nplace. AM bili 5.9/0.3; previous bili 4.9/0.3. Sl.\njaundiced. Cont. to monitor.\n#8 SEPSIS: CBC/diff and blood cx sent b/c of temp\ninstability on day shift and apnea/bradys. 12 bands and 59\npolys present. Gent and Vanco started. Temps stable this\nshift, however cont. to have periods of apnea and appears\nless active this shift. Cont. to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-28 00:00:00.000", "description": "Report", "row_id": 1711578, "text": "PE: well appearing, , normal S1S2, no murmur, bretah sounds clear, badomen soft, nontender, nondistended, ext well perfused. aga\n" }, { "category": "Nursing/other", "chartdate": "2121-12-14 00:00:00.000", "description": "Report", "row_id": 1711656, "text": "Neonatology Admission Note\nDOL# 23\nCGA 32 wk\n\nIn RA with good sats\nRare drifts and desats, self-resolved.\nRR 40-60s.\nOn caffeine.\n\nHR 140-160s, no murmur.\n\nWt 1715 (up 30 gm)\nOn 150 cc/kg BM/SC 28 with promod\nFew spits, minimal aspirates.\n\nIn off isolette.\n\n- Continue current nutritional regimen.\n- Monitor spells/drifts on caffeine.\n- HUS later this week for 1 month check.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-14 00:00:00.000", "description": "Report", "row_id": 1711657, "text": "NPN 0700-\n\n\n2. In RA with sats 96-100%. Lungs clear. RR 30-60's with\nmild retractions. On caffeine. No A&B's this shift.\nOccassional desats to 80's with periodic breathing.\nContinue to monitor for A&B/desats.\n\n3. TF 150cc/k/d BM28 w/PM. Abdomen benign. Voiding and\nhaving heme negative stools. Tolerating NGT feeds without\nspits and min. aspirates. Continue to monitor tolerance to\nfeeds.\n\n4. Temp stable swaddled in off isolette. Awake and active\nwith cares. Rest well inbetween cares. MAE. HUS due on\nThursday. Continue to promote development.\n\n5. in to visit, updated on plan of care and\nindependent with infant cares. Father kangarooed with\ninfant today. Invested . Continue to support and\nupdate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-15 00:00:00.000", "description": "Report", "row_id": 1711658, "text": "NPN/1900-0700\n\n\n#2 RESP: Infant breathing ra w/ sats >90%. RR 20-50's.\nLSC/=. Mild retractions. No bradys, but has occ. QSR\ndesats to 70's. On caffeine. Cont. to monitor.\n#3 FEN: Wt1785, ^70gms. TF=150cc/k/d of BM/SC28w/pm. Feeds\ngavaged over 90 min for hx of spits. Mod. spit x1. Abd.\nbenign. V/S. Girth=24cm. Cont. to monitor.\n#4 DEVELOPMENT: Moved from off isolette to oac; temps\nstable. Active/alert w/ cares; sleeps well b/t. Sucks\nintermitt. on pacifier. . AGA. Support developmental\nneeds.\n#5 : No parental contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-05 00:00:00.000", "description": "Report", "row_id": 1711764, "text": "Nursing Progress Notes.\n\n\n#3 O: Total fluids 140cc/kg/day of BM/SC26. Feeds given\nevery 4 hours over 1 hour. Bottle offered at 0900, 55cc\ntaken with in 50 min. 1 x small spit. Voiding well, no\nstool today. Abdomen benign. A: Tolerating feeds well,\nlearning to PO feed. P: Continue to encourage Po feeding\nwhen alert and active.\n#4 O: Temp stable in open crib. BAby wakes for some feeds\nand is sleepy at others. Baby likes his pacifier and sleeps\nwell between cares. A: Appropriate for age. P: Continue to\nsupport development.\n#5 O: Father called and plan to visit after work\nthis afternoon. A: Involved family. P: Continue to keep\ninformed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-06 00:00:00.000", "description": "Report", "row_id": 1711765, "text": "PCA Progress Note 1900-0700\n\n\n#3 FEN: Weight 2690g ^ 5g. Total fluids 140cc/kg/d pf BM 24=\n63cc q4 po/pg. Pt. took 20cc when bottled. Pt. slow but\ncoordinated with bottling. Abd soft and round, +BS, no\nloops. Pt. had a medium spit X 1 and minimal aspirates.\nPt. is voiding and stooling, heme neg. P: Encourage po's\nand monitor daily weight.\n\n#4 DEV: Temps stable swaddles in a OAC. Pt. waking for some\nfeedings. MAE. Pt likes pacifier. . P: Continue to\nsupport developmental needs.\n\n#5 Parenting: No contact with family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-06 00:00:00.000", "description": "Report", "row_id": 1711766, "text": "PCA Progress Note 1900-0700\nI have examined pt. & agree w/ assessment & documentation. In addition, synagis given to pt. Circ planned for today.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711614, "text": "NPN 1900-0730\nSmall nodule on left antecube still present. No redness or drainage noted.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-05 00:00:00.000", "description": "Report", "row_id": 1711615, "text": "Nursing progress note\nAgree with above note of coworker.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711701, "text": "Neonatology NP Note\nPE\nswaddled in open crib\n, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good \n" }, { "category": "Nursing/other", "chartdate": "2121-12-25 00:00:00.000", "description": "Report", "row_id": 1711702, "text": "PCA NOTE\n\n\nRESP: In RA. No spells or desats noted. Occasionally drifts\nto high 70's-low 80's, self resolved. Otherwise, stable.\nP-Continue to monitor.\n\nFEN: Current weight 2.175, ^ 35gm. TF 140cc/k/d of BM/SC 28\nw/ promod. PG/1 hour. is voiding, trace stool. Active\nbowel sounds. Benign abdomen. Minimal residuals. No spits.\nTolerating feeds. P-Continue to follow current regimen as\nordered.\n\nDEV: Temp stable in OAC. Waking slowly for feeds. Alert and\nactive. Sleeps peacefully. MAE. AF-flat. Sucking on\npacifier. AGA. P-Continue to support developmental\nmilestones.\n\n: No contact over night.\n\n **See flowsheet for further details**\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-25 00:00:00.000", "description": "Report", "row_id": 1711703, "text": "NPN 1900-0700\nI have read and I agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-25 00:00:00.000", "description": "Report", "row_id": 1711704, "text": "Attending Note\nDay of life 34 CGA 34 0/7\nin room air RR 30-40\nlast spell \nstill with some drifts that are SR\nHR 130-160's BP 72/36 mea n49\nweight 2175 grams up 35 on 140 cc/kg/day of SSC or BM 28 cal/oz with promod pg over an hour\nvoiding and stooling\non iron and vit E\n\ns/p Hep B\n\nImp-stable making good progress\nwill begin going to breast\n" }, { "category": "Nursing/other", "chartdate": "2121-12-25 00:00:00.000", "description": "Report", "row_id": 1711705, "text": "Neonatology NP NOte\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small preterm nfant bundled in open crib, transitions easily from sleep to quiet awake state. Pink, arm, well perfused, comfortable brathing pattern.\n, eyes clear, NG in place, MMMP\nCV: RRR, no murmur, pulsess+2=\nAbd: soft, active bs, NTND\nGU: immature, testes palpable in scrotum\nEXT: , , WWP\nNeuro: symmetric , normal postiure and for PMA\n" }, { "category": "Nursing/other", "chartdate": "2121-12-25 00:00:00.000", "description": "Report", "row_id": 1711706, "text": "NPN 0700-1900\n\n\nRESP: Infant continues on RA, RR 30-40s. O2 sat >94%. LS\nc/=, mild SC retractions. No spells thus far this shift.\nOcc drifts to 80%s, QSR. Cont to monitor.\n\nFEN: TF 140cc/k/day, BM/SC 28 with PM, gavaged over 1 hr.\nAbd benign, no loops, active BS. AG=28cm. Voiding, sm\nstool x 1. Infant attempted to BF @ 1300. pt alert and\nactive. Latch <5min; passive/sleepy. Continue to attempt\nBF x 1 each day (as tolerated).\n\nDEV: Maintaining temps while swaddled in OAC. A/a with\ncares. Sleeps well btwn. Sucks on pacifier/hands. ,\n, AGA.\n\nPAR: in for 1300 cares. Updated at bedside by this\nRN. Asking approp questions. Independant with diaper\nchanging & temp taking. Appeared very loving &\naffectionate toward NB. Family mtg to be planned for next\nweek. Continue to support and updated as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-26 00:00:00.000", "description": "Report", "row_id": 1711571, "text": "Neonatology Attending Progress Note:\nDOl #5\nremains on RA\n5 spells/24 hours\n3 spells today--mild stime today\nlungs clear/equal, mild ic/sc retx\nno murmur, BP mean=39\ndouble phototherapy, bili=4.9 yesterday\nwt=1240g (no change). TF=150cc/kg/d, IV at 80, rest feeds\n142/6.0/111/19\nvoiding 4.1 cc/kg/hr, moderate mec overnight\nservo-isolette\n\nImp/Plan: x-29 week infant with mild AOP, advancing on feeds, physiologic jaundice, resolving metabolic acidosis. doing well.\n--continue to advance feeds as tolerated\n--monitor for spells, low threshold for caffeine\n--change to single phototherapy, monitor bilirubin on Friday\n--I updated family at bedside yesterday\n" }, { "category": "Nursing/other", "chartdate": "2121-11-26 00:00:00.000", "description": "Report", "row_id": 1711572, "text": "Nursing NICU note\n\n\n#2 Resp O: RA, 3 spells this shift. Loading does of caffeine\ngiven at 1400, no spells since. Sats >90%, rate 30-60. Lungs\nclear and equal. A: stable P: cont.to monitor for spells.\n#3 FEN O: TF 150cc/kg, IVF/Lipids 80cc's/kg of D10 infusing\nvia PIV without incident. Enteral feeds of SC20 now at\n80cc's/kg, 16cc's gavaged over 20minutes. Abd soft, no\nloops, no stool this shift, u/o 3cc/kg/hr. min. aspirates. D\nstick 78. A: pt tolerating nutritional plan. P: increase\nenteral feeds by 10cc/kg as ordered (5am/5pm schedule).\n#4 Dev. O: temps stable in servo isolette. Active and alert\nw/cares, MAE, sleeps well between cares. Baby likes\npacifier. A: AGA P: cont.to support dev. needs\n#5 O: here for evening care, asking\nappropriate questions, update given re: plan of care. A:\ninvolved P: cont to support, update, educate.\n#7 Hyperbilirubin O: pt now on single light phototherapy,\nsl. jaundiced. Feeds increasing. A: stable P: check bili\nlevel Fri AM per team.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-27 00:00:00.000", "description": "Report", "row_id": 1711573, "text": "npn 1900-0730\n\n\n2. Remains in ra. Sao2 in high 90's. Very few drifts to\nupper 80's with qsr. Ls cl/=. No major increased wob noted.\nCont. with baseline ic/sc retractions.Plan; cont. to monitor\nresp status.\n\n3. Remains on PN. Working up on enteral feeds now at\n90cc/k/d and Pn at 60cc/k/d. Taking 18cc q 4hrs of sim20 or\nbm20. Tolerating well. No spits, or asp. Abd soft, no\nloops.+bs. Voiding, stooling guiac - transitional stool.\nPlan; cont. to monitor tolerance to advancing feeds. Cont.\nto advance per team.\n\n4. Remains in servo isolette with temps stable. A/A. Calming\nwith positin change and pacifier. HOB up aat mainly for\nfeeds. Skin integrity good. All pg feeds at present. Plan;\ncont. to support g/d.\n\n5. NO contact from this eve.\n\n7. Remains under single phototherapy, ,ottled and ruddy in\nappearance. No increase in stool under photo. Plan obtain\nbili on friday per team.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-15 00:00:00.000", "description": "Report", "row_id": 1711659, "text": "Neonatology Attending Progress Note:\nDOL #24\nremains in RA, RR=20-50's, on caffeine, breath sounds clear\nHR=150-160\nBP mean=66\nwt=1785g (inc 70g), TF=150cc/kg/d MM/SC 28 with promod gavage over 90 minutes, one spit overnight\nvoiding, stools heme negative\nopen crib\nImp/Plan: premie doing well with mild feeding intolerance, mild AOP, doing well.\n--d/c caffeine, monitor for spells\n--monitor for feeding intolerance\n--decrease to 140cc/kg/d, monitor weight\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-15 00:00:00.000", "description": "Report", "row_id": 1711660, "text": "Fellow note; physical exam\nAlert and active in open crib. Breathing comfortably in RA. Skin pale, pink. . MMM. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Testes descended bilaterally. Extremities WWP with good cap refil. Good . Moving all extremities well.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-15 00:00:00.000", "description": "Report", "row_id": 1711661, "text": "NPN \n\n\n\n #2. RESP: INfant conts in RA. RR 30-60. LS cl/=. Mild\nretractions. Caffeine d/c'd today. Had 1 A/B during feeding.\nQSR. P: Cont to monitor for AOP.\n\n #3. TF decreased to 140cc/k/d d/t spits and rapid wt gain.\nBM/SC 28w/PM (42cc pg'd over 90min). Abd soft w/active BS,\nmin asp, no spits, no loops, /AG stable, voiding and no\nstool today. P: Cont to support nutritional needs.\n\n #4. DEV: Temp stable swaddled in OC. A&A w/cares. Not\nwaking for feeds. MAEW. Sleeps between cares. AFSO. P: Cont\nto support dev needs.\n\n #5. : Both in at 1700. Updates on infant's progress\ngiven at the bedside. Dad did cares. Both held. P: Cont\nsupport, ewducate and keep updated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711754, "text": "PCA NOTE\n\n\nFEN: Current weight 2.605, ^ 30gm. TF 140cc/k/d of BM/SC 26.\nAlternating PO/PG. Took 20 cc's PO this shift. is\nvoiding, no stool. Active bowel sounds. Abdomen is\nunremarkable. Minimal residuals. Small spit. Tolerating\nfeeds. P-Continue to encourage PO intake.\n\nDEV: Temp stable in OAC. Waking for feeds. Alert and active.\nTires easily. Sleeps peacefully. MAE. AF-flat. Sucks on\npacifier. Sweet natured. AGA. P-Continue to support\ndevelopmental milestones.\n\n: No contact over night.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711755, "text": "NPN:\n\nRESSP/CV: RA. RR=40-50. BBS =/clear. No A&Bs over past 24 h. Soft murmur. HR=140-150. BP=60/30 (42).\n\nG&D: CGA=35 wk. Bottle/gavage feeds. Circ planned for (permit signed).\n\nAgree w/above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711756, "text": "Neonatology Attending Note\nDOL# 43\nCGA 35 wk\n\nIn RA, no spells or desats\nHR 140-150s, MBP 42\n\nWt 2605 (up 30)\nOn 140 cc/kg BM 26\nAlternating PO/PG\n\nVoiding and stooling\n\nA/P:\nPremature infant with feeding immaturity\n- Continue to work on PO feeding\n- Discharge planning underway\n" }, { "category": "Nursing/other", "chartdate": "2122-01-13 00:00:00.000", "description": "Report", "row_id": 1711798, "text": "Nrsg Discharge Note-0700-1900\n\n\nTf remain minimum 130 cc's/kg with bm 26 cal (4 cals by \npowder and also 2 cals by corn oil). Po fdg 60 cc's q 4 hrs\nwith no spits or distention. No loops noted.Written Recipe\ngiven to Mom and with understanding of above. Last fdg\nat 1700 taken eagerly. A-Fen needs wnl this shift. P-Cont to\nassess fen needs.\n#4O/A-Rem nested in oc with minimal stressors noted. Alert\nand active with OT consult for home preparedness. \nreceptive to information. A-Parenting needs wnl this\nshift.P-Cont to assess parenting needs. VNA to follow and\nwill visit. Enable INC was notified with discharge today.\nInfant id band will be removed and infant will be discharged\nafter Mom places infant in car seat. aware that\nvidalyn and ferinsol have been given at 1300 today.\nA-Parenting needs with excited about discharge and\ntook CPR at 1630 with demostration done with mannequins.\nAsked approp questions. P-Cont to assess with VNA visit.\nPedi appt for .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-27 00:00:00.000", "description": "Report", "row_id": 1711574, "text": "Neonatology Attending Progress Note:\nDOL #6\nCGA 30 weeks\nremains in RA!!\nRR=30-60's sc/ic retx\nloaded with caffeine yesterday, 2 mild spells over past 24 hours\nHR=160's, no murmur, BP mean=43\nwt=1260g (inc 20g), TF=150cc/kg/d, advancing on feeds 10 cc/kg \nfeeds now at 90 cc/kg/d BM/SC 20\ndstx=84\nsingle phototherapy\nImp/Plan: x- 29 week infant with resolving RDS, AOP-mild, on caffeine, advancing on feeds, physiologic jaundice\n--d/c PN today\n--monitor spells on caffeine\n--advance feeds as tolerated\n--recheck bili tomorrow, lytes tomorrow\n--HUS tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-13 00:00:00.000", "description": "Report", "row_id": 1711652, "text": "NPN\n\n#2 S. O. Inafnt remains breathing in room air. Breath\nsounds clear and equal. R.R. 30's to 50's. Infant had qsr\ndesaturation to 77. He remains on caffiene as ordered. A.\nHx of a's and b's. P. Document.\n\n#3 S. Weight up 30 grams. voiding. No stool this shift.\nAbdomen soft with no loops. Infant rmeains on breast milk\n/special care28 calorie with promod at 150cc/kg/day. Feeds\ngavaged over 90 minutes. No spits. A. Gaining weight. P.\n Continue with current plan.\n\n#5 S. O. There has been no contact from the at this\ntime on this shift. A. in on day shift. P.\nSupport and keep updated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-13 00:00:00.000", "description": "Report", "row_id": 1711653, "text": "Neonatology Attending Note\nDOL #22, CGA 32 wks.\n\nCVR: Remains in RA, O2sats 95-100%. Mild intermittent retractions. On caffiene, mild desaturations/no bradycardia. Hemodynamically stable.\n\nFEN: Wt 1685, up 30 grams. TF 150 cc/kg/day, BM 28 or SC 28 w/PM, PG over 90 mins for history of spits; no spits overnight. Voiding/stooling.\n\nPE: active comfortable premature infant. Fontanelles soft and flat. Skin warm and pink. Chest clear, mild retractions. Cardiac RRR, no m. Abdomen soft, active BS. and activity appropriate.\n\nIMP: Overall stable growing premature infant, doing well! Gaining weight, tolerating feeds.\n\nPLANS:\n- Continue current management.\n- Continue caffeine for now, monitor spells.\n- Continue 28 cals, monitor growth.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-13 00:00:00.000", "description": "Report", "row_id": 1711654, "text": "NPN 0700-\n\n\n2. Remains in RA with sats 95-100%. Lungs clear. RR\n30-60's with mild SC retractions. On caffeine. No bradys\nthis shift. Occassional desats as low as 70's. One desat\ndown to 66%. Occassional periodic and shallow breathing\nnoted. Continue to monitor for A&B/desats.\n\n3. TF 150cc/k/d of BM28 w/PM. Abdomen benign. Voiding and\nhaving heme negative stools. One medium spit this\nafternoon. No aspirates. Tolerating NGT feeds gavaged over\n90minutes. Continue to monitor tolerance to feeds.\n\n4. Temp stable swaddled in off isolette. Awake and active\nwith cares. MAE. Rest well inbetween cares. Continue to\npromote development.\n\n5. in to visit and updated on plan of care.\n independent with infant cares. Mother able to\nkangaroo with today. Continue to support and update\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711757, "text": "Nursing Progress NOte:\n\nFEN:\nO: Infant recieving 140cc/kg of SC/BM 26, (61cc), po/pg,\nq4h. Po feeds successful, using nipple. At 9am took\n68cc. At 1pm, infant took 40cc, and gavaged rest after\ntiring. Infant presents with a strong suck reflex, and is\neager to feed. Abdominal exam benign. Minimal aspirates. No\nspits noted as of today. Infant voiding, and has not yet\nstooled this shift.\nA: Infant tolerating feeds well.\nP: Continue to advance po feeds as tolerated.\n\nDev:\nO: Infant temp stable. Swaddled in an OAC. WAking for feeds,\nand is alert and active with cares. Reaches hands to mouth.\n within normal limits. Infant enjoys pacifier for\nconsolement.\nA: Appropriate behavior for . age.\nP: continue to support development.\n\nSoc:\nO: in today at 1pm, with mom's sister. Updated\nregarding infant's status by RN. assissted in cares,\nand po fed infant. Dad read to infant. Mom continues to\npump.\nA: Interacting well with infant.\nP: continue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711758, "text": "I have examined this infant. I agree with PCA note and assessment.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-04 00:00:00.000", "description": "Report", "row_id": 1711759, "text": "Neonatology NP NOte\nPLease refer toattending note for details of evaluation and plan.\n\nPE: small well appearing infant nestled in open crib.\n, sutures approximated, ng in place, MMMP\nChest is clear, equal bs, comfortable resp pattern\nABd: soft, active bs, NTND\nEXT: MAE, WWP\nNeuro: symmetric , reflexes\n" }, { "category": "Nursing/other", "chartdate": "2121-12-14 00:00:00.000", "description": "Report", "row_id": 1711655, "text": "NPN\n\n\nNPN#2 O= remains in RA with sats 95-100%, RR 40's-60's, LS\nclear & equal bilat with mild IC/SCE, cont on caffeine as\nordered, no bradys overnight,occ quick SR desat to low 80's\nnoted, A= occ desat/ no bradys..stable in RA P= cont to\nmonitor for AOP, cont plan of care\n\nNPN#3 o= WT= 1715 ^ 30gms, TF at 150cc/kg/d of BM28 with\npromod q4hrs gavaged over 90min for hx: of spits..no spits\novernight, asp=.4-.8cc, abde exam softly rounded & benign,\nAG= 23.0-24.0 + active BS, no loops, voiding & stooling\nyellow G- stoolsA= feeds with good wt gain P= cont plan\nof care\n\nNPN#4 o=remains in off isolette swaddled & nested with\nboundaries in place, Active & alert with cares, good ,\nocc sucking on pacifer, AF soft & flat A= behaviors\nappropriate for GA P= cont to assess & support dev needs\n\nNPN#5 O= no contact from thus far this shift A/P=\ncont to teach/ update & support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711747, "text": "NNP Physical Exam\nPE: pink, active sucking on pacifer supine in crib, , sutures apposed, breath sounds clear/equla with easy WOB, RRr with soft murmur LSB, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711748, "text": "PCA Progress note 0700-1900\n\n\n#3 FEN: Total fluids 140cc/kg/d of BM 26/SC 26= 59 cc q 4hrs\npo/pg. Pt. sleepy at 9 AM cares gavaged full feed. Pt.\ntook 30cc at 1 PM feeding. Pt. uncoordinated, dribbling,\nrequiring chin support. Abd soft and round, no loops, +BS.\nPt. voiding, no stool so far this shift. Pt had a medium\nspit and minimal aspirates. P: Continue to encourage po's\nand monitor for feeding intolerances.\n\n#4 DEV: Pt. is swaddled in a OAC. Temps stable. Pt. waking\nfor some feedings. Pt. likes pacifier. MAE. Fontanelles\nsoft and flat. P: Continue to support developmental needs.\n\n#5 Parenting: No contact with so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711749, "text": "PCA Progress note 0700-1900\nI have examined pt. & agree w/ assessment & documentation.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-03 00:00:00.000", "description": "Report", "row_id": 1711750, "text": "NPN\n\n\n3. FEN: WT 2.575kg, up 60gr. TF 140cc/kg of BM/SC 26 60cc\nq4hr, alt PO/PG. PO fed with nippleat 1am-fairly well\ncoordinated, needing some chin support took 45cc. Abd soft,\nactive BS, no spits, min aspirates, voiding, no stools.\nTolerating feeds, encourage PO feeds QOF, gaining wt.\n\n4. Dev: Alert and active w/cares, sleeping in between. Wakes\nat times prior to feeds. Swaddled, likes pacifier. Temps\nWNL.\nAGA, support developmental needs.\n\n5. Parenting: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-03 00:00:00.000", "description": "Report", "row_id": 1711751, "text": "Neonatology Attending Note\nDOL #42, CGA 35 wks.\n\nCVR: Remains in RA. No spells. Hemodynamically stable.\n\nFEN: Wt 2575, up 60 grams. TF 150 cc/kg/day, BM 26/SC 26, alternating PO/PG, variable PO intake.\n\nPE: see other note.\n\nIMP: Overall stable growing premature infant. Still with feeding immaturity requiring PG feeds.\n\nPLANS:\n- Continue current management.\n- Continue encouraging PO intake.\n- Monitor respiratory status.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-25 00:00:00.000", "description": "Report", "row_id": 1711567, "text": "Neonatology Attending Progress Note:\nDOL #4\nremains in RA--off since , RR=30-50's\n3 spells/24 hours\nno murmur, HR=130-140's\ndouble phototherapy, bili=4.9/0.3\nwt=1240g (inc 15g), TF=140cc/kg/d advancing feeds, currently at 50 cc/kg/d\n144/5.1/111/15\nTG 119\nImp/Plan: premie with some AOP, metabolic acidosis unclear etiology--presumable urine losses but will monitor closely for PDA, advancing on feeds, physiologic jaudice.\n--monitor closely for spells, consider caffeine if increased number/frequency of spells\n--increase to 150cc/kg/d TF\n--continue to advance enteral feeds\n--continue on double phototherapy, check bili in 2 days.\n--check urine pH\n--monitor weight.\n--check lytes.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-25 00:00:00.000", "description": "Report", "row_id": 1711568, "text": "NPN DAYS\n\n\n2. Remains in RA. LS clear. RR 30-40's. O2 sats>94%. No\nspells. Stable in RA. Monitor.\n\n3. TF advanced to 150cc/kg. Feedings currently at 50cc/kg of\nBM20. Gavaged over 30min. IVF PN infusing well. DS stable.\nAbd benign. No spits, no residuals. Voiding 4.8cc/kg/hr\nx8hrs. Urine ph 5 today. Team aware. Will obtain urine UA\nand urine Na and K today. No stool. Abd benign. Lytes to be\nchecked in am. Continue to advance feeds as tolerated and\nf/u with labs.\n\n4. Temp stable in servo isolette. Boundaries in place. Alert\nand active with cares. AGA.\n\n5. in for afternoon cares. Updated. Asking\nappropriate questions. Will kangaroo infant tomorrow. Loving\nfamily.\n\n7. Continues under double phototherapy. Ruddy in color.\nContinue with plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-25 00:00:00.000", "description": "Report", "row_id": 1711569, "text": "Rehab/OT\n\n observed today during cares. Noted infant strengths, stress signals, and ways to make infant comfortable. Care plan created and posted at the bedside. Please refer to for details. OT to follow for developmental care interventions.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-26 00:00:00.000", "description": "Report", "row_id": 1711570, "text": "NPN\n\n\nNPN#2 O= remains in RA with sats>93%, RR mostly 30's-60's LS\nclear & equal with mild IC/SCR, occ spell..x2 overnight both\nSR( see flow sheet), no caffeine yet A= occ spell P=cont to\nmonitor #,frequency & severity of spells..consider caffeine\nif spells ^, cont plan of care\n\nNPN#3 O= WT 1240gms..no change from night before, remain on\nTF of 150cc/kg/d adv on feeds..enteral feeds currently on\n79cc/kg/d of BM/SC20 q4hrs adv by 10cc/kg/..IVF at\n80cc/kg/d of PND10 & lipids..infusing well via PIV, DS= 71,\nlyte= 142/ 6.0/ 111/ 19..abd exam soft/flat +BS, no loops,\nAG= 20.0, tol feeds/ no spits..passing mod/lg mec stools.\nuo= 4.1cc/kg/d A= tol feeds/ hx of metabolic acidosis..TCO2^\n19...P= cont with feeds plan...monitor tolerance of feeds &\nabd exams, follow lytes\n\nNPN#4 O= remains on servo in heated isolette with stable\ntemp, AF soft & flat with overidding sutures, active & alert\nwith cares, good , , hands to face, nested in\nsheepskin with bumper in place, settles nicely between\ncares with containment & pacifer A= behaviors appropriate\nfor GA P= cont to assess & support dev needs\n\nNPN#5 O= no contact thus far from this shift A/P=\ncont to teach, update & support\n\nNPN#7 O= remains under double phototherapy with protective\neye patches in place, color jaundice/ruddy,adv on\nfeeds..passing mec stools, no new bili level ordered for\ntoday A= hyperbili P= cont to monitor bili levels & max skin\nexposure to lights\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-03 00:00:00.000", "description": "Report", "row_id": 1711752, "text": "Nursing Progress Note\n\n\n3. FEN O/A TF=140cc/kg/day of BM or SC26. Alt PO/PG, inf\ntaking 15cc PO at 0900. feeds well, sm spit. Min asp.\nBelly soft, no loops. Voiding, no stool thus far. P cont\nto offer PO feeds as .\n4. DEV O/A remains in an OAC with stable temp. A/A\nwith cares, sleeping well between cares. Likes pacifier.\nLoves to be held. P cont to assess dev needs.\n5. O/A Dad and grandparents in for 1300 cares.\nUpdates given. Dad independent with care of infant. Loving\nfamily. P Mom plans to visit at 1700 cares.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-03 00:00:00.000", "description": "Report", "row_id": 1711753, "text": "Neonatology - NNP Progress Note\n\nInfant is active with good . . He is pink, well perfused, soft murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-24 00:00:00.000", "description": "Report", "row_id": 1711563, "text": "Neonatology Attending Progress Note:\nDOL #3\nRA, 1 spells overnight\nno murmur\nBp=50/32 (MAP=38), on double phototherapy (bili=6.5)\nwt=1225g ( 50g), TF=120cc/kg/d, feeds at 30cc/kg/d (increasing 10 )\nvoiding, trace mec yesterday\nlytes: 148/6.0/115/17\n\nImp/Plan: x-29 week infant with mild AOP, s/p RDS, physiologic jaundice, advancing on feeds.\n--monitor spells, consider caffeine if increased number/severity of spells\n--increase to 140cc/kg/d, continue to advance feeds as tolerated\n--check TG, lytes, bili in am.\n--continue rest of present management.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-24 00:00:00.000", "description": "Report", "row_id": 1711564, "text": "NPN\n\n\n#2 RA, resp rate 30-60 with occasional tachypnea, mild SC/IC\nretractions noted, lungs clear and equal, no desats, no\nbradycardia. Continue to monitor.\n\n#3 Total fluids increased to 140cc/kg/day. Enteral feeds\ncurrently up to 30cc/kg/dayof BM or SC 20/cal/oz. Plan to\nincrease by 10cc/kg/. IVF D10PN with lipids currently at\n110cc/kg via PIV. Voiding, abd soft and benign, BS active.\nPlan to check lytes, bili and triglyceride levels. Continue\nwith current feeding plan.\n\n#4 Active and alert with cares, appropriate response to\nstimuli. Temp stable in servo controlled isolette. Hands to\nface and mouth, sucking on pacifer.\n\n#5 MOm and dad in to visit, dad kangarooing infant.\nParticipating in all cares and asking appropriate questions.\nLoving family.\n\n#7 Continues on double photo. Plan to recheck bili tonight.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-11 00:00:00.000", "description": "Report", "row_id": 1711645, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in RA. Skin pink. . MMM. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Testes descended bilaterally. Extrem WWP. Normal . MAEW.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-11 00:00:00.000", "description": "Report", "row_id": 1711646, "text": "agree with above note by , PCA. here for 1700 cares, Mom held .\n" }, { "category": "Nursing/other", "chartdate": "2121-12-12 00:00:00.000", "description": "Report", "row_id": 1711647, "text": "PCA NOte\n\n\nRESP:\nInfant is in RA, resp rates 30-50's, O2 sats 94-100%, MSCRTX\nnoted, LS C/= bilat to auscultation. Infant is on\ncaffeine.Seems to be breathing comfortably.\nP: COntinue to monitor resp status.\n\nFEN:\nWT is now 1655 up 35 grams. TF are @ 150cc/kg/day of BM/SC\n28 w/ promod; 41 cc's over 90 mins to prevent spits. Infant\nis voiding and had a trace stool, 1 spit, max asp 0f\n1cc-benign.BS+, no loops, belly soft/round. Infant seems to\nbe tolerating feeds well.\nP; Continue to support nutritional needs.\n\nG/D:\nTemps are stable while infant is swaddled in off isolette.\nIs not yet waking for cares, is alert anc active w/ cares,\nsleeps well in between. Calms easily with pacifier , likes\nto bring hands to face to comfort self. Fonts soft/flat.\nAGA.\nP: Continue to support developmental needs.\n\n: No contavt from thus far by this PCA.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-12 00:00:00.000", "description": "Report", "row_id": 1711648, "text": "Nursing\n\n\nI have examined baby and agree w/ the above note.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-12 00:00:00.000", "description": "Report", "row_id": 1711649, "text": "Neonatology Attending Progress Note:\nDOL #21\nPMA 32 1/7 weeks\nremains in RA, no spells, on caffeine\nRR=30-50's, mild ic/sc retx\nno murmur, HR=150-160's, BP mean=54\n1655g BM 28 with promod feeds gavaged over 90 minutes, one moderate spit overnight\nvitamin E and iron\nImp/Plan: x-29 week infant with AOP--on caffeine, F and G, doing well.\nmonitor for spells\nmonitor weight on current regimen\ncontinue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-12 00:00:00.000", "description": "Report", "row_id": 1711650, "text": "Fellow note; physical exam\nAlert and active. Breathing comfortably in RA. Skin pink. . MMM. Lungs clear. RRR. No murmur. Normal femoral pulses. Abd soft, ND, +BS. Testes descended bilaterally. Extrem WWP. Good . MAEW.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-12 00:00:00.000", "description": "Report", "row_id": 1711651, "text": "NPN day\n\n\nRESP: Infant in room air, lungs clear and equal, mild SC\nretractions, RR 30-50's, no spells, no desats. Continues on\ncaffeine will continue to monitor closely for signs or\nsymptoms of increased WOB.\n\nFEN: Total fluids 150cc/k/d of BM 28with promod. All\ngavage feeds Q4hours, given over 90min. No spits, max\nresidual 3cc. Abdomen is soft, pink, active bowel sounds,\nno loops, AG stable. Voiding, no stool this shift.\ntolerating feeds well, will continue per feeding plan, and\nmonitor closely for signs or symptoms of feeding\nintolerance.\n\nDEV: Temps are stable, swaddled in off isolette. alert and\nactive with cares, sleeping well in between cares.\nTolerated kangarooing well today. Will continue to support\ndevelopmental needs.\n\nParenting: Mother and father in today, participating in\ncares. with infant. Asking appropriate ?'s.\nInvolved and loving family. will continue to support and\nupdate family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-24 00:00:00.000", "description": "Report", "row_id": 1711565, "text": "Clinical Nutrition:\nO:\n~29 week CGA BB on DOL 3.\nWT: 1225g(-50)(~50th %ile); BWT: 1360g. WT is ~10% below BWT.\nHC: 26.5cm(~25th %ile); HC @ birth: 26.5cm\nLN: 41.5cm(~75th %ile); LN @ birth: 40.5cm\nLabs noted.\nNutrition: TF @ 140cc/kg/day. PN infusing via PIV. EN feeds SC20/pg. Projected intake for next 24hrs from PN ~62kcal/kg/day, ~2.6g pro/kg/day & ~1.5g fat/kg/day; from EN feeds ~27kcal/kg/day, ~0.7g pro/kg/day & ~1.5g fat/kg/day. Glucose infusion rate from PN ~6.1mg/kg/min.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems, pg. PN infusing/tapering as EN feeds advance. Labs noted & within acceptable ranges except for elevated K+ but reported to be hemolyzed, low CO2; Ac max in PN. WT is still below BWT & HC gain is not yet meeting recs. LN gain is exceeding recs of ~1cm/wk(based on 4days average), ?accuracy. Will follow long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-25 00:00:00.000", "description": "Report", "row_id": 1711566, "text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA with O2 sats > 95%. RR\n30's-50's. Breath sounds are clear and equal. Mild IC/SC\nretractions noted. No spells thus far. A: Stable in RA. P:\nContinue to monitor.\n\n#3. O: Infant remains on TF's of 140cc/k/d. IVF's of D10PN\nand IL's infusing well via PIV at 90cc/k/d. Feeds of BM\ncurrantly at 50cc/k/d. No spits. Minimal aspirates. AG\nstable. Abd soft and round with active bowel sounds. No\nloops. Voiding 3.1cc/k/hr. No stools this shift. A:\nAdvancing feeds. P: Continue to advance feeds 10cc/k/ as\ntolerated.\n\n#4. O: Infant remains in servo isolette with stable temp. He\nis alert and active with cares. MAEW. Sucking on fingers. A:\nAGA. P: Continue to assess and support developmental needs.\n\n#5. No contact from thus far this 11p-7a shift.\n\n#7. O: Infant remains under double phototherapy. Eye \nin place. A: Hyperbili. P: Continue with treatment. A.M.\nbili pending.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-10 00:00:00.000", "description": "Report", "row_id": 1711640, "text": "Neonatology Attending Progress Note:\nDOL #19\n31 6/7 weeks PMA\nremains in RA, RR=30-60's, mild sc/ic retx\noccasional drifts,\none spell yesterday, on caffeine\nno murmur, HR=150-160's, BP mean=58\nwt=1585 (inc 25g), 140 cc/kg/d BM 28 with promod--one spit\non iron vitamin E\nstools heme negative\noff isolette this am.\nImp/Plan: x-29 week infant with AOP--doing well, mild feeding intolerance, doing well.\n--monitor for spells on caffeine\n--monitor weight\n--continue presenst management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-10 00:00:00.000", "description": "Report", "row_id": 1711641, "text": "Resp O/A: RA, occasional mild ic/subcostal retractions, sats\n>90%, RR 30s-60s, 1 spell thus far this shift while sleeping\nHR120, Sat40, became dusky, administered blowby. Drifts to\nhigh 70s/low 80s during feeds. On caffeine. P: Continue to\nmonitor and administer caffeine.\n\nFEN O/A: Min 150/kilo/day BM28 or SC28, 40cc Q4 PG over 1\nhour 30 minutes. Girth 23-25cm, voiding/ stooling heme-, abd\nsoft, round, pink, +BS, max aspirate 2.2cc, no spits. P:\nContinue to monitor.\n\nG&D O/A: Swaddled in off isolette, stable temp 98.7-99.3,\nA&P fontanells soft and flat, alert and active with cares,\ncalms easily, self soothes. P: Continue to monitor.\n\n O/A: No contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-10 00:00:00.000", "description": "Report", "row_id": 1711642, "text": "NPN\n\n\nI supervised , PCA, care of . I\nagree with her care and assessment. I gave medications. No\ncontact with .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-01 00:00:00.000", "description": "Report", "row_id": 1711739, "text": "PCA\n\n\n#3FEN: wt 2445, no change. tf remains at 140cc's/kg/d of\nBM/SC24. alt po/pg schedule. 57cc's Q4H gavaged over 50\nminutes. infant took entire volume x1. abd benign, belly is\nsoft and round, no loops, no spits, max asp 4.8cc's,\nvoiding, no stool yet this shift. A: feeds well P:Cont to\nmonitor and encourage po feedings as tolerated\n\n#4DEVE: temp stable. infant is swaddled in the oac. alert\nand active with cares. sleeps well in between. mae. font are\nsoft and flat. A:AGA P:cont to support\n\n#5PARENTING: no contact thus far A/P:cont to support\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-01 00:00:00.000", "description": "Report", "row_id": 1711740, "text": "Attending Note\nDay of life 41 CGA 35 \nin room air RR 30-40's\nHR 140-150's BP 73/40 mean 50\nweight 2445 grams no change on 140 cc/kg/day of BM 26 cal/oz alternating po/pg\nvoiding but no stool\non iron and vit E\n\nImp-stable making good progress\nwill continue to encourage po feed\nwill continue current calories\n" }, { "category": "Nursing/other", "chartdate": "2122-01-01 00:00:00.000", "description": "Report", "row_id": 1711741, "text": "NPN \n\n\n\n #3. FEN: TF 140cc/k BM/SC 26 (57cc pg'd over 50min).\nOffered bottle x2. Took entire volume both times using\n nipple. Mom did 1 of those feedings. Abd benign. Had\n1 med spit. Voiding and no stool yet today. Given rectal\nstim. A: Learning to po. P: Cont to encourage po feeds.\n\n #4. DEV: Temp stable swaddled in OC. Starting to lighten\nbefore cares. A&A w/cares. Dr. office called to\nset up circ for next week. have Q&A for synergis.\nBath to be done. P: Cont dev care and start d/c\nplanning. Eye exam next week.\n\n #5. : Mom in for 1300 cares today. She left work\nearly today and came w/o dad. She was very excited that \ntook his whole bottle twice in a row. She is seeing an end\nin sight. P: Start d/c teaching. Need CPR. Cont support &\nkeep updated\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-01 00:00:00.000", "description": "Report", "row_id": 1711742, "text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert, , sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711743, "text": "PCA 1900-0700\n\n\n3\nCW 2515g up 70g, TF 140cc/kg/d of BM/SC26, needs 59cc q4h,\nPO as tolerated, bottled 50cc with good coordination, abd\nsoft, bs+, no loops, max asp 1.2cc, small spit x1,\nvoding/stooling heme neg. P:cont to support nutritional\nneeds.\n\n4\nremains swaddled in OAC, temp stable, a/a with cares,\nsettles well in between, occ wakes for feeds, fonts\nsoft/flat. P:cont to support growth and dev.\n\n5\nno known contact thus far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711744, "text": "7p-7a npn\nAgree with above note by PCA.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711745, "text": "Case Management Note\n Pilgrim case manager said to use Partners () if services recommended at d'c. I will cont to follow & assist w/any d'c planning.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-02 00:00:00.000", "description": "Report", "row_id": 1711746, "text": "Attending NOte\nDay of life 42 CGA 35 \nin room air RR 30-50's\nHR 130-150's BP 64/30 mean 46\n2515 up 70 on 140 cc/kg/day of BM 26 or SSC 26 cal/oz took 50/64 cc po alternating\nvoiding and stooling heme negative\nin open air crib\n\nImp-stable currently\nwill continue to encouarge po feeds\n" }, { "category": "Nursing/other", "chartdate": "2121-11-23 00:00:00.000", "description": "Report", "row_id": 1711560, "text": "NPN 7a7p\n\n\nSepsis\nInfant was on amp and gent for 48 hr R/O. No growth in clt.\nAbx dcd this am. No additional S&S of infection. Cont to\nmonitor for infection.\nResp\nInfant in RA with adeq sats. LSC. S/C I/C rtxs. Not started\non caffiene. Did have x 1 desat and near brady at mid day,\nimmediatly after crying and cares and infant also had a\npaciifer in his mouth. No other desats noted. Monitor and\nsupport resp status.\nFEN\nInfant on TF 120 cc/k/d. Fluids increased today. NA 147.\nFeeds increasing by 10 cc and are presently at 20 cc/k/d\nof Bm or SC 20. PND10 and IL at 100 cc/k/d delivered via\nPIV. Abd soft, round with active BS. Had some soft loops\nthis am, transiant. Had x 1 questionable asp midday, refed\nand subsequent asps were min and benign. Small trace mec\nstools. Voiding. DS stable. Increase feeds as tolerated.\nMonitor weight and exam.\nG/D\nInfant in servo isolette with warm temps. Isolette weaned.\nA/A for cares, sleeping well between. Hands to face. MAEs.\nFS&F. Questioned hernia: assessed by NNP but not\nappreciated. HUS scheduled for Friday. AGA. Monitor and\nsupport G/D.\nParenting\nBoth parents in for cares today. Mom dcd home. Will be in\ntomorrow with FOB. Working on transportation issues. Asking\nappropiate question. Interactive and appropiate with infant.\nMom given breast pump from NICU lactation and she\nplans to have it returned by tomorrow. Invested and loving\nparents. Support and educate.\nBili\nInfant p[resently under double lights. Repeat bili risen\nNOC. Ruddy jaundice. Stooling and active. Starting feeds.\nMonitor labs, activity and color.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-23 00:00:00.000", "description": "Report", "row_id": 1711561, "text": "1 Infant with Potential Sepsis\n6 Hemodynamics\n7 hyperbili\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n 6 Hemodynamics; resolved\n 7 hyperbili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-24 00:00:00.000", "description": "Report", "row_id": 1711562, "text": "Nursing NICU Note\n\n\n2. Resp. O/Pt remains in RA. One brief Apneic spell noted\nafter blood draw. Otherwise no drifts in saturations noted.\nA/One spell. Otherwise resp status appears stable in RA.\n\n3. F/N. O/TF remain at 120cc/k/d. Enteral feeds remain at\n20cc/k/d of BM/ SC 20 PNGT. TPN D10 running at 100cc/k/d\nvia intact PIV. Please refer to flowsheet for examinations\nof pt from this shift. Voiding. A/Advancing feeds as ordered\nand as pt tolerates. P/Cont. to monitor for s/s of feeding\nintolerance.\n\n4. Dev. O/Temp slightly elevated on servo control in an\nisolette nested in sheepskin. Adjusting servo control\ngradually. Awake alert and active with cares. Sleeping well\nin between care times. Rooting occasionally noted. Sucks on\npacifier briefly. PKU sent. A/Alt. in G/D. P/Cont. to\nsupport pt's growth and dev. needs.\n\n5. . O/No contact from . A/Unable to fully\nassess involvement. P/Cont. to support and educate\n.\n\n7. hyperbili. O/Pt remains under double phototherapy. Skin\npink and slightly jaundiced. bili sent- pending at this\ntime. A/Treatment for hyperbili. P/Cont. to monitor\neffectiveness of phototherapy.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-11 00:00:00.000", "description": "Report", "row_id": 1711643, "text": "Neonatology Attending Progress Note:\nDOL #20\nRA, RR=30-50's\none spell over 24 hours\nno murmur, on caffeine, BP mean=59\nwt=1620g (inc 35g), TF=150cc/kg/d SC 28 with promod, feeds over 1 1/2 hours, voiding, heme negative stools\noff isolette, temps stable\nImp/Plan: premie with resolved RDS, mild AOP, F and G.\n--monitor for feeding intolerance, monitor weight\n--monitor for spells on caffeine\n--continue present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-11 00:00:00.000", "description": "Report", "row_id": 1711644, "text": "Nursing Progress NOte:\n\nResp:\nO: Respiratory rate 30-60's, with sats remaining above 93%\non RA. No drifts noted as of today. Last spell noted\nyesterday . Infant has mild subcostal retrations. No\nnasal flaring or grunting noted. Infant resting comfortably.\nA: No signs of respiratory distress\nP: Continue to monitor hourly.\n\nNutrition:\nO: Infant recieving 150cc/kg of BM/SC 28 with promod,\n(40cc), every 4 hours, gavaged over 1.5 hours d/t hx of\nspits. One small spit noted this am before feed, as infant\nwas laying supine. Max aspirate of 5cc, also r/t supine\nposition. Minimal aspirates since. Girth remains 22-23cm.\nAbdominal exam benign. Infant voiding and passing heme\nnegative stool.\nA: Infant tolerating feeds well.\nP: Continue to advance feeds as tolerated.\n\nDevelopment:\nO: Infant temperature stable around 99.0 in an off isolette.\nNested with sheepskin, and is also swaddled. Infant active\nand alert with cares. within normal limits. Infant\nsucks hands and pacifier for consolement.\nA: Infant behavior appropriate for gestational age.\nP: Continue to support development.\n\nParenting:\nO: Have not spoke to yet today.\nA: Unable to assess at this time.\nP: Continue to support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711734, "text": "Neonatology NP Note\nPE\nswaddled in open crib\n, sutures opposed\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good \nskin without rash or lesions\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711735, "text": "Attending Note\nDay of life 39 CGA 34 \nin room air RR 40-60\nlast spell \nsoft murmur Hr 150-160's\nweight 2445 up 20 on 140 cc/kg/day of BM or SSC 28 cal/oz with promod alternating po/pg when pg it is over 50 min poor po feeding\nvoiding and stooling heme negative\nin open crib\n\nImp-stable making progress\nwill decrease to 26 cal/oz will d/c promod\nfamily meeting today\n" }, { "category": "Nursing/other", "chartdate": "2121-11-23 00:00:00.000", "description": "Report", "row_id": 1711557, "text": "Nursing NICU Note\n\n\n1. Sepsis. O/Pt remains on Amp and Gent PIV. Blood cultures\nneg to date. A/Sepsis eval. P/Cont. to monitor.\n\n2. Resp. O/Remains in RA. No A/B noted this shift thus far.\nNO desaturations noted. A/Resp status appears stable in RA.\nP/Cont. to monitor for evidence of resp distress.\n\n3. F/N. O/TF remain at 100cc/k/d. Enteral feeds of BM20/SC\n 20 remain at 10cc/k/d. TPN D10 running at 90cc/k/d via\nintact PIV. Please refer to flowsheet for examinations of pt\nfrom this shift. Voiding well. No stool passed this shift.\nA/Appears to be tolerating present feeding regimen. P/Cont.\nto monitor for evidence of feeding intolerance.\n\n4. Dev. O/Sleeping well in between cares. Awake active and\nalert during care times. Temp remains stable on servo\ncontrol in an isolette nested in sheepskin. A/Alt. in G/D.\nP/Cont. to support pt's growth and dev. needs.\n\n5. Parents. O/Mother in briefly. This nurse did not have\ncontact with mother. supplying breastmilk. A/Unable to\nfully assess parent's involvement. P/Cont. to support and\neducate parents.\n\n6. hemodynamics. O/No murmur noted. PLease refer to\nflowsheet for BP results. Skin remains ruddy pink and well\nperfused. Extremities warm to touch. P/Cont. to monitor.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-23 00:00:00.000", "description": "Report", "row_id": 1711558, "text": "Neonatology Attending\n\nDay 2 PMA 29 wks\n\nRemains in RA. Sats >95%. Had one bradycardia episode. BP mean 36. No murmur. Weight 1275 gms (-45). TF at 100 cc/kg/d. Enteral feeds of BM/SC20 at 10 cc/kg/d. Supplemented with PN 10 and lipids. Benign abdomen. Soft loops noted. Passed meconium. Stable temperature in servo-controlled incubator. On ampicillin and gentamicin. Blood culture no growth. Bilirubin 8.4/0.4 under double phototherapy. Lytes 147/4.5/111/25.\n\nMild breathing control immaturity. Will monitor closely. Tolerating feeds well. Will continue to advance as tolerated by 10 cc/kg twice daily. Increasing fluids to 120 cc/kg/d. Following lytes, bilirubin.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-23 00:00:00.000", "description": "Report", "row_id": 1711559, "text": "Neonatology-NNP Progress Note\n\nPE: remains in his isolette, nested, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, V&S, gavage and piv in place, afso, jaundiced under pt\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711633, "text": "PCA 1900-0700\n\n\n2\ninfant remains in RA, RR 30-40, lung sounds cl=, O2 SATs\n92-100%, occ retractions, no spells, no desats. P:cont to\nmonitor.\n\n3\nCW 1560g yp 20g, TF 150cc/kg/d of BM/SC 28 with promod=39cc\nq4h gavaged over 75 minutes, abd soft, bs+, no loops, ag\n23-24cm, max asp 1.0cc, no spits, voiding/stooling qs heme\nneg. P:cont to support nutritional needs.\n\n4\ninfant swaddled in air isolette, temp stable, a/a with\ncares, settles well in between, occ sucks on pacifier, fonts\nsoft/flat. P:cont to support growth and dev.\n\n5\nno known contact thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711634, "text": "NURSING ADDENDUM\n\nI HAVE EXAMINED THIS INFANT AND AGREE WITH ABOVE ASSESSMENT AND NOTE\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711635, "text": "Neonatology Attending Progress Note:\nDOL #18\nx-29 1/7 weeks\nRA, no spell x 24 hours, on caffeine, occasional mild retx, no tachypnea, no murmur, HR=150-160's, BP mean=55\nwt=1516g (inc 20g), TF=150cc/kg/d SC 28 with promod over 1 hour 15 minutes due to hx spits\noff isolette\nImp/Plan: premie with AOP, resolved RDS, F and G.\n--nutrition labs on \n--monitor for spits, monitor weight as tolerated\n-- monitor for spells\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711636, "text": "Resp O/A: RA, 20s-50s, CL=, sats 92-100%, occasional sub/int\nretractions, no spells thus far this shift, on caffeine. P:\nContinue to monitor and administer caffeine.\n\nFEN O/A: 150/kilo/d SC or BM28 with PM. 39cc Q4 PG over 1\nhour 15min. No spits thus far this shift, abdomen soft,\npink, no loops, +BS, voiding/ stooling heme-, girth 23cm,\nmax aspirate 1cc. P: Continue to monitor.\n\nG&D O/A: Isolette at minimum settings, stable temps, A&P\nfontanells soft and flat, sutures approximated, self\nsoothes, moves hands to midline. P: Continue to monitor.\n\nParenting O/A: Mom and Dad in for 2 hours at 1300, both\nhelped with care, Mom kangarooed, both asked appropriate\nquestions, seem like very loving . P: Continue to\ninform and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711637, "text": "Resp: One brady with a spit at 1530 today, low HR 40, low\nsat 60, very quick selve resolving, became slightly dusky,\nused bulb syringe to remove spit from nares and mouth. P:\nContinue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-09 00:00:00.000", "description": "Report", "row_id": 1711638, "text": "I supervised care of by , PCA, I\nagree with her assessment and care of the baby. I updated\nthe , I gave medications.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-10 00:00:00.000", "description": "Report", "row_id": 1711639, "text": "NPN -0430\n\n\nRESP: Infant remains on RA, O2 sat >90%. RR 30-60s, mild\nIC/SC retractions. No spells so far tonight. Occ drifts to\n70-80%s, mild stim required for resolvement. Total of 1\nspell in 24 hrs. Pt is on caffeine.\n\nFEN: CW 1585g (up 25g). TF 150cc/k/d BM/SC28 with PM.\nInfant had lg spit with 2100 cares, therefore feed gavaged\nnow over 1hr 30min. Abd exam benign, no loops, active BS.\nmin asp. Voiding, stooling heme negative.\n\nDEV: Temps stable while swaddled in air isolette. A/a with\ncares, sleeps well btwn. Sucks on pacifier, moves hands to\nface. , , AGA.\n\nPAR: No contact so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711736, "text": "Clinical Nutrition\nO:\n~35 wk CGA BB on DOL 40.\nWT: 2445 g (+20)(~50th to 75th %Ile); birth wt: 1360 g. Average wt gain over past wk ~44 g/day.\nHC: 32 cm (~50th %Ile); last: 31.5 cm\nLN: 44 cm (~25th to 50th %ile); last: 43.5 cm\nMeds include Fe and Vit E\n due but deferred by team.\nNutrition: 140 cc/kg/day BM 26, alternating po/pg over 50 min feeds due to hx of spits. Infant takes only ~ of volume or less po; poorly coordinated. Feeds just decreased today due to good wt gain; projected intake for next 24 hrs ~121 kcal/kg/day and ~3 g pro/kg/day.\nGI: Abdomen benign. Large spit noted; gavage time increased to 50 min.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems except spits as noted above; none since gavage time increased to 50 min. Just starting to po feed. due but team has deferred. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC gain. WT gain is exceeding recommended ~20 to 35 g/day; kcals decreased in response. LN gain is not meeting recommended ~1 cm/wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711737, "text": "PCA Note:\n\n\n#3 FEN: O: Total fluids remain @ 140cc/kg. Calories\ndecreased from 28 to 26 (BM or SC). Q4hr feedings\nalternating PO/PG. PO intake today thus far = 35cc/feed. Mom\nplans to breastfeed this afternoon (1700). Infant's abdomen\nis soft, NT, ND, +BS, no loops. Minimal aspirates, no spits.\nInfant is voiding, no stool today thus far. A: Infant\ntolerating feedings well. P: Continue to encourage PO\nfeedings. Continue to support infant's nutritional needs.\n\n#4 DEV: O: Infant remains swaddled in an OAC, maintaining\nstable temps. Infant sleeps well between cares. Infant wakes\nwith cares and remains alert and active throughout. Infant\ncalms with his pacifier. . A: AGA. P: Continue to\nsupport infant's developmental needs.\n\n#5 : O: plan to be in this afternoon for a\nfamily meeting and 1700 cares. Mom plans to breastfeed. P:\nContinue to support, teach and prepare for\ndischarge.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711738, "text": "Neonatology NP Note\nFamily meeting held with both and RN D. and myself.\nDiscussed:\nexcellent progress thus far\ncriteria for discharge, only remaining goal is mature oral feedings, expect that to occur over the next 2 weeks\n-will d/c on supplemental calories 24 cal/0z\n-fe\nprimary pediatrician at pediatrics.\nDiscussed synagis\n" }, { "category": "Radiology", "chartdate": "2121-12-18 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 850360, "text": " 7:22 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: follow-up previous study; rule out PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 29 weeks now 1 month old\n REASON FOR THIS EXAMINATION:\n follow-up previous study; rule out PVL\n ______________________________________________________________________________\n FINAL REPORT\n This is a baby boy at 29 week gestation now about a month old. Exam performed\n on was normal as is today's exam. There is no evidence of\n intraventricular hemorrhage, ventriculomegaly or parenchymal disease.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-21 00:00:00.000", "description": "BABYGRAM CHEST & ABD (TOGETHER ONE FILM)", "row_id": 847175, "text": " 8:58 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # \n Reason: 29wk, intub\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress, intub\n REASON FOR THIS EXAMINATION:\n 29wk, intub\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM:\n\n ETT is at the orifice of the right main stem bronchus. The study is limited\n due to the patient's arm overlying the left hemithorax. There is hazy opacity\n bilaterally without definite air bronchograms. The findings may reflect early\n hyaline membrane disease, but infiltrate or edema cannot be excluded. There\n is a normal abdominal gas pattern. No pneumothorax or pneumomediastinum is\n seen.\n\n" }, { "category": "Radiology", "chartdate": "2121-11-28 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 848017, "text": " 7:16 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT ASSESS IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 29 weeks now 1 week old\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n CRANIAL ULTRASOUND:\n\n Images were obtained in coronal and transverse planes through the anterior\n fontanelle and in the axial plane through a mastoid approach. No previous\n studies are available for comparison. The ventricles are of normal size\n without evidence of midline shift. There is no evidence of subependymal,\n intraventricular or intraparenchymal hemorrhage. The sulcation pattern is\n normal for age. No gross intraparenchymal pathology is seen. The extra-axial\n spaces are within normal limits.\n\n IMPRESSION: Normal cranial ultrasound.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-30 00:00:00.000", "description": "Report", "row_id": 1711589, "text": "Attending Note\nDay of life 9 CGA 30 \nin room air RR 30-60's no spells in 24 hours on caffeine\nHR 130-160's BP 59/37 mean 43\nweight 1320 up 5 grams on BM or SSC 20 cal/oz at 150 cc/kg/day all pg\ndstick overnight 68\non vanco/ trough 4.2 for the a repeat CBC today was not shifted wbc 10.1 (22P 2B 33L 17 atypical 5 others) plt 344\nblood culture no growth to date\nin servo controlled isolette\non double photo for a bili 6.9/0.3\n\nImp-making slow progress\nwill advance calories tomorrow\nwill recheck bili tomorrow\nwill d/c vanco/ today\n" }, { "category": "Nursing/other", "chartdate": "2121-11-30 00:00:00.000", "description": "Report", "row_id": 1711590, "text": "NPN \n\n\n\n #2. RESP: Infant remains in RA. RR 30-50. LS cl/=. Mild\nretractions. Sating >95%. Occas drifts. 1 A/B so far today.\nConts on caffeine. P: Cont to monitor for AOP.\n\n #3. TF 150cc/k/d BM/SC 20 (34cc pg'd over 45min). Abd soft\nw/active BS, min asp, no spits, AG stable, no loops, voiding\nand stooling guiac neg. P: Tol current feeding plan Increase\ncals tomorrow.\n\n #4. DEV: Temp stable nested in sheepskin boundaries in\nservo control isolette. A&A w/cares. Sleeps between. AFSO.\nMAEW. P: Cont to support dev needs.\n\n #5. : In at 1230. Dad did cares and mom \nhim for 45min. Updates on infant's progress given at the\nbedside. Asking approp questions. A: Involved loving\n. P: Cont support, keep updated and educate.\n\n #7. BILI: Infant conts to be jaundiced. Remains under\ndouble photo therapy. Eye in place. Stooling. P:\nRecheck bili level in am.\n\n #8. Pot sepsis: Infant has stable, Temp No overt S&S of\nsepsis. WBC improved. No growth from bl cultures to date. P:\nIV antibx d/c'd. IV hep lock removed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-30 00:00:00.000", "description": "Report", "row_id": 1711591, "text": "8 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-18 00:00:00.000", "description": "Report", "row_id": 1711672, "text": "#4DEV\nTEMP STABLE IN AN OPEN CRIB. AWAKE AND ALERT WITH CARES.\nQUIET.\nP. CONT TO MONITOR.\n#5PARENT\nNO CONTACT THIS SHIFT\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-18 00:00:00.000", "description": "Report", "row_id": 1711673, "text": "Neonatology Attending Note\nDOL #27, CGA 33 wks.\n\nCVR: Remains in RA. Off caffeine for several days. Freqruent mild drifts in saturations, ? positional. One brady spell, self-resolved. Hemodynamically stable.\n\nFEN: Wt 1880, up 30. TF 140 cc/kg/day, BM 28/SC 28 w/PM, PG over 90 minutes. today: Ca 11.1, Phos 7.1, AP 173.\n\nDEV: In open crib.\n\nNEURO: HUS this morning, results pending. Optho this week.\n\nPE: Active and comfortable at rest. Skin warm and pink. Fontanelles soft and flat. Chest clear. Cardiac RRR, no m. Abdomen soft and flat. and activity appropriate.\n\nIMP: Overall stable growing premature infant. Mild immaturity of respiratory control, stable off of caffeine. Tolerating feeds and gaining weight. No new issues.\n\nPLANS:\n- Continue current management.\n- Continue monitoring for spells.\n- Continue 28 cals.\n- HUS today.\n- Optho this week.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-18 00:00:00.000", "description": "Report", "row_id": 1711674, "text": "2. remains in RA, color pale pink, BBs equal, clear,\nmild sc retractions, RR30-50, very brief brady to 68 x1-QSR.\nContinue to monitor.\n3. TF 140cc/k/d BM/SC28 with promod 44cc pg q4h over 90 min,\nabd soft, voiding, no stool so far this shift, no spits,\nminimal aspirates.\n4. HUS done this am, for eye exam tomorrow, temp stable\nswaddled in open crib, alert and active with cares.\n5. here for 1300 cares, Dad held , Mom\nindependent with temp taking and diaper changing. Continue\nto update and offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-19 00:00:00.000", "description": "Report", "row_id": 1711675, "text": "NPN:\n\nRESP: Sats 97-100% in RA. RR=40-50s w/SC retraction. BBS =/clear. Occasional brief sat-drifts (75-79) w/quick recovery. No A&Bs thus far tonight; x 1 over past 24 h.\n\nCV: No murmur. HR=150-160s. BP=58/34 (40). Color pale pink w/good perfusion.\n\nFEN: Wt=1905g (+ 25g). TF=140cc/kg/d; 44cc BM/SC-28 w/promod q 4 h via NG over 90 min. Tolerating fdgs well w/o spits; minimal residuals. Abd benign. Voiding qs; no stool x 1.5 days. Vit E and FeS04.\n\nG&D: CGA=33 wk. Temp stable in crib. Active and alert w/cares. Swaddled, nested and resting well. Eye exam today.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-19 00:00:00.000", "description": "Report", "row_id": 1711676, "text": "Neonatology Attending PRogress Note:\nDOL #28\n33 1/7 weeks PMA\nin RA, RR=40-60's, mild sc retx, some drifts with feeds\none brady yesterday, no murmur, HR=150-160's, BP mean=40\n1905g (inc 25g), TF=140cc/kg/d BM/SC 28 with promod, pg over 90 minutes, voiding, stool 2 days ago\nImp/Plan: premie with mild AOP, F and G.\n--monitor weight on current regimen\n--HUS normal yesterday\n--ophtho exam today\n" }, { "category": "Nursing/other", "chartdate": "2121-12-19 00:00:00.000", "description": "Report", "row_id": 1711677, "text": "2. remains in RA, color pale pink, BS clear, RR40-60,\nmild sc retractions, no brady so far this shift, some drifts\nin sats to 80's during feeding-self resolving.\n3. TF 140c/k/d BM/SC28 with promod 44cc q4h pg over 90 min,\nabd soft, no spits, minimal aspirates, voiding, no stool, on\nvitamin e and ferinsol.\n4. temp stable swaddled in open crib, active and alert with\ncares, sleeping well in between, sucks on pacifier, eyes\nexamined this am-f/u in 3 wks.\n5. here for 1300 cares, Mom held , pumping\nbreast milk, very loving and involved, continue to update\nand offer support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711772, "text": "Attending Note\nDay of life 47 CGA 35 \nin room air RR 30-50's\nHR 150-160's BP 74/33 mean 45\nweight 2750 grams up 60 on 140 cc/kg/day of BM or SSC 24 cal/oz altenating po/pg. He took most of feeding during the day yesterday but tired overnight and would only 10-15 cc po.\nvoiding but no stool\non iron and vit E\ns/p circumcision\n\nExam: gen well appearing\nlungs clear bilaterally\nCV regular rate and rhythm 1/6 systolic murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\nGU circumcision well healing\n\nImp-stable currently\nwill continue to encourge po feeds\nwill consider decreasing calories when taking all po's\nwill also consider more breast feeding\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711773, "text": "Clinical Nutrition:\nAddendum:\nd/w team: TF decreased to MIN. 130cc/kg/day; projected intake for next 24hrs ~104kcal/kg/day & ~2.8-2.9g pro/kg/day.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-29 00:00:00.000", "description": "Report", "row_id": 1711583, "text": "NPN\n\n\n2. Resp: Infant remains in RA with sats>95%. Apneic spell x1\novernight,sat 59, HR 110, requiring mod stim. RR 30-50's,\nBBS clear with mild IC/SC retractions, on caffeine.\nCont to monitor resp. exam, document spells.\n\n3.FEN: Wt 1.315, up 10gr. TF at 150cc/kg/d: IVF of D10W in\nleft foot PIV at 30cc/kg/d, gavage feeds at 120cc/kg/d of\nBM/SC 20 27cc q4hr. Abd soft, active BS, min. aspirates, AG\n22, voiding QS, no stools.\nTolerating advancement of enteral feeds, cont to advance\n10/kg until reaching full volume feeds.\n\n4. Dev: Temps 97.8-99.6, under phototx. Alert when awake,\nsucking pacifier at times. Settling easily after cares, in\nprone position, has not cried with interventions.\nAGA, alert but quiet cont to support developmental needs.\n\n5. Parenting: No contact from this shift.\n\n7. Hyperbili: Under single phototx bank in servo isolette,\nwith eye shields on. Sl jaundiced. Plan on checking bili\nlevels Sat afternoon w/vanco levels.\n\n8. Sepsis: Active/alert, decreased spells, on antbx vanco\nand , need levels checked today. cont to monitor\nfor signs of sepsis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-29 00:00:00.000", "description": "Report", "row_id": 1711584, "text": "Neonatology Attending Progress Note\n\nNow day of life 8, CA 2/7 weeks.\nIn RA with RR 30-50.\nOnly 1 episode of apnea/bradycardia in the past 24 hours.\n\nCVS - HR 140-160 BP 65/35 48\n\nWt. 1315gm up 10gm on 150ml/kg/d of TF - up to 130ml/kg/d of MM or SSC20 - well tolerated thus far.\nNormal urine and stool output.\nDS 88\n\nBili - on phototherapy - 5.9/0.3 - FU planned for later today\n\nID - on vanco and for presumed sepsis, cultures are no growth\n\nAssessment/plan:\nVery nice progress in past day.\nWill advance to 150ml/kg/d of feedings.\nAntibiotics to continue today - repeat cbc and vanco levels planned for today.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-29 00:00:00.000", "description": "Report", "row_id": 1711585, "text": "NNP Physical Exam\nPE: pink, quiet prone in isolette under phototherapy, , breath sounds clear/equal with mild intercostal retracting, RRR, no murmur, abd soft, non distended, bowel sounds active, sleeping with flexed .\n" }, { "category": "Nursing/other", "chartdate": "2121-11-29 00:00:00.000", "description": "Report", "row_id": 1711586, "text": "NPN \n\n\n\n #2. RESP: Infant remains in RA. RR 40-60. LS cl/=. Mild\nSC/IC retractions. Sating >95%. No A/B's thus far today. 1\nin 24hrs. Conts on caffeine. P: Cont to monitor for AOP.\n\n #3. FEN: TF 150cc/k/d. Adv on feeds 10cc/k/. Prewsently\non 130cc/k enterally BM/SC 20 (29cc pg'd over 45min). IVF\nD10W via PIV at 20cc/k. DS 94. Abd soft w/active BS, min\nasp, AG stable, no spits, no loops, voiding and stooling\n(transitional). A: Tol current feeding plan. P: Cont to\nassess tolerance as adv feeds.\n\n #4. DEV: TEmp stable nested in sheepskin boundaries in\nservo control isolette. A&A w/cares. Sleeps between. MAEW.\nAFSO. P: Cont to support dev needs.\n\n #5. : No contact yet this shift.\n\n #7. BILI: Infant conts to be sl jaundiced. Repeat bili\n6.9/0.3 Added 2nd bili light. Eye in place.\nStooling. P: Cont to follow levels.\n\n #8. Pot SEPSIS: Infant conts on Vanco (levels sent today)\nand . No overt S&S sepsis. Temp WNL. Repeat CBC sent.\nBands now 2% down from 12%. P: Cont antibx as ordered.\nFollow levels.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711774, "text": "Clinical Nutrition:\nO:\n~36 week CGA BB on DOL 47.\nWT: 2750g(+60)(50-75 %ile); BWT: 1360g. Average wt gain over past week ~44g/day.\nHC: 33cm(50-75 %ile); last: 32cm\nLN: 44.5cm(~25th %ile); last: 44cm\nMeds include Fe & Vit.E\n not needed.\nNutrition: 140cc/kg/day as SC/BM 24; po/pg. Average of past 3-day intake ~135cc/kg/day, providing ~108kcal/kg/day & ~2.9-3g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg, did better yesterday, only took 10-15cc today; encourage breastfeeding. not needed. Current feeds & supps meeting weaned recs for kcal/pro/vits/mins. HC gain is meeting recs. Growth is exceeding recs of 20-35g/kg/day for WT gain; kcals just decreased 2days ago; d/w team, c/w current feeds for now since infant is still receiving more gavage feeds than po's. LN gain is not meeting recs of ~1cm/wk. Will monitor trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711775, "text": "NICU PCA Progress Note\n\n\n3.FEN: O/TF decreased to 130cc/k/d of BM24 or SC24 PO/PG.\nAbd benign. No spits. Voiding. No stools yet so far this\nshift. Bottling full volume. (Please refer to flowsheet for\nassessment and PO volumes.) Cont on iron. A/Tolorating PO\nfeeds well. P/Cont with current regime.\n\n4.DEV: O/Temp stable swaddled in open air crib. Active and\nalert with cares. Sleeping well between feeds. MAE. Font\nS/F. A/Alt in growth and development. P/Cont to monitor\nand support growth and development.\n\n5.PARENT: O/ will be in for 17:00 care time.\nA/Appropriate and actively involved. P/Cont to educate and\nsupport .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711776, "text": "NICU nursing note\n\n\n3. FEN=O/TF now at min of 130cc/k/d of BM/SC24 po/pg.\nBottled full vol x2 so far this shift. Abd benign. (Please\nrefer to flowsheet for assessment.) No spits. Voiding. NO\nstool so far this shift. Cont on iron and Vit E.\nA/Bottlefeeding very well. P/Cont to offer po's when awake\nand alert.\n\n4. G&D=O/Temp stable swaddled in open crib. Alert and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. Circ site healing well. Site beefy-red. Scant\nsero-sang dng noted on old gauze. Vaseline gauze applied\nwith Qcare. A/Alt in G&D. P/cont to monitor and support\nG&D.\n\n5. =O/No contact with so far this shift.\nDue in to visit at 1700. P/Cont to support and educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-17 00:00:00.000", "description": "Report", "row_id": 1711668, "text": "Neonatology Attending Note\nDOL #26, CGA 32 .\n\nCVR: Remains in RA. 3 spells in 24 hours. Off caffeine x 2 days. Hemodynamically stable.\n\nFEN: Wt 1850, up 25 grams. TF 140 cc/kg/day, BM 28 w/PM, over 90 mins. In crib. On vitamin E, and iron.\n\nNEURO: Due for HUS this week.\n\nPE: comfortable premature infant, no distress. Skin warm and pink. Fontanelles soft and flat. Chest clear. Cardiac RRR, no m. Abdomen soft, no HSM. and activity appropriate.\n\nIMP: Overall stable growing premature infant. Mild apnea of prematurity, off of caffeine. Tolerating feeds, gaining weight.\n\nPLANS:\n- No changes to current management.\n- Continue 28 cals.\n- HUS this week.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-17 00:00:00.000", "description": "Report", "row_id": 1711669, "text": "Clinical Nutrition\nO:\n~32 wk CGA BB on DOL 20.\nWT: 1850 g (+25)(~50th to 75th %ile); birth wt: 1360 g. Average wt gain over past wk ~20 g/kg/day.\nHC: 30 cm (~25th %Ile); last: 27.5 cm ()\nLN: 43.5 cm (~50th %Ile); last: 40 cm ()\nMeds include Fe and Vit E\n due this wk\nNutrition: 140 cc/kg/day BM 28 w/ promod, all pg over 90 min feeds due to hx of spits. Average of past 3 day intake ~151 cc/kg/day, providing ~141 kcal/kg/day and ~4 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. due this wk. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. Average HC and LN gains over past 2 wks are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Overall trends on both growth charts are acceptable, however; will follow long term trends. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-17 00:00:00.000", "description": "Report", "row_id": 1711670, "text": "NPN 7A-7P\n\n\n#2 Infant remains in RA, had one drift of HR (88) and sao2\n(76) during feed infusion while being held, handling\ninfant well and are quietly interactive with him. LS = and\nclear, no murmur heard. Con't to monitor.\n\n#3 TF at 140cc/k/d of BM/SCF 28 w/PM, infusing over 90 min.\nHad small spit x 1, seems to have sao2 drifts during and\ntoward end of feed infusion, making \"chewing\" motions and\nfaces. Caffeine was d/c'd 2 days ago but infant's drifts\nappear to be feeding related. Con't to monitor.\n\n#4 Maintaining temp in crib while swaddled. Sleeps\ncomfortably between cares, feeds are gavaged (is 32 \nwks). Eyes open with cares and settles well. Con't present\ninterventions.\n\n#5 in to visit daily, dad changed infant's diaper\nand held him after mom's turn. Both speak freely about their\nadjustment to this dad's paraplegia. They are in the process\nof building an addition onto their house with handicap\naccess/conveniences. are very supportive of each\nother and are appreciative of their infant's steady\nprogress. Con't to update and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-18 00:00:00.000", "description": "Report", "row_id": 1711671, "text": "#2RESP\nLUNGS CLEAR WITHMILD SC RETRACTIONS. RR 40-60 . SAT IN MID\n90'S. HOWEVER, SAT DID DRIFT TO MID 80'S TOWARD END OF\nGAVAGE. WHEN BABY PLACED PRONE, DRIFTING IMPROVED. BABY HAD\nONE TRUE SPELL\nA. RA.\nP. CONT TO MONITOR.\n#3FEN\nWT 1.88 UP 30G. BABY CONT TO RECEIVE SC 28/BM28 WITH PROMOD.\n\nCONT TO RECEIVE FEED BY GAVAGE OVER 90 MIN. NO SPITS . MIN\nASP. VOID, SM STOOL. NUTRITIONAL SENT. ABD SOFT, ACTIVE\nBOWEL SOUNDS.\nA. FEED AND GAINING WEIGHT\nP. CONT TO MONITOR\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-06 00:00:00.000", "description": "Report", "row_id": 1711767, "text": "Attending Note\nDay of life 46 CGA 35 \nin room air RR 30-40\nHR 150-160's BP 73/36 mean 51\nweight 2690 grams up 5 on 140 cc/kg/day of BM or SSC 24 cal/oz alternating po/pg feeds\nvoiding and stooling\non iron and vit E\n\nExam-well appearing no distress\nlungs clear bilaterally\nCV regular rate and rhtyhm 1/6 systolic murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\n\nImp-stable making progress\nwill continue to encouarge po feeds\nwill consider po attempts with each feed\n" }, { "category": "Nursing/other", "chartdate": "2122-01-06 00:00:00.000", "description": "Report", "row_id": 1711768, "text": "NICU PCA Progress Note\n\n\n3.FEN: O/TF cont at 140cc/k/d of BM24 or SC24 PO or PG over\n1hr. Abd benign. No spits. Voiding. Stooling. (Please refer\nto flowsheet for assessment and PO volumes.) A/Tolorating\nPO and PG feeds. P/Cont with current regime.\n\n4.DEV: O/Temp stable swaddled in open crib. Active and\nalert with cares. Sleeping well in between feeds. MAE. Font\nS/F. A/Alt in growth and development. P/Cont to monitor\nand support growth and development.\n\n5.PARENT: O/Dad and grandmother in for 13:00 care time. Dad\nbottle fed x1. A/Appropriate and actively involved. P/Cont\nto educate and support .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-06 00:00:00.000", "description": "Report", "row_id": 1711769, "text": "NICU nursing note\nThis RN has assessed pt and agrees with above PCA's note. Circ done at 1230. Baby premedicated with Tylenol and given oral sucrose during procedure. Tylenol given 6hr following first dose for pain management. Circ care reviewed with both and handout given. Circ site remains beefy-red, minimal swelling noted. Scant sero-sang dng noted on old gauze. New vaseline gauze applied at 1700. Cont to monitor site closely. Give Tylenol as needed for pain control X24hrs.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711770, "text": "PCA 1900-0700\n\n\nFEN\nCW 2750g up 60g, TF 140cc/kg/d of BM/SC24 needs 64cc q4h,\nbottled 15cc X2 with remainder gavaged, abd soft, bs+, no\nloops, max asp 1.6cc, voiding qs, no stool thus far this\nshift, no spits. P:cont to support nutritional needs.\n\nDEV\nremains swaddled in OAC, temp stable, a/a with cares,\nsettles well in between, fonts soft/flat. P:cont to support\ngrowth and dev.\n\nPAR\nno known contact thus far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-07 00:00:00.000", "description": "Report", "row_id": 1711771, "text": "1900-0700 NPN\nI have examined and agree with the above note and assessments per flowsheet documented by , PCA.\n\nCircumcision: Scant amt of serosanguineous drainage noted to gauze. Slight erythema and edema noted to circ site. Continue to apply vaseline and gauze with each diaper change. Tylenol given at 0100 as per order. Infant resting comfortably in OAC. Continue to monitor infant's status.\n\n: No contact with family so fat this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-02 00:00:00.000", "description": "Report", "row_id": 1711600, "text": "Lactation Progress Note\nSpoke with mom over the phone re: supply issues. Mom was using a classic pump but it was not user friendly with all the appointments mom has to keep. Today she secured a symphony pump and hopes that it will travel better. Reviewed the pumping handout and explained the importance of pumping 8-12 times per day to establish a supply. Recommended mom keep a breastfeeding diary to see if her supply increases with increased pumping and the new pump. We also discussed the use of reglan. A handout was left at the baby's bedside for mom to read. It was explained to mom that reglan does not replace pumping and will not work without pumping. Discussed some of the side effects of reglan. She was told that her OB could prescribe the regaln. Encouraged mom to ask for lactation support when she visits.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-02 00:00:00.000", "description": "Report", "row_id": 1711601, "text": "NPN DAYS\n\n\nAlt in Resp due to prematurity: In room air. LS clear and\nequal. Mild IC/SC retractions. No desats or spells. On\ncaffeine. O2 sats >94%. Continue to monitor.\n\nALt in Fluid/elect/nutrition: TF 150cc/kg/day SC/BM24\ngavaging feeds over 1 hour. Belly full and soft, no loops.\nAG 23-23.5cm. Voiding. Stools are heme -. Small spit x1.\nStarted on FeSO4 and VitE. Tolerating feeds. Continue with\ncurrent plan of care.\n\nDevelopment: Temp stable in servo isolette. Nested on\nsheepskin with boundaries in place. Kangaroo'd x1 hour with\ndad and both did well. Awake and quietly alert with cares.\nWill continue to provide for developmental needs.\n\nParenting: and grandmother in to visit. \nparticipating in cares. Mom did temp check and diaper\nchange. Dad kangaroo'd. Updated them on the baby's status.\n very involved and loving with baby. continue to\nprovide for developmental needs.\n\nHyperbili: Phototherapy remains off. Will check rebound bili\nin the morning.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711602, "text": "NPN\n\n#2 S. O. Infant remains breathing in room air. Breath\nsounds clear and equal. There have been no a's or b's noted\nat this time on this shift.Infant remains on caffiene as\nordered. A. Hx of a's and b's. P. Continue to monitor.\n\n#3 S. O. Weight up 20 grams. Voiding. No stool at this\ntime on this shift. Infant remains on 150cc/kg/day of\nbreast milk 24 calorie. Feeds gavaged over 1 hour. Minimal\naspirants. One spit. A. Gained weight. P. Continue with\ncurrent plan.\n\n#5 S. O. There has been no contact from the family at this\ntime. A. in on day shift. P. Support and keep\nupodated.\n\n#7 S. O. Infant slightly jaundiced. Voiding. A. Hx of\nhyperbilirubinemia. P. Check bili this am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711603, "text": "NPN ADDENDUM\n\nThis R.N. noted a small nodule ,left antecubital. The NNP attending were notified and the infant was examined. Dr. attempted to aspirate but was unable to obtain anything. A cbc and diff was sent.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-01 00:00:00.000", "description": "Report", "row_id": 1711596, "text": "Nursing Note/Lactation Note\nI have assessed Baby and agree w/ PCA note as written above. Infant increased to 22cals today.\n in to visit at 4pm for 5pm cares. Mom's milk supply is low at this time. Mom is pumping 6-7X per day yielding ~20-30cc per pumping session. Encouraged mother to increased pumping to 8-10X per day. Suggested mother try Mothers Mild and also to consider Reglan to help increase milk supply. Also encouraged to kangaroo each day instead of every other day. Mother kangaroo'd w/ and then pumped an amount of milk equal to a regular pumping after pumping 1 1/2 hrs prior. Mother pleased w/ this plan and is willing to trial Reglan.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-02 00:00:00.000", "description": "Report", "row_id": 1711597, "text": "NPN\n\n\n#2\nInfant remains in RA with sats >93%. BS clear= with mild\nretractions. Occasional drifts in sats--SR. Color is pink;\nwell perfused. Murmer not audible. No spells noted thus\nfar tonight.\n\n#3\nInfant remains on TF=150cc/k of BM/SC22 q4 hours. Infant\nhas tolerated gavage feedings over an hour without any spits\nand max aspirates of ~1cc. Abd is soft and round;\nvoiding/no stool. Wt is up 20gms-1365.\n\n#4\nInfant remains in an isolette on servo control--temp has\nbeen stable. Infant is quietly alert with cares; sucks on\nthe pacifier briefly before falling off to sleep. Nestled\nin sheepskin with boundaries.\n\n#5\nNo contact tonight from the .\n\n#7\nPhototherapy lights shut off yesterday morning. Color\nremains slightly jaundiced. Bili level to be checked\ntomorrow.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-02 00:00:00.000", "description": "Report", "row_id": 1711598, "text": "Neonatology Attending Progress Note:\nDOL #11\nPMA 30 5/7 weeks\nremains in RA, 30-60's, clear/equal, mild ic/sc retx\non caffeine, one spell/24 hours\nHR=140-160's, BP mean=45\nbili=2.9 double phototherapy--> d/ced\n1365g (inc 20g)\nTF=150cc/kg/d, BM/SC 22 minimal aspirates\nvoiding, stooling\nservo-isolette\nImp/Plan: premie with AOP-mild, on caffeine; resolving physiologic jaundice, advancing on feeds, doing well\n--check bilirubin rebound tomorrow\n--increase to 24 calories\n--monitor for spells\n--start Vitamin E and Ferinsol\n" }, { "category": "Nursing/other", "chartdate": "2121-12-02 00:00:00.000", "description": "Report", "row_id": 1711599, "text": "Progress Note\nPE: Gen: A, NAD, in an isolette\nHEENT: \nCVS: RRR, NS1S2, with out murmor\nLungs: CTA bilaterally\nAbd: NT, NBS\nSkin: pink well perfused\n\nA/P: 30 wk old premie, former 29 wk old, is doing well from a cardiac and respiratory stand point. Calories have been increased today to 24 of breast milk and started on Iron and Vitamin E. Will continue to advance calories. Will monitor for any changes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-21 00:00:00.000", "description": "Report", "row_id": 1711685, "text": "NPN 0700-\n\n\n2. IN RA with sats 98-100%. Lungs clear. RR 30-40's with\nmild SC retractions. Few desats to 80's noted thus far. No\nA&B's thus far. Stable in RA with a few desats. Continue\nto monitor for A&B/desats.\n\n3. TF 140cc/k/d BM28 w/PM. Abdomen benign. Voiding and no\nstool thus far. Tolerating all NGT feeds with minimal\naspirates and no emesis. Continue to monitor tolerance to\nfeeds.\n\n4. Temp stable swaddled in open crib. Alert and active\nwith cares. Rest well inbetween cares. MAE, suckles well\non pacifier at times. Continue to promote development.\n\n5. No parental contact. due to visit at 1700\ntoday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-22 00:00:00.000", "description": "Report", "row_id": 1711691, "text": "nursing note\n\n\n2. Resp: O: baby in room airwith mild retractions\nsubcostally. no A,B, D's this shift. A:stable P:continue to\ndocument spells.\n3:FEN: O: baby with total fluids 140 cc/dg/day of BM28 with\npromod. Tolerating well over one hour. Abdomen soft. weight\nup 50 grams tonight, 2085grams. Baby did go to breast with\n5pm feeding. Did latch on several times. A; stable,\ntolerating feeds. P:continue to offer breast feeds as\ntolerated.\n4. Developement: baby in open crib, temp stable. alert and\nactive, awkes for feeds. A: stable P:continue to monitor.\n5.Parenting: O: in and participated with care. Both\n held baby, and asked appropriate questions. Mom did\nput baby to breast during 5pm feed. A:loving family\nP:continue to support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-23 00:00:00.000", "description": "Report", "row_id": 1711692, "text": "#5 PARENT\ns/o: No contact this shift.\n#4 DEV\ns/o: Temp stable in open crib. Swaddled with extremities\nsoftly flexed. , . A: CGA- 33 wks. P: Cont dev\nsupportive care.\n#3 FEN\ns/o: Waking at feeding times. Consoled with non-nutritive\nsucking. Abd exam benign. feeds pg without spits this\nshift. A: Gaining wt on 28 cal BM/ with promod. P: COnt\nto mtr tolerance, daily wt. Po as approaches 34 wks CGA\n#2 RESP\ns/o: Clear and equal BS in RA. Color pink. No spells.\nA/P: Cont to mtr.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-23 00:00:00.000", "description": "Report", "row_id": 1711693, "text": "Case Management Note\n Pilgrim case manager, RN , states we can use Partners for any d'c home services. I will cont to follow & assist w/any d'c needs.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-23 00:00:00.000", "description": "Report", "row_id": 1711694, "text": "Attending Note\nDay of life 32 CGA 33 \nin room air RR 30-50 saturation above 95%\nHR 140-160 Bp 59/38 mean 46\nweight 2085 grams up 50 on 140 cc/kg/day of BM 28 cal/oz with promod pg over 1 hr\nvoiding and stooling\non iron and vit E\n\nExam: gen active well appearing\nlungs clear bilaterally\nCV regular rate adn rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft with active bowel sounds no masses or distention\nExt warm well pefused brisk cap refill\n\nImp-stable currently making progress\nwill conintue current calories\n" }, { "category": "Nursing/other", "chartdate": "2121-12-23 00:00:00.000", "description": "Report", "row_id": 1711695, "text": "PCA Note 0700-1900\n\n\nRESP - Infant remains in RA. RR 30-60 and O2 sats 96-100%.\nLS cl/equal bilaterally. Mild subcostal retx noted. No\ndesats or spells thus far this shift. Cont to monitor.\n\nFEN - TF 140cc/k/d of BM/SC28 with Promod = 49cc q4. Full\nfeeds gavaged over 1hr. Infant tolerating feeds well. No\nspits and a max asp of 2.0cc. Abd is soft with no loops.\nActive bs. Voiding with each diaper change. No stool thus\nfar this shift. Cont to monitor infant's . to feeds.\n\nDEV - Stable temps while swaddled in oac. is a/a for\ncares and sleeps well between. Occas. sucks on his pacifier.\nBrings hands to face. FS&F. MAEs. Cont to support\ndevelopmentally.\n\n - No contact from the thus far this shift.\nCont to support and educate.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711541, "text": "NPN admit\nInfant is a 29 wker delivered precipitously this am . Infant placed on CPap 21% prong cpap 6 increased to 40% for line placement. Mild grunting noted. Temp 97.2, HR 152, RR 40. BP map 31. D/S 71. Vit K and E mycin given . attempted line placement. CBC, BC and ABG sent.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711542, "text": "Neonatology Attending\n29-week GA infant admitted with respiratory distress\n\nMaternal Hx - 33 year old G1P0->1 woman with unremarkable PMHX and the following prenatal screens: A positive, DAT negative, HBsAg negative, RPR non-reactive, rubella immune, GBS unknown.\n\nAntenatal Hx - for EGA 29 weeks today. Antepartum course uncomplicated until onset of preterm labor today leading to SVD without anesthesia. No intrapartum fever noted. ROM at delivery, yielding clear amniotic fluid, with intrapartum antibacterial prophylaxis administered at that time.\n\nNeonatal course - Infant vigorous at delivery. Orally and nasally bulb suctioned, dried, free flow oxygen supplied, but no significant distress noted in delivery room. Apgars 7 at one minute, 8 at five minutes. Transferred uneventfully to NICU for further management, where mild intercostal retractions and grunting respirations were noted.\n\nPE (prior to CPAP)\nhr 152 rr 40 T 97.2 BP 43/23 (31) SaO2 92% in room air\nBW 1360g (50-75th %ile) OFC 26.5cm (25-50th %ile) LN 40.5cm (75th %ile)\nHEENT AFSF; non-dysmorphic; palate intact; neck/mouth normal; significant occipital caput without other cranial abnormality; moderate nasal flaring\nCHEST mild ot moderate intercostal retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal male genitalia; testes palpable bilaterally\nCNS active, alert, resp to stim; tone AGA and symm; MAE symm; weak suck; gag intact; grasp symm\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nINV\nD-stick 71\nABG 7.22/62/75/27/-3\nhct 48.9 plt 186 WBC pending\n\nIMPRESSION\n29 week AGA infant with\n1. Respiratory distress. This is statistically most likely to be surfactant deficiency, and is clinically consistent with this diagnosis, but cannot exclude pneumonia or other less common pathologies at this point\n2. Sepsis risk, based on unexplained preterm labor and post-natal respiratory symptoms\n\nPLAN\n-Infant has been placed on CPAP and is currently in room air with mild distress. However, the respiratory acidosis suggests significant ventilatory compromise; we will therefore intubate and administer surfactant. Target SaO2 87-94% and strategy of permissive hypercapnia\n-Cardiac examination is currently unremarkable. Maintain vigilance for PDA and target MAP > 33 mmHg\n-A CBC and blood culture have been drawn and broad spectrum antibiotic therapy started for anticiapted course of 48 hours pending WBC, culture and resolution of clinical symptoms\n-Feeds will be deferred until cardiorespriatory stability is established. in the interim, will provide maintenance D10W at 80 cc/kg/day with the usual attention to fluid monitoring and metabolic issues\n-Screening per protocl for IVH, ROP, hearing and car seat stability\n-Parents updated in delivery room. Continue to provide support\n\nDelivering OB: Dr. \nOB: Dr. \nPED: Not yet charted\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711543, "text": "Case Management Note\nHave reviewed chart & events noted. Infant will be followed on-site by Pilgrim case manager. List of Early Intervention Programs have been placed in record. For any home care , prior approval needed thru at . I will cont to follow & assist w/any d'c planning needs once medically indicated.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711544, "text": "Clinical Nutrition:\nAddendum:\nPLEASE DISREGARD ABOVE NOTE: INFO FOR WRONG BABY!\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711545, "text": "Clinical Nutrition:\nAddendum:\nPLEASE DISREGARD ABOVE NOTE: INFO FOR WRONG BABY!\n" }, { "category": "Nursing/other", "chartdate": "2121-11-21 00:00:00.000", "description": "Report", "row_id": 1711546, "text": "Clinical Nutrition:\nO:\n~37 week CGA BB on DOL 53.\nWT: 2005g(+45)(<10th %ile); BWT: 958g. Average wt gain over past week ~18g/kg/day.\nHC: 30.5cm( %ile); last: 28.5cm\nLN: 42cm(<10th %ile); last: 41cm\nMeds include Fe, Vit.E, diuril & KCl.\nLabs noted.\nNutrition: 150cc/kg/day as BM/SC 30 w/promod; po/pg & breastfeeding well. Feeds changed 2days ago; Projected intake for next 24hrs ~150cc/kg/day, providing ~150kcal/kg/day & ~3.9-4g pro/kg/day plus unquantified amounts from breastfeeding.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; /pg & breastfeeding well. Labs noted & within acceptable ranges. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT/LN gains. HC gain exceeding recs of ~0.5-1cm/wk. Will monitor trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711604, "text": "Neonatology Attending Progress Note:\nDOL #12\n30 6/7 weeks PMA\nRA, no spells, on caffeine\nHR=120-150\nlast night left antecubital area with small nodule, aspirated without fluid. CBC with WBC=12, crit=40, plt=406 (diff:24P1B)\nBP mean=50\noff phototherapy, bili=4.8\nwt=1385g (inc 20g), TF=150cc/kg/d 24 calories\nvitamin E and iron\n\nImp/Plan: premie with AOP, advancing on feeds, nodule in left antecubitus benign CBC, resolving jaundice, mild AOP, doing well\n--increase calories today\n--monitor for spells on caffeine\n--monitor nodule, low threshold for starting antibiotics\n--continue monitoring weight\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711605, "text": "Progress Note\nPE: Gen: A, NAD in servo isolette\nHEENT: \nLungs: CTA bilaterally\nCVS: RRR NS1S2, no murmor\nAbd: ND, NBS\nSkin: pink well perfused\n\nA/P: 30 wk old premie former 29 wk old is now cardiovasuclar and respiratory stable is on caffeine. Is tolerated feeds and now going up on calories. Last night and this morning temperature instability, sepsis evaluation was started. Will await blood culture results. Will continue to monitor temperature and any other signs of sepsis.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711606, "text": "NPN \n\n\n\n #2. RESP: Infant remains in RA. RR 40-70. LS cl/=. Sating\n>94%. Occas drifts. No A/B's thus far today. Conts on\ncaffeine. P: Cont to monitor for AOP.\n\n #3. FEN: TF 150cc/k/d BM/SC 26 (35cc pg'd over 1hr). Abd\nsoft w/active BS, min asp, no spits, no loops, AG stable,\nvoiding and stooling heme neg. A: Tol current feeding plan.\nP: cont to support nutritional needs.\n\n #4. DEV: Temp 97.3 this am in servo control isolette.\nInfant alert and active w/cares, acting well. Increased set\npoint in isolette and infant has had temp WNL. Team aware.\nMAEW. AFSO. Occas sucks on pacifier. P: Cont to support dev\nneeds.\n\n #5. : Both in for 1700 cares. Dad independent\nw/cares and Mom did kangaroo care for 1 hr. Updates on\ninfant's progress given at the bedside. Asking approp\nquestions. A: Involved loving . P: cont support,\neducate and keep updated.\n\n #7. BILI: Rebound bili 4.8/0.2 up from 2.9/0.1. Infant is\nstooling and remains sl jaundiced. A: Hyperbili resolved.\nP: Follow clinically.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-03 00:00:00.000", "description": "Report", "row_id": 1711607, "text": "7 hyperbili\n\nREVISIONS TO PATHWAY:\n\n 7 hyperbili; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-04 00:00:00.000", "description": "Report", "row_id": 1711608, "text": "NPN 1900-0700\n\n\n2. RESP\nO: Remains in RA. Breathing 30-60's, sats >96%. Mild IC/SCR\nnoted. LS clr/=. No drifts or spells noted thus far this\nshift. Last spell . A: Stable in RA. P: Cont to monitor\nfor s/s resp distress.\n\n3. FEN\nO: Current wgt= 1415g (+30). TF 150cc/kg/day of BM26/SC26.\nGavaging 35cc over 1hr. Abd exam benign. A/G 21-22cm. No\nspits. Min aspirates. Voiding and stooling (heme-). A:\nTolerating feeds. P: Cont to monitor for s/s feeding\nintolerance.\n\n4. G&D\nO: is alert/active with cares. Initially warm this\nshift in servo isolette (T max= 99.6). Iso temp weaned, now\nstable. Nested in sheepskin. ,. Sleeps well b/w\ncares. Sm nodule remains on L antecube, moveable, no\ndraining or redness noted. Will monitor. Brings hands to\nface and occ sucks on pacifier. A: AGA. P: Cont to provide\ndev appropriate care.\n\n5. \nNo contact w/family thus far this shift. Unable to assess.\nWas told in report that family would return to kangaroo @\n1630 today.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711696, "text": "PCA NOTE\n\n\nRESP: No spells or desats noted thus far this shift.\nDrifting occasionally towards end of feeding. Resolves\nquickly. Otherwise, stable in RA. P-Continue to closely\nmonitor.\n\nFEN: Current weight 2.140, ^ 55gm. TF 140cc/k/d of BM/SC 28\nw/promod. PG/1 hour 15 mins. is voiding, trace stool.\nActive bowel sounds. Girth is stable. Minimal residuals.\nBenign abdomen. Spit noted. Tolerating feeds. P-Continue to\nfollow current regimen as ordered.\n\nDEV: Temp stable in OAC. Waking slowly for feeds. Alert and\nactive. Sleeps peacefully. MAE. AF-flat. Sweet natured. AGA.\nP-Continue to support developmental milestones.\n\n: Mom and dad in at change of shift. Updated by this\nPCA on son's status and immediate plan. Asking appropriate\nquestions. Loving and vested. P-Continue to keep informed.\n\n ***See flowsheet for further information***\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711697, "text": "1900-0700 NPN\nI have examined and agree with the above note and assessments per flowsheet documented by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711698, "text": "Attending NOte\nDay of life 33 CGA 33 \nin room air RR 30-50's sat above 96%\none desat to 60's and a brady yesterdays\nHR 140-160's\nweight 2140 grams up 55 on 140 cc/kg/day of BM 28 cal/oz with promod pg over an hour 15 minutes\nvoiding but only a trace stool\nin open crib\ns/p hep B\n\nImp-stable making progress\nwill plan a family meeting today\nwill increase iron dose today to 0.2 ml daily of (25 mg/ml solution)\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711699, "text": "Clinical Nutrition:\nO:\n~34 week CGA BB on DOL 33.\nWT: 2140g(+55)(50-75 %ile); BWT: 1360g. Average wt gain over past week ~19g/kg/day.\nHC: 31.5cm(50-75 %ile); last: 30cm\nLN: 43.5cm(25-50 %ile); last: 43.5cm\nMeds include Fe & vit.E\n due next week.\nNutrition: 140cc/kg/day as BM/SC 28 w/promod; pg over 1hr 15mins d/t spits. Average of past 3-day intake ~141cc/kg/day, providing ~132kcal/kg/day & ~3.7-3.8g pro/kg/day.\nGI: Abd benign; x1 spit.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems except as noted above/benign; pg feeds. due next week. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT gain. HC gain is exceeding recs of ~0.5-1cm/wk & is not meeting recs of ~1cm/wk for LN gain. Will monitor long-term growth trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-24 00:00:00.000", "description": "Report", "row_id": 1711700, "text": "Nrsg Progress Note-0700-1900\n\n\n#2O/A-Rem in RA withg rr 30-50's. Bbs clear and equal with\ngd aeration noted. Color pink with 02 sats between 93-100%.\nNo desats. A-Resp needs wnl this shift.P-Cont to assess resp\nneeds.\n#3O/A-Tf remain 140 cc's/kg of bm 28 with promod with no\nspits or asps noted this shift. Abd soft with no spits or\nasps. A-Fen needs wnl this shift. P-Cont to assess fen\nneeds.\n#4O/A-Rem in oc with minimal stressors noted. Corrected age\nof 33 6/7 weeks. Temp stable in oc. A-G&d needs wnl this\nshift. P-Cont to assess g&d needs.\n#5O/A-No parental contact noted this shift. A-Parental needs\nwnl this shift. P-Cont to enc calls and visits.\nPlans for report at 1900.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-12 00:00:00.000", "description": "Report", "row_id": 1711794, "text": "Nursing note\n\n\n#3 FEN O: Child remains on min of 130cc/k of bm26/sim26.\nbottle feeding all feeds with the yellow nipple. Bottles\nwhole bottle but is slow to bottle. takes feed in about 30\nminutes. Abdomen remains soft. No loops noted. Good bowel\nsounds heard. abdomen benign. Child started on vydaylin\ntoday. Vit e d/c'd as ordered and remains on iron. Child\nvoiding well. No stool as yet this shift. brought in\ncorn oil. P: will continue to bottle feed as tolerated.\n#4 DEV O: Child remains in open crib. Temp stable. \nto take CPR tomarrow. Brought in car seat. VNA called and\nset up for a wednesday visit with VNA. Called and\nleft message with Early intervention. P: Will continue to\nsupport child coping skills.\n#5 Parenting O: mom and in for the 1700 cares. Mom\nbottle fed the child. Both interacted well with the child.\n shown how to measure out medications and how to\nfortify BM or formula. demonstrated measuring out\nvydaylin. also made pedi Appt for thursday. P: Will\ncontinue to support and conitnue reinforcing\nteaching.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-13 00:00:00.000", "description": "Report", "row_id": 1711795, "text": "PCA NOTE \n\n\nFEN: Current weight 2.860, ^ 30gm. TF min 130cc/k/d of\nBM/ 26. PO. (Took 70 cc's x2 this shift, does take a\nwhile to finish bottle, passive and curious, not sleepy).\nTotal 24 hour intake 113 cc/ is voiding, no stool.\nActive bowel sounds. Belly is soft and full. No spits.\nTolerating feeds. P-Continue to follow current regimen as\nordered.\n\nDEV: Temp stable in OAC. Waking early for feeds. Alert and\nactive. Sleeps peacefully. MAE. AF-flat. Car seat test in\nprogress. Plan for D/C today. Sweet natured. P-Continue to\nsupport developmental milestones.\n\n: No contact over night.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-13 00:00:00.000", "description": "Report", "row_id": 1711796, "text": "Nursing NICU Note\nPlease refer to CoW's note. This nurse also in to examine pt. Well appearing infant. PLease see volumes of feedings consumed by pt this shift. Pt passed carseat test without base. Page 1 and 2 of VNA initiated- to be completed by d/ RN.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-13 00:00:00.000", "description": "Report", "row_id": 1711797, "text": "Attending Note\nday of life 52 CGA 36 \nin room air RR 30-60\nHR 140-150's BP 75/38 mean 57\nweight 2860 up 30 on min 130 BM 26 cal/oz took in 113 cc/kg/day\nvoiding and stooling\non vidaylin and iron\n\npassed hearing passed car seat test\nVNA following\nped is scheduled for Thursday\n\ns/p hep B and synagis\n\nImp-stable currently\nwill anticipate discharge today\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-01 00:00:00.000", "description": "Report", "row_id": 1711592, "text": "Neonatology Attending Progress Note:\nDOL #10\n30 4/7 weeks PMA\nremains in RA, RR=30-60's\nno spells overnight (1 spell yesterday)\non caffeine\nno murmur, HR=130-150's, BP mean=55\nbili=2.9, double phototherapy\nwt=1345g (inc 15g), TF=150cc/kg/d BM/SC 20 tolerating feeds over 45 minutes, one large spit overnight\nheme stool negative\nabdominal girth stable\ns/p r/o sepsis\nblood culture negative\nremains on servocontrol\nImp/Plan: premie with AOP, advancing on feeds, doing well\n--increase to 22 calories\n--d/c phototherapy, check bili in 2 days\n--monitor for spells on caffeine\n" }, { "category": "Nursing/other", "chartdate": "2121-12-01 00:00:00.000", "description": "Report", "row_id": 1711593, "text": "Neonatology Fellow Note\nPhysical Exam\nPreterm male in isolette, NAD\n, OP clear, neck supple\nCTA bilat, good AE, no retractions\nRRR, s1s2nl, no murmur\nAbd soft ND NABS, no HSM\nExt well perfused, no edema, fem pulses 2+ intact\nSpont MAE, appr \n" }, { "category": "Nursing/other", "chartdate": "2121-12-01 00:00:00.000", "description": "Report", "row_id": 1711594, "text": "Clinical Nutrition:\nO:\n~30 week CGA BB on DOL 10.\nWT: 1245g(-75)(25-50 %ile); BWT: 1360g. WT is ~8% from BWT.\nHC: 20.5cm(<10th %ile); last: 26.5cm\nLN: 40cm(25-50 %ile); last: 41.5cm\nLabs noted.\nNutrition: 150cc/kg/day as SC/BM 22; pg over 45 mins. Feeds just changed; projected intake for next 24hrs ~150cc/kg/day, providing ~110kcal/kg/day & ~3.6-3.7g pro/kg/day.\nGI: Abd benign; x1large aspirate at night.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems except as noted above; pg fed. Current feeds & supps meeting recs for pro/kg/day but not quite yet for kcal/vits/mins until feeds are @i initial goal of ~150cc/kg/day SC/BM 24. Growth is not yet meeting recs of ~15-20g/kg/day for WT gain(still below BWT), of ~0.5-1cm/wk for HC gain(?accuracy; please remeasure) & of ~1cm/wk for LN gain; caloric density in feeds advancing as tolerated. Will monitor long-term growth trends. Will cont. to follow w/ team & participate in nutrition plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-21 00:00:00.000", "description": "Report", "row_id": 1711686, "text": "NEonatology-NNP Progress Note\n\nPE: in room air, bbs lc=, rrr s1s2 no murmur, abd soft, nontender, V&S, afos, active\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-22 00:00:00.000", "description": "Report", "row_id": 1711687, "text": "NPNOte\n\n\n#2.Remains in Rair, BBS clear, equal, mild subcostal\nretractions present, no spells thus far this shift.\nOccassional desats to low 80's QSR. A; no spells thus far\nthis shift. P; cont to monitor for spells.\n\n#3.Todays weight=2035, up45gms, TF=140cc/kg/day,BM28 with\npromod, PG fed tolerated, BS+, no loops, voided, no stool\nthus far this shift. A; feeds tolerated. P; cont current\nfeeding plan.\n\n#4.Alert,active with acre, temp atble in a open crib,\nswaddled with blanket, mae. A; AGA P; cont dev support.\n\n#5.No contacts from thus far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-22 00:00:00.000", "description": "Report", "row_id": 1711688, "text": "Attending Note\nDay of life 31 CGA 33 \nin room air RR 30-50's\nsat drift to 80's overnight and to the 70's yesterday with pg feeds\nHR 150-160 71/47 mean 63\nweight 2035 up 45 on 140 cc/kg/day of BM 28 cal/oz with promod pg over an hour no spits\nvoiding but no stool overnight\nin open crib\nactive with cares\non iron and vit E\n\nImp-stable making progress\nstill have some drifts which could be reflux\nwill monitor\nwill give hep B#1 today\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-22 00:00:00.000", "description": "Report", "row_id": 1711689, "text": "NNP Physical Exam\nPE: pink infant quiet supine in crib, , sutures apposed, breath sounds clear/equal with minimal retracting, RRR without murmur, abd soft, non distended, + bowel sounds, active with good .\n" }, { "category": "Nursing/other", "chartdate": "2121-12-22 00:00:00.000", "description": "Report", "row_id": 1711690, "text": "NPN 0700-1500\n\n\n#2 O: Infant remains in RA. RR 30's-40's with mild SC\nretractions. LS clear and =. No spells, does have occasional\ndrifts in o2 sats to 70's and 80's which are self resolved.\nA: Stable in RA. P: Cont to monitor.\n\n#3 O: TF= 140cc/kg/d. Infant taking 48cc's of BM 28 with\npromod q 4h via gavage. Feding was over 1h; had med spit so\nplaced 1300 feed over 1h 10 minutes. Abdomen benign; voiding\nand stooling guaic neg. Minimal aspirates. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#4 O: Maintaining temp in oac. Awake and alert with cares;\nsleeping well between. Swaddled in blanket; brings hands to\nface for comfort. Hep B given today with parental consent.\nA: AGA. P: Cont to support development.\n\n#5 O: No contact as yet. A/P: Cont to support and update.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-10 00:00:00.000", "description": "Report", "row_id": 1711784, "text": "npn 1900-0730\n\n\n3. Wt. today 2.785gms. No change from yesterday. Tf cont. at\nmin of 130cc/k/d of BM or SC 24 or 60cc q 4hrs. Taking b/t\n22-52cc at each care using nipple. More coordinated\nwith this nipple. Abd soft no loops, +bs. No stool so far\nthis shift. No spits or asp. noted. Voiding well. Plan;\ncont. to attempt po feedings. Monitor tolerance to\nincreasing volumes.\n\n4. Remains in oac. Temps stable. Coordinated with feedings\nusing nipple but tires during feeding therefore still\npg feeds as well. Swaddled. Hands to face. AGA. . Plan;\ncontinue to support g/d.\n\n5. No contact from so far this shift.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-10 00:00:00.000", "description": "Report", "row_id": 1711785, "text": "Neonatology Attending Note\nDay 49, CGA 36 1\n\nRA. RR40-50s. Pink and well perfused. Mild SC rtxns. HR 160s. Pale/pink. +int soft murmur. BP 58/40, 45. TF 130 po/pg. Nl voiding. Wt no change 2785. In open crib.\n\nContinue current management. Awaiting maturation of po skills.\n" }, { "category": "Nursing/other", "chartdate": "2122-01-11 00:00:00.000", "description": "Report", "row_id": 1711790, "text": "Neonatology Attending\n\nDOL 51 PMA 36 2/7 weeks\n\nStable in RA. No A/B.\n\nIntermittent murmur.\n\nOn 130 ml/kg min BM/SC24. All po x 24 hours. Voiding. Stooling. Wt 2785 grams (no change).\n\nTemp stable in crib.\n\nHearing referred on L.\n\n in and up to date.\n\nA: Stable. Newly fully po. Hearing referred on L. Nearing discharge.\n\nP: Monitor\n Change to 26/BM 26 (with corn oil) to promote wt gain\n Repeat hearing screen\n Home in next few days if he continues fully po and is gaining wt\n EIP and VNA referrals\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-11 00:00:00.000", "description": "Report", "row_id": 1711791, "text": "Nursing progress Notes.\n\n\n#3 O: Total fluid min 130cc/kg/day. Feeds changed to BM/\n26. Feeds offered on demand. Baby woke every 3 to 4 hours\ntoday and took 55 to 70cc. Abdomen benign, voiding well.\nStooled last night. A: PO feeding full amounts with\nencouragement. P: Continue to encourage Po feeding when\nawake.\n#4 O: Temp stable in open crib. Baby woke early for\nfeedings and was changed to ad lib feeds. Hearing screen\nneeded. A: Appropriate for age. P; Continue to support\ndevelopment. EI and VNA referal to be made after obtaining\nautherization.\n#5 O; unable to visit today but did call for an\nupdate. are aware of potential discharge tomorrow\nor Tuesday. Dad stated that they will bring in the car seat\ntomorrow and some corn oil. will make pedi\nappointment and they are aware of VNA and EI referals.\nA:Involved family preparing for discharge home soon. P:\ncontinue to keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-12 00:00:00.000", "description": "Report", "row_id": 1711792, "text": "#5 PARENT\ns/o: no contact this shift.\n#4 DEV\ns/o: Crit and retic sent this Am. A/P: result pending\n#3 FEN\ns/o: Wt up tonight 45 gms to 2830 gms. PO 26- fairly\nwell tonight. Cont to require frequent breaks. Intake for\ntoday just shy of ordered vol of 130cc/k/d minimum. Abd exam\nbenign. A: All po > 48 hr. P: COnt mtr intake to see if avg\nwill acheive ordered min intake. Support BF efforts.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-12 00:00:00.000", "description": "Report", "row_id": 1711793, "text": "Attending Note\nDay of life 52 CGA 36 \nin room air RR 30-60\nHr 140-160 BP 79/37 mean 49\nweight 2830 grasm up 45 on BM 26 cal/oz or 26 cal/oz taking 136 cc/kg/day\nvoiding and stooling\nhct 26.5\non \n\n\nExam: active well appearing no distress\nlungs clear bilaterally\nCV regular rate and rhythm 1/6 systolic murmur\nAbd soft with active bowel sounds no masses or distention\neXt warm well perfused brisk cap refill\n\nImp-stable making good progress\nHe continues to take all feeds po but is very slow with feeding .Will monitor one more day of growth and feeding. If today goes well, will anitcipate diashcarge on tomorrow.\nHe needs a car seat test proior to discharge\n" }, { "category": "Nursing/other", "chartdate": "2121-12-01 00:00:00.000", "description": "Report", "row_id": 1711595, "text": "PCA Note 0700-1900\n\n\nRESP - Infant remains in RA. RR 30-60 and O2 sats >95%. Mild\nsubcost/intercost retx noted. Infant had one spell while\nsleeping thus far this shift that required mild stim.\nRemains on caffine. Cont to monitor.\n\nFEN - TF 150cc/k/d of BM/SC22 = 34cc q4. Cal increased this\nshift from 20cal. All feeds PG and gavaged over 50 min. Min\nasp and one lg spit. Abd is soft and no loops. AG stable and\nactive bs.Voiding and stooling. Cont to monitor tol. to\nfeeds.\n\nDev - Temps stable while nested on sheepskin in Servo\nisolette. A/A with cares. settles easily and sleeps\nwell between cares. Occas sucks on pacifier. Brings hands to\nface. FS&F. MAEs. AGA. Cont to support developmental needs.\n\n - are visiting infant at this time\nIndpendent with cares. Both are very supportive of\neachother. Mom is with infant. Updated at\nbedside by RN. Cont to support and educate family.\n\nBili - Phototherapy d/c'd at 11:00 am. Infant appears sl.\njaundice. Well purfused. Cont to monitor bili.\n\n\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-19 00:00:00.000", "description": "Report", "row_id": 1711678, "text": "Neonatology-NNP PRogress Note\n\nPE: remains in room air, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, acitve\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-20 00:00:00.000", "description": "Report", "row_id": 1711679, "text": "NPN:\n\nRESP: Sats 97-100% in RA. RR=40-60 with SC retraction. BBS =/clear. Occasional mild sat-drifts to low 80s w/quick recovery. No A&Bs thus far tonight; none over apst 24 h.\n\nCV: No murmur . HR=150-160. BP=76/33 (42). Color pale pink w/good perfusion.\n\nFEN: Wt=1960g (+ 55g). Tf=140cc/kg/d; 46cc BM/SC-28 w/promod q 4 h via NG over 80 min. Tolerating fdgs well w/o spits; minimal redsiduals. Abd benign. Voiding qs; stool. Vit E and FeS04.\n\nG&D: CGA=33 wk. Temp stable in crib. Active and alert w/cares. Swaddled, nested and resting well.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-20 00:00:00.000", "description": "Report", "row_id": 1711680, "text": "Neo Attend\nDay 29 CGA 33.2wk\nRA, SpO2 95-100%, occas drifts, sr, clear=BS, rr 40-50s, no A/B/Ds x 24 hrs. no caffeine.\nCV: no murmur, hr and bp, pulses wnl.\nTW , up 55gm.\nTF 140 cc/kg/day BM28+PM. H/O spits. gavage over 70 min. no spits now.\nabd wnl. UOP and stool wnl.\nTemp stable in open crib.\nEye exam: IR retina.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-20 00:00:00.000", "description": "Report", "row_id": 1711681, "text": "Neonatology NP Note\nPE\nswaddled in open crib\n, sutures opposed\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended,\nactive with mild generalized hypertonicity,no clonus\n" }, { "category": "Nursing/other", "chartdate": "2121-12-20 00:00:00.000", "description": "Report", "row_id": 1711682, "text": "NPN 0700-\n\n\n2. In RA with sats 95-100%. Occassional desats as low as\n75%, all self resolved. Lungs clear. RR 28-40's with mild\nSC retractions. No A&B's thus far. Stable in RA with\noccassional desats. Continue to monitor for A&B/desats.\n\n3. TF 140cc/k/d BM28 w/PM. Abdomen benign. Voiding and\nhaving heme negative stools. Gavage time decresed from 1hr\nand 20mins to 1hr and 10mins this afternoon. Tolerating NGT\nfeeds without aspirates or emesis. Continue to monitor\ntolerance to feeds.\n\n4. Temp stable swaddled in open crib. Alert and active\nwith cares, rest well inbetween cares. MAE. Suckles on\npacifier at times. Continue to promote development.\n\n5. No contact thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-10 00:00:00.000", "description": "Report", "row_id": 1711786, "text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in open crib, sleeping\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed; symmetric facial features\nChest: breath sounds clear/=\nCV: RRR< no murmur; normal S1 S2; pulses +2\nAbd: sof;t no masses; + bowel sounds; umbilicus healed\nGU: testes descended; circumcision well-healed\nExt: moving all\nNeuro: easily roused to drowsy state; + suck; + grasps\n" }, { "category": "Nursing/other", "chartdate": "2122-01-10 00:00:00.000", "description": "Report", "row_id": 1711787, "text": "Nrsg Progress Note-0700-1900\n\n\n#3O/A- Tf remain minimum 130 cc's/kg with bm 24 cal with no\nspits or asps noted this shift. Abd soft with no spit or\nasps noted. Po fed well 60 cc's x2. A-Improved po fdgs with\nno asps.P-Cont to offer po fdgs based on cues.\n#4O/A- Rem nested in oc with minimal stressors noted. Waking\nfor fdgs with alert and active states. Slightly mottled with\ncares. A-G&d needs wnl this shift.P-Cont to assess g&d\nneeds.\n#5O/A-Mom and dad both here at 1300 for fdg at 1300.\nDischarge teaching done with cpr class planned for this Tues\n\n. chose pediatrics for pedi. \nalso requesting VNA prior to discharge. A-Parenting needs\nwnl this shift. P-Cont to assess parenting needs.\nPlans for report at 1900.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-11 00:00:00.000", "description": "Report", "row_id": 1711788, "text": "NPN\n\n\n#3 is waking for his feeds q4h and bottling well\n in shift. took 2 whole feeds. On BM24/SC24 at\n130cc/k/d. Abd benign, soft, +BS, no loops or distention\nnoted. vdg qs, no stool. Wt unchanged at 2785 grams. A:\nfeeding well P: no change at present.\n#4 stable in open crib. waking for feeds, calm with cares,\nsleeps between. sucks some on pacifier. A: AGA P: cont to\nsupport development.\n#5 no contact in shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-11 00:00:00.000", "description": "Report", "row_id": 1711789, "text": "Neonatology-NNP Progress Note\n\nPE: in his open crib, in room air,bbs cl=, rrr s1s 2no murmur (reporteldy intermittent) abd soft, nontender, V&S, healing circumcision,afso, acitve with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-21 00:00:00.000", "description": "Report", "row_id": 1711683, "text": "NPN\n\n\n#2-O: RA sats >95 , no spells, clear and equal, RR 30's-50's\n\n\n#3-O: on tf 140cc/k/d full entral feeds of BM28/SC28/promod\n= 46cc q 4 hrs PG over 1hr well, no spits, asps 0.5-2cc,\nabd soft, active bowel sounds, voiding qs and stoioled mod\nsoft yell x 1. wt up 30 gms today to 1.990kg.\n\n#4-O; temps stable swaddled in crib, alert and active\nw/cares, , MAE, no spells, cont to assess\n\n#5-O;no contact this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-21 00:00:00.000", "description": "Report", "row_id": 1711684, "text": "Neonatology Attending\nDOL 30 / CGA 33-3/7 weeks\n\nIn room air with no distress. No apneas/bradycardias in > 24 hours.\n\nNo murmur.\n\nWt (+30) on TFI 140 cc/kg/day BM28PM, tolerating well by gavage over 1 hour. Abd benign. Voiding and stooling normally (guiac negative).\n\nTemp stable in open crib.\n\nA&P\n29 week GA infant with feeding immaturity\n-Continue to await maturation of oral feeding skills\n-No other changes in management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2122-01-08 00:00:00.000", "description": "Report", "row_id": 1711777, "text": "1900-0700 NPN\n\n\nFEN: Weight=2.735kg (-15 grams). TF=min of 130cc/kg/d of\nBM24/SSC24 PO/PG q4hr. Infant has bottled 40cc and 15cc so\nfar this shift/remainder gavaged via NGT. Abdomen pink,\nsoft, round, +BS, no loops. No spits, no aspirates.\nVoiding/no stool. Continues on Iron and Vitamin E. Continue\nto monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well in btw cares. Brings hands to face, likes\npacifier. MAE. Circ site healing. No drainage noted. Circ\nsite with mild edema and erythema. Vaseline and gauze\napplied with each diaper change. Continue to support G+D.\n\n: No contact with family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-08 00:00:00.000", "description": "Report", "row_id": 1711778, "text": "Attending Note\nDay of life 47 CGA 35 \nin room air RR 40-50's\nHR 140-160's BP 72/36 mean 52\nweight 2735 dwon 15 on min 130 cc/kg/day took po's well during the day but tired overnight on 24\nvoiding and stooled overnight\ncirc healing well\n\n\nImp-stable making some progress\nwill continue to monitor growth\nwill consider increasing minimum\n" }, { "category": "Nursing/other", "chartdate": "2122-01-08 00:00:00.000", "description": "Report", "row_id": 1711779, "text": "Neonatology NP Note\nPE\nswaddled in open crib\n, sutures opposed\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur appreciated, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nhealing circumcision with granulation tissue\nactive with symmetric and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2122-01-09 00:00:00.000", "description": "Report", "row_id": 1711780, "text": "1900-0700 NPN\n\n\nFEN: Weight=2.785kg (+50 grams). TF=min of 130cc/kg/d of\nBM24/SSC24 PO/PG q4hr. Infant bottled 20cc at 2100/remainder\ngavaged. Infant bottles well, but tires easily. Gavage\nfeeding given at 0100 via NGT over 1hr. Abdomen pink, soft,\nround, +BS, no loops. No spits, min aspirates. Voiding and\nstooling (heme negative). Continues on Vit e and iron.\nContinue to monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well in btw cares. Brings hands to face, MAE.\nCirc site healing (no erythema/edema/drainage noted).\nVaseline and gauze applied with each diaper change. Continue\nto support G+D.\n\n: No contact with family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2122-01-09 00:00:00.000", "description": "Report", "row_id": 1711781, "text": "Attending Note\nDay of life 48\nin room air\nno spells\nRR 40-60\nHR 130-160 73/42 mean 58\nweight 2785 up 50 on min 130 cc/kg/day of BM or SSC 24 cal/oz took in about half of feeds po and the remainder pg\nno spits\non vit E and iron\n\nImp-making improvement\nwill continue to encoarge po feeds\n" }, { "category": "Nursing/other", "chartdate": "2121-11-30 00:00:00.000", "description": "Report", "row_id": 1711587, "text": "NPN 7p-7a\n\n\nResp: Infant remains in RA. ls clr/=. RR 30-60's. No spells\nor desats so far this shift. Conts on caffeine. Mild ic/sc\nretractions. Cont to monitor.\n\nFen: Wt 1.320kg (+5gms). Conts on tf 150cc/kg of bm/sc 20.\nTol feeds well over 45\". No spits. Minimal aspirates. Abd\nsoft. Active bs. Voiding with each diaper change. Stool x1\nthus far. Quaic neg. Ag stable 20-20.5cm. Cont with current\nplan.\n\nDev: Temp stable nested in servo isolette. Sheepskin with\nboundries in place Alert irritable at times with cares.\nSleeps well between. Cont to support developmental\nmilestones.\n\nParenting: No contact from so far this shift.\n\nBili: Conts under double phototx. Eyes covered.\n\nSepsis: Conts on vanco and . No new signs of sepsis\nnoted. post level pending. Cont to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-30 00:00:00.000", "description": "Report", "row_id": 1711588, "text": "NNP Physical Exam\nPE pink, jaundiced infant prone in isolette under phototherapy, , breath sounds clear/equal with good air entry, easy WOB, RRR without murmur, normal pulses and perfusion, abd soft, non distended, bowel sounds active, sleeping comfortably with flexed .\n" }, { "category": "Nursing/other", "chartdate": "2122-01-09 00:00:00.000", "description": "Report", "row_id": 1711782, "text": "Neonatology NP Note\nPE\nswaddled in open crib\n, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nl/Vl SEM at LUSb only, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good \nhealing circumcision\n" }, { "category": "Nursing/other", "chartdate": "2122-01-09 00:00:00.000", "description": "Report", "row_id": 1711783, "text": "NPN 0700-1900\n\n\n1. FEN: TF=130cc/k/day BM/SC24. Bottled 45cc each feeding\nthus far today using nipple. Min asp/no spits.\nVoiding with each diaper change. Stooled small brown x1.\nAbd is soft and round with active bs. Circ site is clean\nand intact. No drainage. Area covered with 2x2 and\nVaseline.\n\n2. G&D: is alert and active with cares. Sleeps well\nbetween cares. Quietly alert after bottling. Wakes for\neach feeding. Uses pacifier to comfort self. Temps stable\nswaddled in open crib. . AGA.\n\n3. Parenting: No contact yet this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-11-22 00:00:00.000", "description": "Report", "row_id": 1711554, "text": "Neonatology Attending Note\nDay 1, CGA 29 2\n\ns/p intubation and surfactant. Currently in RA. Cl and = BS. RR30-60s. On caffeine.\n\nNo murmur. HR 120-140s. s/p NS boluses and Dopamine, now off. Last BP mean 35.\n\nWt 1320, down 40 gms. NPO. d/s 170s. TF 100 cc/k/day.\n146/4.8/112/24\nBili 6.4/0.3 -> under phototherapy.\nPND8\n\nVoiding 5.\n\nOn amp/gent. BCX NGTD.\n\nIn isolette.\n\nA/P:\nResolving RDS.\nMonitor for AOP.\nLater today consider initiation of enteral feedings.\nCont photot, follow bili levels.\nComplete sepsis evaluation.\nLabs: Lytes and bili in am.\nWill schedule for HUS next week.\n" }, { "category": "Nursing/other", "chartdate": "2121-11-22 00:00:00.000", "description": "Report", "row_id": 1711555, "text": "Neonatoalogy-NNP Progress Note\n\nPE: in his isolette, in room air, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, cord drying, V&S, afso, active with care\n\nSee attending note for plan\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711627, "text": "NICU nursing note\n\n\n2. Resp=O/Cont in room air. No spells so far this shift.\n(Please refer to flowsheet for resp assessment.) Cont on\ncaffeine. A/Stable in room air. P/Cont to monitor for resp\ndistress.\n\n3. FEN=O/Current wt=1540g (^25g). TF cont at 150cc/k/d of\nBM/SC28PM gavaged over 75min. Abd benign. Bright yellow lg\nspit at 2400. 0.6cc mint asp at 0100. NNP. No further\nissues since. (Please refer to flowsheet for assessment.)\nVoiding/stooling, heme (-). Cont on Vit E and iron. A/Alt\nin FEN status. P/Cont to monitor for s/sx feeding\nintolerance.\n\n4. G&D=O/Temp stable swaddled in off isolette. Alert and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. A/Alt in G&D. P/Cont to monitor and support G&D.\n\n5. =O/No contact with .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711628, "text": "Neonatology Attending Progress Note:\nDOL #17\nPMA 31 4/7 weeks\nremains in RA, RR=20-40's\none desat today, on caffeine\nno murmur\nHR=130-170's, BP mean=42\nwt=1540g (inc 25g), TF=150cc/kg/d SC/MM 28 gavage over 1 1/2 hours due to spits, on promod\n?left inguinal hernia\nvitamin E and Iron\nHUS on Friday normal\nImp/Plan: x-29 week infant with resolved RDS, AOP--on caffeine, some spitting, improved with increased span of feeds\n--monitor for feeding intolerance\n--monitor for spells\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711629, "text": "Clinical Nutrition\nO:\n~31 wk CGA BB on DOL 17.\nWT: 1540 g (+25)(~50th %Ile); birth wt: 1360 g. Average wt gain over past wk ~17 g/kg/day.\nHC: n/a\nLN: n/a\nMeds include Fe and VIt E\nLabs not due yet.\nNutrition: 150 cc/kg/day BM/SSC 28 w/ promod, all pg over 75 min feeds due to hx of spits. Feeds just recently increased; projected intake for next 24hrs ~140 kcal/kg/day and ~3.9 to 4 g pro/kg/day.\nGI: Abdomen benign. Infant had one large yellow spit and one small mint colored aspirate, but no problems since.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems except occasional spits and transient aspirates as noted above. Monitoring closely for any further signs of feeding intolerance. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN measurements n/a for comparison. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711630, "text": "Resp O/A: RA, 20s-40s, CL=, no spells thus far this shift,\nmild sub/int retractions, on caffeine. P: Continue to\nmonitor and administer caffeine.\n\nFEN O/A: 150/kilo BM28 or SC28 with Promod. 39cc PG Q4/1:15.\nSoft abdomen, no loops, no spits, max aspirate 4.4cc\npartially digested breast milk, + BS. Voiding/ no stool thus\nfar. P: Continue to monitor.\n\nG&D O/A: Off Isolette, stable temps, A&P soft and flat,\nsutures approximated, moves hands to midline, alert and\nactive with cares. P: Continue to monitor.\n\nParenting: No contact thus far this shift.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711631, "text": " O/A: Mom and Dad in 1700, both helped with \ncare, Dad . asked appropriate questions and\nseem like very loving . P: Continue to inform and\nsupport.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-08 00:00:00.000", "description": "Report", "row_id": 1711632, "text": "0700- NPN\nI agree with above note by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711726, "text": "PCA NOTE\n\n2 Alt In Resp due to prematurity\n\nFEN: Current weight 2.425, ^ 80gm. TF 140cc/k/d of BM 28 w/\npromod. Alternating PO/PG. (took small amount PO this shift,\nsee flowsheet). is voiding, no stool. Active bowel\nsounds. Abdomen is unremarkable. Minimal residuals. No\nspits. Tolerating feeds. P-Continue to follow current\nregimen as ordered.\n\nDEV: Temp stable in OAC. Waking for feeds. Alert and active.\nSleeps peacefully. MAE. AF-flat. Roots. Curious, adorable\ndisposition. AGA. P-Continue to support developmental\nmilestones.\n\n: No contact over night.\n\nREVISIONS TO PATHWAY:\n\n 2 Alt In Resp due to prematurity; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711727, "text": "I have examined this infant and agree with above documentation as stated by PCA .\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711728, "text": "Attending Note\nDay of life 38 CG 34 \nin room air RR 40-60's\nHR 140-160's BP 79/49 mean 57\nweight 2425 grams up 80 on 140 cc/kg/day of BM 28 or SSC 28 with promod alternating po pg feeds\nvoiding but not stool no spits no aspirate\nin open crib\n\nImp-stable currently\nwill continue to encouarge po feeds\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711729, "text": "Neonatology - NNP PRogress Note\n\nInfant is active with good . . He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711730, "text": "NPN 0700-1900\n\n\n#3FEN: TF 140cc/kg/d of BM 28 w/pm/SSC 28w/pm= 57cc Q 4hrs.\n Pt. alt po/pg. Pt.took 25cc when bottled today. Pt\nwell-coordinated w/ bottling but tires quickly. Abd soft &\nround, +BS, no loops. No spits, min asp. Pt. voiding, no\nstool so far this shift. P: cont to encourage po's &\nmonitor FEN.\n\n#4DEV: Temps stable swaddled in OAC. Pt. awake & alert for\ncares. MAE. Putting hands to face. Pt. likes pacifier.\nP: cont to support dev needs.\n\n#5Parenting: NO contact from family so far this shift.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-30 00:00:00.000", "description": "Report", "row_id": 1711731, "text": "Rehab/OT\n\nInfant very alert, enjoys auditory stimulation. Recommended read to him or bring in music. excited. OT to reassess in one week for developmental play plan.\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711732, "text": "PCA NOTE\n\n\nFEN: Current weight 2.445, ^ 20gm. TF 140cc/k/d of SC/BM 28\nw/ promod. Alternating PO/PG. Took 10cc's PO this shift.\n is voiding, stooled x1, hem neg. Active bowel sounds.\nAbdomen is unremarkable. Minimal residuals. Large spit\nreported, increased gavage time, no spits noted x2.\nTolerating feeds. P-Continue to follow current regimen as\nordered.\n\nDEV: Temp stable in OAC. Slowly waking for feeds. Alert and\nactive. Tires easily. Sleeps peacefully. MAE. AF-flat. Sweet\nnatured. AGA. P-Continue to support developmental\nmilestones.\n\n: No contact over night.\n\n **See flowsheet for further examination of shift**\n\n\n" }, { "category": "Nursing/other", "chartdate": "2121-12-31 00:00:00.000", "description": "Report", "row_id": 1711733, "text": "1900-0700 NPN\nI have examined and agree with the above note and assessments per flowsheet documented by , PCA.\n" } ]

[ { "category": "Echo", "chartdate": "2193-10-09 00:00:00.000", "description": "Report", "row_id": 77175, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease. /?VSD/murmur\nStatus: Inpatient\nDate/Time: at 08:05\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-06 00:00:00.000", "description": "Report", "row_id": 1924432, "text": "Neonatology Attending\n\nDOL 5 CGA 35 weeks\n\nStable in RA. No A/B x 48 hrs.\n\nMurmur present. Cardiac w/u to date wnl (4 ext BP, CXR, EKG, hyperoxia test). Due for echo tomorrow. BP 67/28 mean 40.\n\nOn 140 ml/kg/d BM/ 20 po/pg. Voiding. Stooling. Wt 2115 grams (down 15).\n\nParents visiting and up to date.\n\nA: Stable. Murmur being evaluated. Tolerating feeds. Needs to learn to feed.\n\nP: Monitor\n Echo tomorrow\n Increase to 150 ml/kg/d\n Encourage pos\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-06 00:00:00.000", "description": "Report", "row_id": 1924433, "text": "NPN 0700-1900\n\n\n#1 O: Infant remains in RA. RR 30's-60's with mild SC\nretractions. LS clear and =. No spells. Desat to 73%; QSR'd.\nO2 sats otherwise high 90's-100%. A: Stable in RA. P: Cont\nto monitor.\n\n#2 O: Maintaining temp in oac. Awake and alert with cares;\nsleeping well between. Waking on own for most feeds, though\nsleepy at 1230. Brings hands to face for comfort. A: AGA. P:\nCont to support development.\n\n#3 O: Both parents in to visit with infant's siblings. Mom\ndeciding infant too sleepy to BF. Mom may be in to visit at\n. Asking appropriate questions while here. A: Involved.\nP: Cont to support and update.\n\n#4 O: TF increased to 150cc/kg/d. Infant taking 57cc's of\nBM20/similac 20 q 4h via po/pg feeds. Bottled 40cc's at 0830\nand gavaged entire amount at 1230; infant too sleepy.\nAbdomen benign; voiding and stooling. No spits, no\naspirates. A: Tolerating feeds. P: Cont to monitor.\n\n#5 O: + loud murmur heard. BP 67/28 mean 40. HR 140's-160's.\nColoring pink and well perfused. A: CV stable thus far. P:\nPossible echo to be done tomorrow.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-06 00:00:00.000", "description": "Report", "row_id": 1924434, "text": "Neonatal NP-Exam\n\nSee dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. nl S1S2, grade murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-08 00:00:00.000", "description": "Report", "row_id": 1924441, "text": "1. in RA, color pink, RR40-60, BBS equal, clear, mild sc\nretractions, no spells P: continue to monitor and document.\n2. temp stable swaddled in open crib, waking for some\nfeedings, active and alert with cares, may need synagis A:\nAGA P: continue to promote growth and development.\n3. MOM here ~0830, put baby to breast, requesting to meet\nwith cardiology MD tomorrow P: continue to update and offer\nsupport, page cardiology fellow when Mom is here\ntomorrow(Wed).\n4. TF 150cc/k/d BM=57cc q4h, latched on this am but only few\nsucks then sleepy, feeding given pg, abd soft, no loops,\nvoiding and passing guiac neg stool A: tolerating feedings,\nlearning to po P: continue present care.\n5. murmur audible, cardiology in to see baby, HR 130-150, BP\n73/40 48, pulses nl, precordium quiet, color pink A: stable\nP: continue to monitor/assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-08 00:00:00.000", "description": "Report", "row_id": 1924442, "text": "NICU Fellow PN\nOne apnea with bradycardia last evening\nweight 2145 (down 10g)\nPE: Asleep, comfortable, in NAD\nHEENT: AFOF, soft, OP clear, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, III/VI systolic murmur heard at LLSB, cap refill brisk\nAbd: Soft, +BS\nExt: WWP\nPlan: Dol 7 for this 34 weeker with small muscular VSD on echo yesterday. Working on taking po feeds, breast feeding. Updated mom about echo yesterday, cardiology to talk with her today. Had one spell so still needs monitoring\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-10 00:00:00.000", "description": "Report", "row_id": 1924450, "text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains in RA, O2 sats >95%. RR\n~30-60's, no increase work of breathing noted. LS clear/=.\nNo A&B's noted this shift thus far. A: Pt. remains stable\nin RA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#2. Growth/Development O: Pt. remains in an open crib,\nswaddled w/ stable temps. She is alert and active w/ cares,\nsleeps well in between. Fontanelle soft/flat. She loves to\nuse her pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#3. Parents O: Mom in to visit this am and was updated on\npt's current status and daily plan of care. Mom is active\nand independent in cares. A: Family is loving and\ninvolved. P: Continue to udpate, support and educate.\n\n#4. FEN O: TF 150cc/kg/d of BM20 =57cc Q 4hrs. She is\noffered a bottle or to breast Q feed and took ~55cc PO this\nafternoon. Pt. went to breast x~15min this am w/ half vol.\ngavaged after. Abdomen is sfot, pink, +bs, no loops/spits\nnoted. A: Pt. is tolerateing current nutritional plan. P:\n Continue w/ current feeding plan. Monitor for s/s of\nintolerance. Encourage PO feeds. Plan to increase cal to\nBM22 tonight.\n\n#5. CV Status O: Pt. is pink, warm and well perfused.\nShe has +VSD, Loud murmur. A: stable P: Continue to\nmonitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1924487, "text": "PCA 1900-0700\n\n\n1\nRA, RR 30-40, LUNG SOUNDS CL=, NO SPELLS. P:CONT. TO\nMONITOR.\n\n2\nREMAINS SWADDLED IN OAC, TEMP STABLE, A/A WITH CARES, WAKES\nFOR FEEDS, FONTS SOFT/FLAT, LIKES PACIFIER, BRINGS HANDS TO\nMOUTH. P:CONT. TO SUPPORT GROWTH AND DEVELOPMENT\n\n3\nMOM IN FOR CARES, BF INFANT, UPDATED AT BEDSIDE.\nP:CONT. TO UPDATE\n\n4\nCW 2500G UP 5 G, TF 130CC/KG/D OF BM24=54CC Q4H, BF 20\nMINUTES @ , BOTTLED 40CC @ 2400, 24 HOUR INTAKE 117\nCC/KG PLUS BF X1, ABD SOFT, BS=, NO LOOPS, VOIDING/STOOLING\nQS HEME POS. P:CONT. TO SUPPORT NUTRITIONAL NEEDS.\n\n5\nHR 150-160, LOUD MURMUR HEARD X2, B.P. 69/31 (45). P:CONT.\nTO MONITOR.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1924488, "text": "NPN Addendum: Agree with above note from PCA, . Infant has been stable in RA. She has bottled all her feedings tonight, but has not quite made her minimum of 54cc q4 hours (~40-50cc). Will hold off on replacing NGT for now and follow closely. Mom was in last evening-update given. Mom is aware that we will have to replace NGT if becomes too tired. Mom will be in later today.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1924489, "text": "Neonatology Attending Note\nDay 19\nCGA 37\n\nRA. RR40-60s. BS cl and =. +VSD murmur. HR 130-160s. Pink and well perfused.\n\nWt 2500, up 5 gms. TF 130 cc/k/day. All po since am. Nl voiding and stooling (h/o int heme positive).\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with improving po skills. Monitor off NG x 48 hrs. Approaching discharge readiness.\n\nIn prep of discharge will change to 24 cals with powder. Discharge planning and teaching in progress.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1924490, "text": "NPN 0700-1900\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feed and bottle feeding well, taking > than minimum. No spells.\nA: Maturing behaviors\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: Mom in for 1200. Updated. Signed consent for Hep B immunization. Fed infant and did all cares. Plans to return tonight. Will bring in car seat for screen. Excited for possible D/C to home on Tuesday.\nA: Involved, loving mom\nP: Continue discharge preparations and keep informed.\n\n#4 Alt. in Nutrition\nO: TF=. 130cc/kg=54cc Q 4 hrs. Changed to BM24 with Similac powder today in preparation for possible D/C on Tuesday. Abd. exam in benign. Voiding and stooling, guaiac - X 2 today. Mod. spit X 1. All POs. Waking Q 2.5-3.5 hrs. Taking 50-65cc.\nA: Improved PO feeding, exceeding minimum\nP: Continue with present feeding plan and follow daily wts.\n\n#5 Alt. C-V Function d/t VSD\nO: Pink in RA with easy respirations. Lungs clear. No edema. HR 130's-160's with loud VSD murmur audible, unchanged.\nA: Stable with non-compromising VSD murmur\nP: Continue to monitor. To F/U with cardiology after D/C.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-20 00:00:00.000", "description": "Report", "row_id": 1924491, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures opposed\ncomfortable respirations in room air, lungs clear/=\nll/Vl holsosystolic murmur across precordium, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-12 00:00:00.000", "description": "Report", "row_id": 1924456, "text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 95-100%.RR 40-50's.LS\nclear and equal with mild sc retractions.Infant with no A's\nand B's thus far.A:Stable P:Cont. to assess resp. status.\n\nG/D:AFOS.Infant alert and active with cares;sleeping well\nb/t.Infant with good tone.MAE.Sucking intermitently on\npacifier.Infant remains in open crib,swaddled with nested\nboundaries.Temp. maintained.A:AGA P:Cont. to support growth\nand dev.\n\n:No contact from thus far d/t \nHoliday.Plan to visit on Sunday.A/P:Cont. to\nupdate,support,and educate.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day,rec.BM24 57cc's q 4\nhrs.Infant bottled x 2 and took 32-57cc's with a yellow\nnipple.Weight=2.270 kg up 35 grams.Abd. soft with pos bs,no\nloops or spits,minimal aspirates.Infant voiding and stooling\nheme negative stool.A:Tolerating Feeds Well.P:Cont. to\nassess tolerance of feeds and monitor weight gain.\n\nCV:Infant's HR 130-170'S.Audible murmur.Infant appears\nslightly jaundice but well perfused.Normal pulses.BP\n64/29(42)A:Stable P:Cont. to assess for cardiac compromise.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-12 00:00:00.000", "description": "Report", "row_id": 1924457, "text": "Neonatology Attending\nDOL 11 / CGA 35-6/7 weeks\n\nIn room air with no cardiorespiratory events.\n\nBP 64/29 (42). VSD murmur.\n\nWt 2270 (+35) on TFI 150 cc/kg/day BM24. Alternating PO/PG, with occasional full volume feeds.\n\nA&P\n34-2/7 week GA infant with VSD, feeding immaturity\n-No changes in management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1924468, "text": "Neo Attend\nDay 14, GA 34.2 cga 36.2\nResp stable. RA 40-50s, wnl, no spells, last desat 5 days ago\nCV: mus VSD, well perfused\n2360, up 30\n150 cc/kg/day BM24 popg + BF. Encourage po.\nUOP and stooling well\nin crib, good temp\n involved. Will meet with family.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1924469, "text": "NPN\n\n\n#1 Resp: infant remains in RA with RR 30-50's, sats 97-100%.\nBBS clear/=, breathing comfortably. no desats or brady's so\nfar this shift. cont to monitor.\n\n#2 Dev: infant remains in OC with stable temps, active and\nalert, AGA. waking for feeds. cont to provide dev support.\n\n#3 : Mom in this AM for feeding, independent with\ncare and put infant to breast without difficulty. Infant\nsleepy and not eager to latch and nurse. Mom plans to visit\nagain this afternoon and put infant to breast for 1600\nfeeding. cont to provide updates and support.\n\n#4 FEN: infant TF remain 150cc/kg/d = 59cc PO/NG Q4h.\ntolerating feeds well, abd full, soft, +BS, voiding and\nsmall stool this AM. Gavaged feeding this AM after infant\nsleep while nursing and took 30cc (of 59cc volume\nrequirement)PO this afternoon with remainder gavaged. cont\nto closely monitor and encourage PO adn breast feedings.\n\n#5 CV: infant continues with loud murmur, pink, well\nperfused, HR 130-150s. cont to closely monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-07 00:00:00.000", "description": "Report", "row_id": 1924435, "text": "PCA NOTE\n\n\nRESP: O/A-NO SPELLS OR DESATS NOTED. NO DRIFTS. STABLE IN\nRA. P-CONTINUE TO MONITOR.\n\nG/D: O/A-TEMP STABLE IN OAC. WAKES FOR FEEDS. ALERT AND\nACTIVE. SLEEPS PEACEFULLY. MAE. AF-FLAT. ROOTS. SWEET\nNATURED. AGA. P-CONTINUE TO SUPPORT G/D.\n\nPARENTS: O/A-MOM IN THIS SHIFT AND CALLED X1. UPDATED ON\n STATUS AND IMMEDIATE PLAN BY R.N. WILL BE IN AT\n0830. LOVING AND VESTED. P-CONTINUE TO KEEP INFORMED.\n\nFEN: O/A-CURRENT WEIGHT 2.125, ^ 30GM. TF 150CC/K/D OF\nBM/ 20. PO/PG. BREASTFEEDS WELL. IS VOIDING AND\nSTOOLING. HEM NEG. ACTIVE BOWEL SOUNDS. ABDOMEN IS\nUNREMARKABLE. MINIMAL RESIDUALS. NO SPITS. TOLERATING FEEDS.\nP-CONTINUE TO ENCOURAGE PO INTAKE.\n\nCV: O/A-LOUD MURMUR OBVIOUS. ECHO PLANNED FOR TODAY.\nP-CONTINUE TO ASSESS.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-07 00:00:00.000", "description": "Report", "row_id": 1924436, "text": "Neonatology Attending\nDOL 6 / CGA 35-1/7 weeks\n\nRemains in room air with no distress. Occasional desaturations but no bradycardias/apneas.\n\nMurmur persists. BP 58/28 (38).\n\nWt 2155 (+30) on TFI 150 cc/kg/day BM20, tolerating well. Bottling partial volumes only. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n34-2/7 week GA\n-Echo to be completed today\n-Otherwise continue current management as detailed above\n" }, { "category": "Nursing/other", "chartdate": "2193-10-08 00:00:00.000", "description": "Report", "row_id": 1924439, "text": "Nursing NICU Note\n\n\n1. Resp. O/PT remains in RA. One spell noted thus far this\nshift-see flowsheet. A/Occasional apneic spells noted.\nP/Cont. to monitor for A/B/desaturations and intervene as pt\nneeds.\n\n2. G/D. O/Temp remains stable in crib swaddled. Awake, alert\nand aggressive at care times. EAgerly rooting prior to being\nfed. Mother in evening and stated that pt nursed well.\nA/Alt. in G/D. P/Cont. to support pt's growth and dev.\nneeds.\n\n3. Parents. O/Mother in evening. Mother updated on pt's\nstatus and plan of care. Mother independent with\nbreastfeeding. Mother supplying breastmilk. A/Mother is\nactively involved in pt's care. P/Cont. to support and\neducate parents.\n\n4. F/N. O/TF remain at 150cc/k/d of BM20 PO/PNGT. PLease\nrefer to flowsheet for examinations of pt from this shift.\nPt nursed well evening with mother. Pt took full volume\nof feeding early this am. Voiding. No stool passed this\nshift as of yet. A/Appears to be tolerating present feeding\nregimen. P/Cont. to monitor for s/s of feeding intolerance.\nEncourage PO feedings as pt shows interest and tolerates.\n\n5. CV. O/Loud persistent murmur noted. Mother stated that\nCardiology plans to meet with her to discuss results of \nECHO. A/Uncompromising murmur at this time. P/Cont. to\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-08 00:00:00.000", "description": "Report", "row_id": 1924440, "text": "Neonatology Attending\nDOL 7\n\nIn room air with no distress. One apnea overnight.\n\nMurmur (VSD on echo). BP 73/40 (48).\n\nWt 2145 (-10) on TFI 140 cc/kg/day BM20, tolerating well. Bottling partial volumes.\n\nTemp stable in open crib\n\nA&P\n34-2/7 week GA infant with VSD, respiratory and feedingimmaturity\n-Continue to encourage maturation of oral feeding skills\n-Will require synagis\n" }, { "category": "Nursing/other", "chartdate": "2193-10-10 00:00:00.000", "description": "Report", "row_id": 1924451, "text": "NICU NPN\n\n1: Infant in RA, no desats, or bradys this shift. BS cl= to\nbases, RR WNL. A: No resp distress. P: Consider dc pulse ox.\nMonitor for spells or increased WOB.\n\n2. O: WT gain of 40g tonight. Tolerating open crib, wakes\nfor feeds, PO feeds fairly well when awake and eager. A:\nAGA. P: Support developmental needs.\n\n3. O: No contact from this shift. /\nholiday. A/P: Will support and keep informed with contact.\n\n4. O: Wt gain 40g. On 150cc/k/d of BM22cal (increased from\n20cal today). Tolerating well. No spits, PO fed great\nx1-entire volume. A: Tolerating increased cals, growing. P:\nEncourage PO feeds when eager. Monitor for intoerance.\n\n5. O: Audible murmur.COlor pink, well perfused, HR stable\n130-160 range. Fedding well, gaining weight. A: No apparent\ncompromise. P: Monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-11 00:00:00.000", "description": "Report", "row_id": 1924452, "text": "Nursing Note\n\n\n1. Infant remains stable in RA. RR and sats as doc in\nflowsheet. BLS c/=, mild to no retractions at rest. No ^WOB.\nNo spells. Occassional drift to 80% with HR 100-115 with PO.\nAssociated with some uncoordination with feed. Otherwise,\nstable in RA. P/Cont to support resp req.\n2. Temps stable in OAC, swaddled. MAE, AFOSF, PFOSF. AA with\ncares, sleeps well between. Wakes occassionally for feeds\nquietly. Sucks fingers. Sucks paci. P/Cont to support dev\nmilestones.\n3. No contact thus far.\n4. TF=150cc/kg/d BM22PG/PO as tol. Infant took 29ccPO at\n0100 with some uncoordination. Remainder of feeding gavaged.\nAbd exam is unremarkable. V/ stooling x1, min asp, no spits,\nabd soft, NT/ND. P/Cont to support fen req. Enc PO's.\n5. Infatn continues with loud murmur. Pulses =bilat. Pink,\nbottles well, AA with cares. BP and HR as doc in careview.\nMurmur to be f/u outpt. P/Cont to monitor.\nRefer to flowsheet for additional details.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1924470, "text": "Neonatology Fellow Note\nExam:\nGeneral: alert preterm female infant in open crib\nHEENT: , nares patent, MMM\nCV: RRR with III/VI systolic murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally, no inc WOB\nAbd: soft, NT/ND, +BS, no HSM\nGU: normal preterm female external genitalia\nExt: WWP\nSkin: pink, no lesions\nNeuro: alert, normal tone, MAEW\n\nMet with mother for 30 to discuss feeds. She is still only taking about PO. Mother's other preterm infants fed more quickly and were home at 35 weeks corrected. She is very frustrated that the PO is not progressing more quickly and is concerned that we just NG feed her because it's easier. Explained that would determine her own time line for learning to feed. We offer bottles every feed but do not attempt for more than 30 so as not to over-tire her. Expect her to improve her ability to take PO over the next few weeks.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1924471, "text": "NPN 2300-0700\n#1 Alt. in Resp. Function\nO:In RA with sats 98-100. No apnea, bradycardia or desats noted. RR 40's-50's with easy respirations. Breath sounds are clear and =.\nA: Doing well in RA\nP: Continue to monitor and assess. Document any spells.\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Not waking for feeds but alert with cares. No spells. Took all POs tonight, close to full volume each time.\nA: Maturing behaviors\nP: Continue to support developmental needs.\n\n#4 Alt. in Nutrition\nO: TF=150cc/kg=61cc BM24 Q 4 hrs. Wt. 2440 (up 80gms) Abd. is full, soft with + BS, no loops. Minimal aspirates, mod. spit X 1. Voiding and stooling QS. PO fed X 2, taking 55-60cc. No gavage needed this shift.\nA: Tolerating feeds, gaining wt, improving POs\nP: Continue with present feeding plan. Follow daily wts and encourage POs as able.\n\n#5 Alt. in C-V Function\nO: HR 130's-150's. BP-73/39 m-49. Pink, brisk cap. refill. Loud murmur present, known VSD.\nA: VSD murmur, no s/s compromise\nP: Continue close observation and monitoring.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1924492, "text": "Nursing Progress Note\n\nresp/cv: remains in RA with no A&B's tonight. Color pink and well perfused. BP 69/38-46. BS cl&=, loud murmer audible.\n\nfen: weight 2550gms tonight, up 50gms. remains on minimum of 130cc/kg/d of BM24cal. Bottled a total of 136cc/kg/d plus nursing over past 24hrs. Took 55-60cc plus breast fed well tonight. abd soft, pink with +bs and stool x1, heme-.\n\ndev: Temp stable in crib. Could not do car seat challenge due to age of car seat. Mom notified of need to bring in newer car seat for safety. Hep B vaccine given as ordered. Awaiting hearing screen.\n\nsocial: mom in at 2100 and nursed well. Updated this am and will be in for 0900. Ready for discharge tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1924493, "text": "Neonatology Fellow Note\nExam:\nGeneral: sleeping preterm female in open crib in NAD\nHEENT: , eyes clear, MMM\nCV: RRR with III/VI murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally\nAbd: soft, NT/ND, +BS\nGU: normal preterm female ext gen\nExt: WWP\nSkin: olive-complexion, no lesions\nNeuro: arouses on exam, normal tone, MAEW\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1924466, "text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: Pink in RA with sats 98-100. Breath sounds clear and =. RR 30's-70. No spells.\nA: Doing well in RA\nP: Continue to monitor and document any spells.\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feeds and acting hungry, but tires out and unable to take full volume. Still nedds gavage. No spells.\nA: Immature feeding skills\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: Mom called this AM for update. Expressing concern that is not PO feeding well yet. Requesting family meeting, planned for tomorrow. Mom in for 1600. She is independent with cares and breastfeeding. Spent a long time talking with mom re normal behaviors for infants at GA (36 wks. corrected) and reassuring her that her daughter's behaviors (immature feeding skills in particular) are completely within the range of normal. Mom stated that she felt better after her visit and did not need family meeting tomorrow. She plans to be back this PM for feeding.\nA: Involved, loving mom, concerned about infant's immature feeding skills\nP: Continue to keep informed and support. Assure mom that family meeting is still available for tomorrow if she would like one.\n\n#4 Alt. in Nutrition\nO: TF=150cc/kg=58cc BM24 Q 4 hrs. Abd. is full, soft with + BS, no loops. No spits. Voiding and stooling Q diaper change. Acting hungry at feeding times. Took 28-50cc by bottle and gavage fed remainder. BF well X ~15 min for mom. Gavage fed 30cc after breastfeeding.\nA: Tolerating feeds, gaining wt, still needs gavage\nP: Continue to encourage POs as able and follow daily wts.\n\n#5 Alt. in C-V Function\nO: Loud murmur present, known muscular VSD. Pink, HR 120's-160's. Brisk cap refill. No edema.\nA: VSD, no evidence compromise\nP: Continue to monitor and assess.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-15 00:00:00.000", "description": "Report", "row_id": 1924467, "text": "npn 1900-0730\n\n\n1. Remains in ra. Sao2 > 95%. No drifting or spells so far\nthis shift. RR 50's-60's. Ls cl/=. Mild scr. Plan; Cont. to\nmonitor resp. status.\n\n2. Remains in oac. Temps stable. Waking q 4hrs. Po'ing about\n of volume with each feeding. Gavaging rest. Quietly\nalert after cares. Sucking on pacifier and swaddled to calm.\nPlan; Cont. to support g/d.\n\n3. Both in for cares. Both holding. Mom\ntaking temps and changing diaper. BF well. Mom very\ncomfortable with infant. D/c teaching reveiwd. Signed up for\ncpr for , . at . Plan; cont. to support g/d.\n\n4. Wt. 2.360gms. Up 30gms from yesterday. Tf cont. on\n150cc/k/d of bm24 or 59cc q 4hrs. Remains po/pg feeder. Abd\nsoft, no loops,+bs. Voiding, stooling guiac - stool. No\nspits. Min asp. Plan; cont. to m onitor wt. gain on current\nfluids. Monitor tolerance to po feeding.\n\n5. Hr 140's-160's. VSD murmer still loud. Infant pwp. Pulses\ngood. Plan; cont. to m onitor for any comprimise r/t vsd.\nSupport .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1924494, "text": "Neo Attend\nDay 20, CGA 37.1 wk\nRA, wnl, no spells.\nCV loud muscular VSD. nl HR, and BP\nTW 2550 gm, up 50\n 130 cc/kg/day 24\\all po since . + BF.\nstools heme neg\nHep B \nCar seat testing today.\nHearing screen today.\nDischarge planning completing. Anticpating discharge tomorrow.\nDr. is Ped.\nPeds Cardiology f/up 1 month after discharge. Appointments for PEd in days and Cardiology to be made by mother.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-21 00:00:00.000", "description": "Report", "row_id": 1924495, "text": "NPN 0700-1900\n\n#2 Alt. in Nutrition\nO: On 130cc/kg=55cc BM24 Q 4 hrs. Abd. exam is benign. Voiding and stooling QS. Waking for feeds q 2-4 hrs. Bottling well, taking 60-75cc.\nA: Exceeding minimun TFI\nP: Continue with present feeding plan and check for wt. gain.\n\n#3 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feeds and PO feeding well. No spells. Passed hearing screen. To have car seat screen tonight. Hep B given.\nA: Mature behaviors\nP: For D/C tomorrow.\n\n#4 Alt. in Parenting\nO: Mom in at 1500. Brought in car seat. Reviewed 24cal breastmilk preparation and storage. Written instructions (recipe cards) given to reinforce verbal teaching. Mom also given samples of Similac powder for preparation of breastmilk at home. Mom stated that she understood all instructions and had no questions. \"Safe Travels\" and \"Back to Sleep\" brochures reviewed and given to mom. referral called in to Caregroup . They will see infant on Wed. Mom aware. Mom will call Dr. for pedi apt. this Thursday or Friday.\nA: Involved mom preparing for D/C tomorrow\nP: Continue with D/C preparations. Keep informed and support.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-05 00:00:00.000", "description": "Report", "row_id": 1924426, "text": "Nursing NICU Note\nThis nurse also examined pt; well appearing infant. Persistent loud murmur noted. Skin pink and jaundiced. No contact made from parents during this shift r/t Holiday.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-05 00:00:00.000", "description": "Report", "row_id": 1924427, "text": "Neonatology Attending Note\nDay 4\n\nRA. RR30-60s. 1 desat yest. Cl and = BS. Mild sc rtxns. BP 54/33, 40. +murmur.\n\nWt 2140, up 60 gms. TF 120 cc/k/day BM20 po/pg. Tol well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with immature feeding skills and cardioresp control. Cont to monitor. Will increase TF to 140. Plan for ECHO to evaluate murmur early next week if persistent.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-05 00:00:00.000", "description": "Report", "row_id": 1924428, "text": "NPN 0700-1900\n\n\n#1 O: Infant remains in RA. RR 30's-60's with mild SC\nretractions. LS clear and =. O2 sats 97-100%. No spells this\nshift. A: Stable in RA. P: Cont to monitor.\n\n#2 O: Infant maintaining temp in oac. Awake and alert with\ncares; sleeping well between. Waking on own for feeds acting\nvigorous. Brings hands to face for comfort. Needs hearing\ntest. A: AGA. P: Cont to support development.\n\n#3 O: No contact as yet from parents this shift. A/P: Cont\nto support and update.\n\n#4 O: TF increased to 140cc/kg/d. Infant to take 53cc's of\nBM20/similac 20 q 4h via po/pg feeds. Bottled 30-40cc's this\nshift; gavaged remainder. Abdomen benign; voiding and\nstooling sm amount. No spits, minimal aspirates. A:\nTolerating feeds. P: Cont to monitor.\n\n#5 O: Loud murmur heard this shift. coloring pink and well\nperfused. To be followed up by TCH on Monday with possible\necho if murmur persists. A: Stable CV thus far. P: Cont to\nmonitor.\n\n#6 O: Last bili was yesterday; 8.2/0.3. No further order to\ncheck. Coloring slightly jaundiced. A/P: Cont to follow\nclinically.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-05 00:00:00.000", "description": "Report", "row_id": 1924429, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds thsi am.\n\nAFOF. breath sounds clear and equal> nl S1S2, grade murmur. Pink and well perfused. Pulses 2+/4. Abd benign, no HSm. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-06 00:00:00.000", "description": "Report", "row_id": 1924430, "text": "PCA NOTE\n\n\nRESP: O/A-No spells or desats noted. No drifts. Stable.\nP-Continue to monitor.\n\nG/D: O/A-Temp slightly borderline low. Swaddled w/ hat. Two\nblankets. is waking for feeds. Alert and active.\nTiring easily tonight. Sleeps peacefully. MAE. Roots. AGA.\nP-Continue to support developmentally.\n\nPARENTS: O/A-Mom in this shift. Updated at bedside. Asking\nappropriate questions. Breast fed with maximum results. Will\nbe in today. Loving and involved parents. P-Continue to keep\ninformed.\n\nFEN: O/A-Current weight 2.125, -15gm. TF 140cc/k/d of BM/\n20. PO/PG. is voiding and stooling. Hem neg. Active\nbowel sounds. Benign abdomen. Minimal residuals. No spits.\nTolerating feeds. P-Continue to encourage PO feeds.\n\nCV: O/A-Loud murmur noted. BP WNL. Well perfused. Echo\nplanned for Monday per DR. . P-Continue to assess.\n\nBILI: O/A- remains slightly jaundice. No PT light thus\nfar. Infant is eating well and stooling with each diaper\nchange. P-Will re-evaluate further when warranted.\n\n ***See flowsheet for further information***\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-06 00:00:00.000", "description": "Report", "row_id": 1924431, "text": "npn 1900-0730\nI have read above note and have assessed infant and agree with above note written by pca.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-07 00:00:00.000", "description": "Report", "row_id": 1924437, "text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: Infant in RA with sats 98-100. RR 30's-60's with mild SC retractions. Breath sounds are clear and =. No apnea, bradycardia or desats noted today.\nA: Doing well in RA\nP: Continue to monitor. Document any spells.\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for some feeds, not for others. Alert and active with cares. Sucks well on pacifier. PO feeds well at beginning but tires easily and unable to take full volume, requiring gavage. No spells.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: Mom in this AM to feed infant. She is independent with cares and breastfeeding. She called X 2 during the day for updates and plans to return this evening. Mom notified of ECHO results by Dr..\nA: Involved, loving mom\nP: informed and support.\n\n#4 Alt. in Nutrition\nO: TF=150cc/kg=57cc BM Q 4 hrs. Abd. is full, soft with + BS, no loops. Minimal aspirates, no spits. Voiding and stooling, guaiac -. BF well for mom this AM 5-10 min. Bottle fed 35cc at 1230 and gavage fed remainder. Gavage fed full volume at 1630 as mom is returning to BF at .\nA: Tolerating feeds, learning to PO\nP: Continue with present feeding plan. Follow daily wts. and encourage PO feeding as able.\n\n#5 Alt. in C-V Function\nO: Loud murmur remains audible. HR 130's-150's, sats 98-100. Pink with brisk cap refill. Lungs clear. No edema. Pulses WNL. Cardiac ECHO done. Reported to show small muscular VSD.\nA: Stable with VSD\nP: Continue close observation and monitoring. Plan as per NICU team and cardiology.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-07 00:00:00.000", "description": "Report", "row_id": 1924438, "text": "NICU Fellow PE\nWeight 2155 (up 40g)\nPE: breast feeding with mom, in NAD\nHEENT: AFOF, soft, OP clear\nChest: Clear BS bilaterally, no distress\nCV: RRR, III/VI systolic murmur, harsh, heard throughout the precordium, cap refill brisk\nAbd: Soft, NT, ND, no masses, +BS\nExt: WWP\n35 CGA infant with murmur. Echo today shows small muscular VSD. Cardiology to see parents tomorrow, but I updated them by phone this evening.\nContinue to work on po feeds and breast feeding\n" }, { "category": "Nursing/other", "chartdate": "2193-10-10 00:00:00.000", "description": "Report", "row_id": 1924447, "text": "NPN 1900-0700\n\n\n1. RESP\nO: Remains in RA. Breathing 30-50's, sats >96%. No\nretractions or ^ed WOB noted. LS clr/=. No A&B's. A: Stable\nin RA. P: Cont to monitor for s/s resp distress.\n\n2. G&D\nO: is alert/active with cares. Waking for feeds. Temps\nstable swaddled in OAC. ,. Brings hands to face and\nsucks on pacifier. A: AGA. P: Cont to provide dev\nappropriate care.\n\n3. PARENTS\nNo contact w/family thus far this shift. Unable to assess.\n\n4. FEN\nO: BW 2280g. Current wgt= 2195g (-10). TF 150cc/kg/day of\nBM20 PO/PG. Offering PO's qfeed as infant is awake and\ninterested. Bottling 27-40cc of 57cc minimum this shift.\nGavaging remainder of volume. Abd exam benign. No spits or\nasps. Voiding and stooling (heme-). Applying Desitin to\nbottom for sl.reddened area. A: Tolerating feeds. P: Cont to\nmonitor PO intake, wgt gain, monitor for s/s feeding\nintolerance.\n\n5. CV\nO: Loud VSD murmur persists. HR 120-140's. BP 76/31(45).\nInfant is pink and well-perfused. Pulses WNL. \ncardiology following, spoke w/family yesterday. A: Stable CV\nstatus. P: Cont to monitor for changes in exam.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-10 00:00:00.000", "description": "Report", "row_id": 1924448, "text": "Neonatology Attending\nDOL 9\n\nIn room air with no distress. No cardiorespiratory events.\n\nVSD murmur persists. BP 76/31 (45).\n\nWt 2195 (-10) on TFI 150 cc/kg/day BM20, tolerating PO/PG. Bottling partial volumes and breastfeeding intermittently. Voiding and stooling (guiac negative). Abd benign.\n\nTemp stable in open crib.\n\nA&P\n34-2/7 week GA infant with VSD, feeding immaturity\n-Continue to encourage maturation of oral feeding skills\n" }, { "category": "Nursing/other", "chartdate": "2193-10-10 00:00:00.000", "description": "Report", "row_id": 1924449, "text": "NICU Fellow PN\nNo spells, now on countdown day 2 of 5\nweight 2195 (down 10g)\nPE: Awake, MAE, pink and in NAD\nHEENT: AFOF, soft, ng in place, OP clear, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, harsh, III/VI systolic murmur at sternal border, 2+ femoral pulses\nAbd: Soft, flat, +BS\nExt: WWP\nPlan: dol 9 for this 34 weeker, now 35 4/7 weeks CGA. Small VSD by echo, will f/u with cards in one month. Still working on po feeds, breat feeding. If she feeds better, may be discharged by MOnday. Ongoing d/c planning\n" }, { "category": "Nursing/other", "chartdate": "2193-10-13 00:00:00.000", "description": "Report", "row_id": 1924460, "text": "1900-0700 NPN\nI have examined baby girl and agree with the above note and assessments per flowsheet documented by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-13 00:00:00.000", "description": "Report", "row_id": 1924461, "text": "NPN 7A-7P\n\n\n#1 Remains in RA, sao2's >97%, no brady's/desat's so far\nthis shift. LS = and clear, is pink. Loud murmur (muscular\nVSD) to be followed on an out-patient basis. Will con't to\nmonitor.\n\n#2,4 Maintaining temp in crib, resting comfortably b/t\ncares. Bottling at cues (sometimes taking all), remainder\ngavaged. Is voiding and stooling, abdominal exam\nunremarkable. Will con't to promote bottling.\n\n#3 Mom called this AM asking about care times and was\ninformed that infant's feed times are 8-12-4. Mom plans on\nvisiting at 12noon to beastfeed. Con't to support/teach.\n\n#5 Loud murmur remains audible, is pink, respiratory status\nuncompromised at this time. VSD will be follwed out-patient.\nMonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-13 00:00:00.000", "description": "Report", "row_id": 1924462, "text": "NICU Attending Note\nDOL # 12 = 36 weeks CGA, learning to PO feed. No new concerns.\n\nPEx today: AFSOF, RRR with 2/6 systolic murmur (muscular VSD), occasional mild retractions, BS clear/=, abd benign, skin pink and well perfused, resting comfortably in NAD.\n\nCVR/RESP: RA, good sats. Will continue to monitor.\n\nFEN: weight today 2310 gm, up 40 gm on 150 cc/kg/d MM 24, mostly PG. Will continue to encourage PO intake.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1924463, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=96-100%. RR=30-60's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nmonitor resp status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, loves\npacifier. MAE. Cont to support G+D.\n\n: Mom in to visit tonight. Independent, involved, and\nloving. Updated on infant's current status/plan of care by\nthis RN. Continue to support and update family.\n\nFEN: Weight=2.330kg (+20 grams). TF=150cc/kg/d of BM24 PO/PG\nq4hr. Infant BF x 10min (see flowsheet) at /35cc gavaged\nvia NGT as per Mom. Infant bottled 30cc at 0000/remainder\ngavaged. Infant bottles well, but tires easily. Abdomen\npink, soft, round, +BS, no loops. No spits, no aspirates.\nVoiding and stooling (guiac negative). Bottom slightly\nred/desitin applied q diaper change. Continue to monitor FEN\nstatus.\n\nCV: Loud murmur noted. HR=130-170's. BP=63/31 (42). Infant\npink/well perfused. Brisk cap refill and normal pulses\nnoted. Continue to monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1924464, "text": "Neo Attend\n\nCGA 36.1 Day 13\nResp: RA, R 30-60, O2 Sat 96-100%\nCV: loud murmur: VSD muscular , 130-170s, mean BP 42\nWt 2330, up 20 gm\nFEN: 150 cc/kg/day BM 24 + HMF, immature po. Takes 30-40cc/feed, needs 60 cc/feed.\nFamily meeting tomorrow.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-14 00:00:00.000", "description": "Report", "row_id": 1924465, "text": "Neonatology - Exam Note\nPlease see note by Dr. for details regarding medical plan.\nOn today's exam infant is resting comfortably in open crib. . Lungs CTA, =. CV RRR, blowing holosystolic murmur, known muscular VSD. 2+FP. Abd soft, +BS. Nl female genitalia. Ext warm, pink and well perfused. MAEW.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1924483, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=97-100%. RR=30-60's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nmonitor resp status.\n\nCV: Loud murmur noted. HR=120-170's. Infant slightly\njaundiced. Infant well perfused. Brisk cap refill and normal\npulses noted. Continue to monitor CV status.\n\nFEN: Weight=2.495kg (35 grams). TF=150cc/kg/d of BM24 PO/PG\nq4hr. Infant offered bottle qcare. Infant has bottled 49cc\nand 66cc with good coordination so far this shift/remainder\ngavaged via NGT. Infant bottles well, but tires easily.\nAbdomen pink, soft, round, +BS, no loops. No spits, no\naspirates. Voiding and stooling (trace guiac positive/NNP\naware). Bottom slightly red/desitin applied qdiaper change.\nContinue to monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, loves\npacifier. MAE. Continue to support G+D.\n\n: No contact with family so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1924484, "text": "Neonatology\nDOing well. REmains in RA. COmfortable apeparing.\nMurmru as before. VSD as dcoument3edby echo.\n\nWt 2495 up 35. Tolerating feeds at 150 cc/k/d of 24 cal.cal. Abdomen benign Almost making full pos. Will dcerease feeding volume to 130 cc/k/d and then allow ad lib amounts in attempt to define spontaneous intake.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1924485, "text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: In RA with sats 96-100. Breath sounds are clear and =. RR 40's-70's. No spells. Oximeter D/C'd.\nA: No resp. issues\nP: D/C problem.\n\n#2 Alt. in Development\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for feeds Q 3-3.5 hrs. PO feeding well, taking 55-70cc. No spells.\nA: Maturing behaviors\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: No contact with family to time of note.\nA: Unable to assess\nP: Keep informed and support.\n\n#4 Alt. in Nutrition\nO: TF decreased to 130cc/kg=54cc BM24 Q 4 hrs. Abd. is full, soft with + BS, no loops. No spits. Voiding and stooling. Guaiac +, no visable blood. Dr. aware. PO feeding well, taking 55-70cc.\nA: Improved PO feeding, guaiac+ stools with benign exam\nP: Continue with present feeding plan. Close observation for any changes in abd. exam or behavior.\n\n#5 Alt. in C-V Function d/t murmur\nO: Infant pink in RA with HR 130's-170's. Loud VSD murmur present, unchanged. Brisk cap refill, pulses WNL. No edema.\nA: Loud VSD murmur, no compromise\nP: Continue close observation and monitoring.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-19 00:00:00.000", "description": "Report", "row_id": 1924486, "text": "Neonatology NP Note\nPE: small infant nested in open crib. Active and responsive withe exam.\nAFOF, sutures approximated, MMMP\nComfortable breathing pattern clear and equal bs\nCV: RRR Gr murmur, pulses+2=\nAbd: soft, active bs\nGU: normal; female ext genitalia\nExt: MAE, WWP\nNeuro: symmetric tone and reflexes\n" }, { "category": "Nursing/other", "chartdate": "2193-10-09 00:00:00.000", "description": "Report", "row_id": 1924443, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=95-100%. RR=30-50's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nmonitor resp status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, loves\npacifier. MAE. Continue to support G+D.\n\nParents: Mom called x1 for update, updated by this RN.\nContinue to support and update family.\n\nFEN: Weight=2.205kg (+60 grams). TF=150cc/kg/d of BM20 PO/PG\nq4hr. Infant offered bottle with each care. Infant has\nbottled 30cc and 53cc with good coordination so far this\nshift (remainder gavaged via NGT). Abdomen pink, soft,\nround, +BS, no loops. No spits, minimal aspirates. Voiding\nand stooling (guiac negative). Bottom slightly red/desitin\napplied with each diaper change. Continue to monitor FEN\nstatus.\n\nCV: Loud murmur noted. HR=130-170's. BP=67/33(44). Infant\npink/well perfused. Normal pulses and brisk cap refill\nnoted. Continue to monitor CV status.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-09 00:00:00.000", "description": "Report", "row_id": 1924444, "text": "Neonatology Attending\nDOL 8 / CGA 35-3/7 weeks\n\nIn room air with no distress and no cardiorespiratory events since .\n\nMurmur persists. BP 67/33 (44).\n\nWt 2205 (+60) on TFI 150 cc/kg/day BM20, tolerating well. Bottling partial up to full volumes. Abd benign. Voiding and stooling (guiac negative)\n\nTemp stable in open crib.\n\nA&P\n34-2/7 week GA infant with feeding immaturity and resolving respiratory immaturity\n-Continue to encourage development of oral feeding skills\n-Monitor respiratory drive for 5 asymptomatic days\n" }, { "category": "Nursing/other", "chartdate": "2193-10-09 00:00:00.000", "description": "Report", "row_id": 1924445, "text": "NICU Fellow PN\nNo spells (last 11pm )\nstill working on po feeds\nweight 2205 (up 60g)\nPE: Asleep, confortable, in NAD\nHEENT: AFOF, soft, ng in place, MMM\nChest: Clear BS bilaterally\nCV: RRR, loud III/VI systolic murmur throughout precordium\nAbd: Soft, ND, +BS\nExt: WWP\nPlan: 35 3/7 weeks CGA for this preterm infant with VSD on dol 8. Still workiing on po feeding and breast feeding. On day of A/B countdown. Continue d/c preparation\n" }, { "category": "Nursing/other", "chartdate": "2193-10-13 00:00:00.000", "description": "Report", "row_id": 1924459, "text": "PCA Note 19:00-07:00\n\n\nRESP - Infant remains in RA. RR 40-60 and O2 sats 95-100%.\nLS cl/= bliaterally. Infant appears to be breathing\ncomfortably. No drifts noted thus far this shift. Cont to\nmonitor.\n\nG/D - Stable temps with swaddled in OAC. Alert and active.\nSucks on pacifier for comfort. Sleeps well between cares.\nFS&F. MAEs. Cont to support developmentally.\n\n - Mother was here for 20:00 cares. Independent with\ncares. Mother put infant to breast and became frustrated\nthat infant was not bf as well as she has in the past. Mom\nwas concerned it was because she has not been able to visit\nfor a couple of days. RN spoke to mom and helped encourage\nher. Lactation specialist, G, also spoke with mom.\nMother seemed to be more at ease afer this. Very loving and\ninvolved family. Cont to support and educate.\n\nFEN - WT= 2310g (up 40g). TF 150cc/k/d of BM24 with HMF =\n58cc q4. PO/PG. Infant put to breast at 20:00. Infant was\nfrustrated at first, but then latched on for >10 min. 35cc\nwas also gavaged at this feed. Bottled 35cc at next feed,\nremainder of feed gavaged. Bottles well, but tires easily.\nTolerating feeds well. One med spit and min asp. thus far\nthis shift. Abd benign. Voiding. Stooling, heme-. Cont to\nencourage PO feeding.\n\nCV - HR 130-170. Continues with an audible murmur. Normal\npulses. Pink and well purfused. BP 57/29 (40). Cont to\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1924472, "text": "NPN 2300-0700 Cont.\n\n#3 Alt. in Parenting\nO: No contact with family overnight.\nA: Unable to assess\nP: Keep informed and support.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1924473, "text": "Neo Attend\nDay 15, 36.3 wk CGA\nResp stable RA, wnl, no spells, >95%\nCV: VSD muscular, 130-150s, mean bp 49. stable.\nFEN: 2440gm up 80\n150 cc/kg/day bm 24, still needs gavage. po improving, BF well. abd wnl\nUOP and stool wnl\nTemp wnl.\n involved.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1924474, "text": "NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 96%. RR stable. BBS\ncl/=. No retractions noted. No apnea/brady spells noted. A:\nstable in RA P:Cont to monitor and provide support as\nneeded.\n\n#2: Temps stable while swaddled in an air isolette. She is\nalert/active with cares. MAE. Fonts soft/flat. Sucks on\npacifier intermittently. A: AGA P:Cont to support dev\nneeds.\n\n#3: Mom in for noon care. Indep with care and breastfeeding.\nMom updated. Met with LC at bedside. Will be in for\n16care. A: Involved parent P:Cont to support and educate.\n\n#4: TF: 150cc/k/d. Conts on BM24, 61cc q4hrs. Infant woke\non own this am rooting and eager to feed. Bottled 33cc and\nthen stopped. Tired out. At noon feeding Mom breastfed.\nInfant fed well for ~30mins, one side. Gavaged 30cc after.\nNo spits noted. benign asps. Abd soft, +, no loops.\nVoiding qs. Stooling- heme negative. A: tol'ing feeds well\nP:Cont with current feeding plan. Monitor tol to feeds.\nFollow wt and exam.\n\n#5: Hr stable. Conts with loud murmur. BP stable. No palmar\npulses noted. A: non-compromising murmur P:Cont to monitor\nand provide support as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-16 00:00:00.000", "description": "Report", "row_id": 1924475, "text": "Neonatology Fellow Note\nExam:\nGeneral: alert preterm female in open crib in NAD\nHEENT: , nares patent, MMM\nCV: RRR with III/VI murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally\nAbd: soft, NT/ND, + BS\nGU: normal preterm female gen\nExt: WWP\nSkin: no lesions\nNeuro: alert, normal tone, MAEW\n" }, { "category": "Nursing/other", "chartdate": "2193-10-09 00:00:00.000", "description": "Report", "row_id": 1924446, "text": "Nursing note\n\n\n#1 RESP O: Child remains on room air. RR as noted. Mild\ninter and subcostal retractions noted. No desats or bradys\nnoted this shift. Breath sounds are clear and equal. P:\nWill monitor and support as needed.\n#2 G+D O: Child remains in open crib. Temp is stable. Wakes\nfor cares. Alert and active during cares. Bottling most of\nher bottles. P: Will continue to support her coping skills.\n#3 Parenting O: Mom in this am. Given update. Mom did temp\nand diaper and breast and bottle fed the child. Mom also\nspoke to Cardiology at about murmur. Mom stated\nthat she was much reassured. P: Will continue to support and\ninform the parents.\n#5 CV O: Child continues to have a loud murmur. Pulses\nequal. Child pink and well perfused. Mom talked with\nCardiology. P: Will monitor and continue with plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-11 00:00:00.000", "description": "Report", "row_id": 1924453, "text": "Neonatology Attending Note\nDay 10\nCGA 35 5\n\nRA. RR30-60s. No A&Bs. +loud VSD murmur. HR 130-160s.\n\nWt 2235, up 40 gms. TF 150 cc/k/day BM22. Tol well. Nl voiding and stooling. PO/PG.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant learning how to po feed. To optimize growth will increase cals to 24. VSD not clinically significant at this time, will have cardiology follow-up as an outpat.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-11 00:00:00.000", "description": "Report", "row_id": 1924454, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF\nmild subcostal retractions in room air, lungs clear/=\nlll/Vl SEM across precordium radiating to axilla\npink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with great tone.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-11 00:00:00.000", "description": "Report", "row_id": 1924455, "text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: In RA with sats 97-100. Breath sounds are clear and = with mild SC retractions. RR 30's-50's. No apnea, bradycardia or desats.\nA: Doing well in RA\nP: Continue close observation and monitoring. Document any spells.\n\n#2 Alt. in Developmant\nO: Maintaining temp in open crib, swaddled and positioned supine. Waking for some feeds and acting hungry. PO fed X2 but not able to take full volume and requiring gavage. No spells.\nA: Immature feeding skills\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: No contact with family d/t Holiday.\nA: Unable to assess\nP: Await contact from when religious holiday concluded.\n\n#4 Alt. in Nutrition\nO: TF=150cc/kg=57cc Q 4 Hrs. Increased to 24cal BM today. Abd. is full, soft with + BS, no loops. No spits. Voiding and stooling. PO fed X 2. Took 40-50cc and required gavage to finins.\nA: Tolerating feeds, gaining wt. still requires gavage\nP: Continue to encourage PO feeds. Follow daily wts.\n\n#5 Alt. in C-V Function\nO: Loud murmur persists. HR 130's-170's. Lungs clear. Pink in RA with good sats. No edema. Pulses WNL.\nA: VSD by ECHO, no evidence of compromise\nP: Continue to monitor and assess.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-12 00:00:00.000", "description": "Report", "row_id": 1924458, "text": "NPN 7A-7P\n\n\n#1,5 Remains in RA, no brady's, no desat's, baseline\nsaturation >95%. LS = and clear, murmur audible, is pink and\nwell-perfused. Cardiology will be following on an\nout-patient basis. Will con't to monitor.\n\n#2 Maintaining temp in crib, usually alert and active with\ncares but was drowsy this AM. Bottling well at times but\noften is gavaged. Buttocks slightly reddened, Desitin\napplied. Con't present interventions.\n\n#3 No parental contact today ( are orthodox ) but\nthey will reportedly contact NICU tomorrow. Infant's\nsiblings (2?) have also been premature, seem\nexperienced with info/care. Con't to update/teach.\n\n#4 TF at 150cc/k/d of BM24, working on bottling stamina, and\nhas bottled all of volume last evening. Still requiring some\ngavage. Very alert and active, settling well, voiding and\nstooling. Con't to promote bottling.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1924476, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=98-100%. RR=30-50's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Cont to\nmonitor resp status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, loves\npacifier. MAE. Continue to support G+D.\n\n: No contact with family so far this shift.\n\nFEN: Weight=2.425kg (-15 grams). TF=150cc/kg/d of BM24 PO/PG\nq4hr. Infant offered bottle with each care. Infant has\nbottled 70cc and 27cc so far this shift (remainder gavaged\nvia NGT). Infant bottles well, but tires easily. Abdomen\npink, soft, round, +BS, no loops. No spits, no aspirates.\nVoiding, no stool. Continue to monitor FEN status.\n\nCV: Loud murmur noted. HR=130-160's. Infant pink and well\nperfused. Brisk cap refill and normal pulses noted. Continue\nto monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1924477, "text": "Neo Attend\nDay 16, 36.4 CGA\n\nResp: RA, wnl. No h/o spells.\nCV: muscular VSD. Follow-up outpatient.\n jaundice: (Day 3, 8.2)\nTW 2425gm, down 15\n150 cc/kg/day BM24, taking of feeds with po. Continue to increase po.\nabd wnl\n\nHome when all po feed consistently.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1924496, "text": "NPN NIGHTS\n\n\nCV:CONTINUES TO HAVE LOUD MURMUR. HR 160'S. GOOD COLOR AND\nCAP REFILL. BP 84/37 52. NO EVIDENCE OF CARDIAC COMPROMISE.\nMOM TO MAKE FOLLOW UP APPOINTMENT WITH CARDIOLOGY FOR 1MONTH\nFROM NOW. CONTINUE TO MONITOR FOR ANY CHANGES IN EXAM.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON AD\nLIB DEMAND SCHEDULE, OF BM24. BABY EATING Q4HRS. ABD EXAM\nBENIGN. NO LOOPS, NO SPITS. VOIDING AND STOOLING WELL.\nSSTOOL GUIAC NEG. WGT UP 25 TO 2575 TONIGHT. BABY BOTTLED\n60CC Q4HRS. SHE TOOK IN 148CC/K/D YESTERDAY. CONTINUE\nCURRENT FEEDING PLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nSUCKS ON PACIFER VIGOROUSLY. BABY PASSED CAR SEAT TES T\nONIGHT. CONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING:MOM CALLED FOR UPDATE ONCE THIS EVE.\nCONTINUE TO UPDATE AND SUPPORT, AND CONTINUE D/C TEACHING.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1924497, "text": "Neo Attend\nDay 21 day, now CGA 37.2 wk\nRespr RA, 40-50s, clear, no spells\nCV: muscular VSD. Stable. Ped Cardiology appointment 1 month.\nTW 2575gm, up 25gm\n 130 cc/kg/day BM24. Took 148cc/kg/day. Needs Fe and Vidaylin\nUOP and stooling wnl\nHearing passed\nCar seat test passed.\nHepB vaccine given on .\nPE discharge exam wnl.\nPed visit in 2 day.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-22 00:00:00.000", "description": "Report", "row_id": 1924498, "text": "Nursing Progress and Discharge Note\n\n\n2. DEV O/A Infant remains in an OAC with stable temp.\nA/A with cares. Waking q4 hrs. P D/C to home with \n3. O/A Mom and Dad in for discharge. Independent\nwith care of infant. P D/C to home\n4. FEN O/A TF= of 130cc/kg/day of BM24. PO feeding\n60cc q 4 hrs. Tol well. N o spits. Voiding, stooling.\nBelly soft. P have recipe card for 24 cal BM.\n5. CV O/A Loud murmer audible. Good pulses, well\nperfused. P Mom to call cardiology for F/U appt in 1 month.\nSee flowsheet for further details. Discharge infant to home\nwith as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1924478, "text": "Nursing progress note\n\n\n#1 O: Remains in RA with lungs clear and equal with good\naeration to bases, breathing comfortably without compromise\nA: stable in RA P: resolved concern, monitor per newborn in\nNICU protocol\n#2 O: Awakening for feedings at times and interacting well\nwith caregiver, sleeping well between cares, loves to hold\nfingers A: AGA P: support, teach and keep informed\n#3 O: in for 1200 care and independant with\ndaughter, mom verbalizing frustration with daughter's\nfeeding slowly and can't wait to get her home, reassured mom\nthat she will catch on with little more time-mom appearing\nmore comfortable A: Involved anxious to get daughter\nhome P: support, teach and keep informed\n#4 O: Abdomen softly round with active BS without loops,\nnon-tender, po feeding well at times with whole volume/feed\ntaken then at other times tiring with feeds requiring pg\nsupplementation, voiding and stooling A: stable infant\nlearning to po feed P: encourage oral feedings, wt. daily\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-17 00:00:00.000", "description": "Report", "row_id": 1924479, "text": "Neonatology Fellow Note\nExam:\nGeneral: sleeping preterm female in open crib in NAD\nHEENT: , NG in place, MMM\nCV: RRR with III/VI systolic murmur, 2+ fem pulses, CR brisk\nPulm: CTA bilaterally, no inc WOB\nAbd: soft, NT/ND, + BS, no HSM\nGU: normal preterm female genitalia\nExt: WWP\nNeuro: arouses on exam, MAEW, normal tone\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1924480, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=98-100%. RR=40-60's.\nBreath sounds clear and equal bilaterally, no retractions\nnoted. No bradys, no desats so far this shift. Continue to\nmonitor resp status.\n\nG+D: Temps stable, swaddled in OAC. Active and alert with\ncares, sleeps well btw cares. Brings hands to face, loves\npacifier. MAE. Continue to support G+D.\n\n: No contact with family so far this shift.\n\nFEN: Weight=2.460kg (+35 grams). TF=150cc/kg/d of BM24 PO/PG\nq4hr. Infant offered bottle with each care. Infant has\nbottled 40cc and 50cc with good coordination so far this\nshift (remainder gavaged via NGT). Infant bottles well, but\ntires easily. Abdomen pink, soft, round, +BS, no loops. No\nspits, no aspirates. Voiding and stooling (guiac negative).\nContinue to monitor FEN status.\n\nCV: Loud murmur noted. HR=130-160's. BP=66/31(45). Infant\nslightly jaundiced/well perfused. Brisk cap refill and\nnormal pulses noted. Continue to monitor CV status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1924481, "text": "Neo Attend\nDay 17, 36.5 CGA\nRespr RA stable, wnl\nCV: VSD muscular, P 130-160, mean BP 45. Stable.\nFEN: wt 2460, up 35\nFEN 150 cc/kg/day, BM24; po 35-50cc/62 cc. Improving on po feeds.\nabd wnl. UOP and stool wnl.\nClinically stable. Continue to advance po feeds as tolerated.\n\nPO ad lib with 150 cc/kg/day minimum.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-18 00:00:00.000", "description": "Report", "row_id": 1924482, "text": "NPN 0700-1900\n\n\nRESP: Remains in RA, LS C/=, no increased work of breathing.\nNo spells or desats. Problem resolved.\n\nG/D: Temp stable swaddled in OAC. A&A w/cares, sleeps well\nin between. Wakes for all feeds. Brings hands to face for\ncomfort.\n\n: Both in for first cares, updated by this\nRN, asking appropriate questions. Anxious to get home.\nPlan to visit tomorrow evening.\n\nFEN: Learning to PO feed. Mom BF infant x1 this am w/good\nresults, offered bottle after BF and w/each cares. Infant\ncoordinated but gets tired. No spits or aspirates. Abdomen\nsoft/round, good bs, V&S.\n\nCV: Loud murmur heard (Muscular VSD via echo), pulses\nnormal, well perfused.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-10-04 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 839550, "text": " 5:39 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate heart and lungs\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with murmur, in RA\n REASON FOR THIS EXAMINATION:\n evaluate heart and lungs\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP SUPINE (BABYGRAM):\n\n Nasogastric tube terminates in the stomach. The lungs are clear. The heart\n size and pulmonary vascularity are normal.\n\n IMPRESSION: Normal chest.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-01 00:00:00.000", "description": "Report", "row_id": 1924406, "text": "Neonatology Attending\n34-2/7 week GA infant admitted for prematurity\n\nMaternal Hx - 30 year old G4P3->4 woman with the following prenatal screens: B positive, DAT negative, HBsAg negative, RPR non-reactive, rubella immune.\n\nAntenatal Hx - for EGA 34-2/7 weeks. Pregnancy complicated by preterm labor with cerclage placement and bedrest. Received full course of betamethasone. Spontaneous onset labor leading to SVD without anesthesia. ROM one hour PTD yielding clear amniotic fluid. No intrapartum fever or other clinical signs of chorioamnionitis.\n\nNeonatal course - NICU team not in attendance at delivery. Infant received free flow oxygen. Apgars 9 at one minute, 9 at five minutes. Subsequently pink and in no distress in room air.\n\nPE\nvery well-appearing infant with exam c/w 34 weeks\nhr 136 rr 40 T 97.7 BP 63/36 (49) SaO2 97% in room air\nBW 2280g OFC 30cm LN 43.25cm\nHEENT AFSF; non-dysmorphic; palate intact; no nasal flaring; neck/mouth normal; normocephalic\nCHEST no retractions; no grunting; good bs bilat; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent; 3-vessel umbilical cord\nGU normal female genitalia\nCNS active, alert, resp to stim; tone AGA and symm; MAE symm; suck/root/gag intact; grasp/Moro symm\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nIMPRESSION\n 34-2/7 week GA infant with\n1. Sepsis risk, based on unknown maternal GBS colonization status and spontaneous preterm labor of unexplained etiology. Infant is asymptomatic without other sepsis risk factors\n\nPLAN\n-Infant has been admitted to NICU for cardiorespiratory monitoring to ensure respiratory, feeding and thermoregulatory maturity\n-CBC and blood culture have been drawn. Given the absence of other sepsis risk factors or symptoms, we will defer antibiotic coverage for now, pending culture and WBC\n-We will attempt ad lib feeds today\n\nOB: Dr. \nPediatrician: Dr. ()\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-01 00:00:00.000", "description": "Report", "row_id": 1924407, "text": "NPN admission note\n\n1 Resp\n2 G/D\n3 Parents\n4 FEN\n\nBaby girl was admitted from L&D at 1430 today.\nInfant was placed on open warmer with CVR monitoring placed\non. VSS stable. Please see flowsheet for specific values.\nTemp initially 97.7 rectal - infant was placed on\nservo-warmer and temp in an hour was 98.6. CBC and BC were\ndrawn and sent. Abx were not started. Erythro and Vit K\ngiven as ordered. Tags checked with L&D. Please see above\nattending note for further details on prenatal and maternal\nhx.\n\nResp: Infant in RA, maintaining her O2 sats greater than\n96%. Lung sounds clear/=. RR 40-50. Mild SCR noted. No\nA's or B;s noted. P: Cont. to monitor resp. status.\n\nG/D: Temps stable swaddled now on warmer with hat. Alert\nand active with cares. Settle well in between cares. AFSF.\n AGA. P: Cont. to support developmental needs.\n\nParents: Mom and Dad and siblings up to visit. Updated at\nbedside on infant's condition and plan of care by this RN\nand NNP Buck. Asking appropriate questions. Mother\nbreastfed infant with minimal assistance from nursing. Time\nwas spent orienting parents to NICU environment. Loving,\ninvolved parents. P: Cont. to support and update parents.\n\nFEN: BW 2280 gms. TF adlib with min of 40 cc/kg/ of 20\nor breastfeeding. Infant bottled 25 cc thus far x 1 with\ngood coordination and breastfed well for 15 minutes with\ngood latch and some sucks noted. Abd exam benign, no spits,\nactive BS, no loops. DTV and DTS. D/S 61/73/70. P: Cont.\nto support nutritional needs.\n\nREVISIONS TO PATHWAY:\n\n 1 Resp; added\n Start date: \n 2 G/D; added\n Start date: \n 3 Parents; added\n Start date: \n 4 FEN; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924408, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=98-100%. RR=50-60's.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nG+D: Temps stable. Infant swaddled on off warmer. Active and\nalert with cares, sleeps well btw cares. Brings hands to\nface, sucks on pacifier for comfort. MAE. Continue to\nsupport G+D.\n\nParents: Mom up to visit x1. Involved and loving. Updated on\ninfant's current status/plan of care by this RN and NNP\n. Continue to support and update family.\n\nFEN: Ad lib with a min of 40cc/kg/d of BM20/SSC20, all PO.\nInfant has bottled 20cc and 27cc so far this shift. Infant\nalso BF x 5min at 2100. Abdomen pink, soft, round, +BS, no\nloops, ag=26cm. No spits. Voiding and stooling (meconium).\nD/S=83. Continue to monitor FEN status.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-03 00:00:00.000", "description": "Report", "row_id": 1924415, "text": "Neonatology Attending\n\nDay 2 CGA 34 4/7 weeks\n\nRemains in RA. RR 50-60s. No bradycardia. Weight 2140 gms (-140). TF at 80 cc/kg/d. Took 70 cc/kg po. Gavaged for remainder. Blood glucose 79. Stable temperature in off incubator.\n\nDoing well overall with adequate breathing control. Monitoring cardio-respiratory status. Will continue to encourage po feeding. Following temperature.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-03 00:00:00.000", "description": "Report", "row_id": 1924416, "text": "NPN\n\n\n#1 Resp: infant remains in RA with RR 30-50s and Sats\n95-100%. breathing comfortably, no spells or desats noted so\nfar this shift. cont to closely monitor.\n\n#2 Dev: infant remains in OFF isolette with stable temps,\nactive and alert, waking for feeds. plan to move into OC\nthis evening. cont to provide dev support.\n\n#3 Parents: Mom in this AM prior to her discharge from\npostpartum. Put infant to breast briefly. Asking appropriate\nquestions. Plan to hold a family meeting tomorrow or early\nnext week. Cont to provide updates and support.\n\n#4 FEN: TF increased to 100cc/kg/d =38cc PO/NG Q4h. taking\n~20cc PO and req the remainder gavaged over 20minutes.\ntolerating feeds well, abd soft, +BS, voiding and stooling.\nno spits, min residuals. cont to closely monitor and\nencourage PO intake.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-03 00:00:00.000", "description": "Report", "row_id": 1924417, "text": "NICU Fellow PN\nNo events, took in 70 cc.kg po plus breast feeding\nweight 2140 (down 140g)\nPE Awake, alert, pink and well-perfused\nHEENT: AFOF, soft, OP clear, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, III/VI systolic murmur heard throughout precordium, no radiation, nl S1 and question of split S2, femoral pulses normal\nAbd: Soft, NT, ND, no HSM, +BS\nExt: WWP\nPlan : 2 day old 34 weeker working on oral feeding. Will increase minimum to 100cc/kg, work on breast feeding. Bili in acceptable range at 6.8, will follow. Murmur noted on last two days on exam, now >48 hrs of age so will check CXR, EKG, sats, hyperoxia to assess for cardiac disease. Will update parents today.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924418, "text": "5 CV\n\nREVISIONS TO PATHWAY:\n\n 5 CV; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924419, "text": "NPN 1900-0700\n\n6 Bili\n\n#1Resp: Pt. remains in RA, RR 30-50's, sats > 99%. Pt. had\none spell d/t apnea requiring mild stim. LS clear\nbilaterally w/ occas. mild SCR. P: cont to monitor resp\nstatus.\n\n#2G/D: Temps stable swaddled in OAC. Pt. awake, alert, &\nirritable w/ cares. Pt. waking for feeds. Pt. MAE's\napprop. AFSF. Pt. likes pacifier. PKU drawn this am. P:\ncont to support dev needs.\n\n#3Parents: No contact from family so far this shift.\n\n#4FEN: Weight 2080g down 60g. TF 100cc/kg/d of BM/SSC 20=\n38cc Q 4hrs PO/PG. Pt. taking 25-35cc po. Abd soft &\nround, +BS, no loops. AG 24-25cm. MIn asp, no spits. Pt\nvoiding & stooling. Frank blood evident in stool at 1am\ncares. Had NNP in to assess. NNP stated she saw a fissure\n@ 12 o'clock. P: cont to monitor abdomen closely.\n\n#5CV: HR 130-150's. Murmur became louder @ 1am cares. NNP\nin to assess. 4-ext BP taken & CXR ordered for am. EKG\nwill be done on days. Pt. remains sl jaundice, WWP, brisk\ncap refill. P: Complete cardiac w/u today.\n\n#6Bili: Bili this am is 8.2/0.3 which is increased from\n6.8/0.2. Pt. remains sl jaundice. P: cont to monitor.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924409, "text": "Case Management Note\nHave reviewed record to date. List of Early Intervention Programs and VNA's, that service , have been placed in chart. Will cont to follow & assist w/any d'c needs w/team & family.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924410, "text": "NICU Fellow PN\nAdmitted from Labor and delivery yesterday secondary to prematurity. Taking po ad lib, with BF when mom is here\n\nweight\nPE: Awake, MAe, pink and well-perfused\nHEENT: AFOF, soft, +suck, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, II/VI systolic murmur at sternal border, no radiation, femoral pulses normal, cap refill brisk\nAbd: Soft, NT, ND, +BS\nExt: WWP\nPlan: 34 3/7 weeks infant, doing well. Continue to po ad lib and breast feed. Will check bili in am 9/23Stable on room air, continue to monitor. Murmur on exam consistent with closing PDA, follow.\nSpoke with Dr. who is aware of her presence in NICU as well as her clinical course overnight.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924411, "text": "Neonatology Attending\nDOL 1 / CGA 34-3/7 weeks\n\nIn room air with no distress and no cardiorespiratory events.\n\nMurmur noted.\n\nHct 43.1.\n\nNot on antibiotics.\n\nBW 2280. On min TFI 40 cc;/kg/day wiht ad lib intake of 60 cc/kg/day. Abd benign. Voiding and stooling normally.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924412, "text": "Neonatology Attending\nContinued\n\n34-2/7 week GA infant\n-Bilirubin in 24 hours\n-Continue to encourage oral feeds\n-Otherwise continue current management\n" }, { "category": "Nursing/other", "chartdate": "2193-10-02 00:00:00.000", "description": "Report", "row_id": 1924413, "text": "NPN\n\n\n#1 Resp: infant remains in RA with RR 40-50s and Sats\n95-100%. BBS clear/=, breathing comfortably, no desats or\nspells so far this shift. cont to monitor.\n\n#2 Dev: remains in an isolette, able to wean air temp per\ninfant temp. Active and alert, waking for feeds. well\ncoordinated with PO feeds and put to breast X1. plan to wean\nto OC when appropriate. cont to provide dev support.\n\n#3 Parents: Mom in throughout the shift, taking infant temp\nand changing diaper independently. Updated on infant status\nand asking appropriate questions. Mom put infant to breast\nX1. cont to provide updates and support.\n\n#4 FEN: TF increased to 80cc/kg/d =30cc Q4h. infant\ncurrently taking 22-27cc Q4h plan to place NG tube if\nvolumes do not increase with next feeding. tolerating feeds\nwell, abd full and soft. voiding, X2 mec stools. plan to\nobtain bili in AM. cont to closely monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-03 00:00:00.000", "description": "Report", "row_id": 1924414, "text": "1900-0700 NPN\n\n\nRESP: Infant remains in RA, O2 sats=98-100%. RR=60-64.\nBreath sounds clear and equal bilaterally, mild SCR noted.\nNo bradys, no desats so far this shift. Continue to monitor\nresp status.\n\nG+D: Temps stable, swaddled in air mode isolette. Active and\nalert with cares, sleeps well btw cares. Brings hands to\nface, MAE. Continue to support G+D.\n\nParents: Mom in to visit at 2100. Involved and loving.\nUpdated on infant's current status/plan of care by this RN.\nContinue to support and update family.\n\nFEN: Weight=2.140kg (-140grams). TF=min of 80cc/kg/d of\nBM20/SSC20, all PO. Infant has bottled 25cc and 36cc with\ngood coordination so far this shift. Infant BF x 5min at\n2100. Total intake for yesterday=71cc/kg/d +BF. Abdomen\npink, soft, round, +BS, no loops, AG=26-27cm. No spits,\nminimal aspirates. Voiding and stooling. Continue to monitor\nFEN status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924420, "text": "Respiratory Care\nHyperoxia text completed, pt passed 311 on the TcPO2 monitor while breathing in 100% O2. Pt's respiratory rates 40's to 60s' with clear B/S.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924421, "text": "Neonatology Attending\nDOL 3\n\nIn room air with no distress. One bradycardia overnight.\n\nMurmur persists. Hyperoxia test pending this morning. BP 73/41 (47). LA 56/44 LL 68/45 RA 73/41 RL 66/51\n\nBilirubin 8.2/0.3 (not under phototherapy).\n\nWt 2080 (-60) on TFI 100 cc/kg/day Sim20/BM20, tolerating well. Bottling partial volumes. Abd benign. Voiding and stooling, with blood in stool and fissure noted. Subsequent stools trace guiac positive but no frank blood.\n\nTemp stable in open crib.\n\nA&P\n34-2/7 week GA infant with murmur (initial work-up normal), respiratory and feeding immaturity\n-Increase TFI to 120 cc/kg/day and continue to encourage development of oral feeding skills\n-Given clinical characteristics of murmur, will proceed with echocardiogram (EKG pending)\n-Blood in stool is explained by fissure, and clinical examination is entirely reassuring, but will follow feed tolerance and abdominal examination closely\n-Mother up to date\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924422, "text": "0700-1100\n\n\nInfant stable in RA. VSS. Had one desat to 60's this AM. See\nflowsheet. Cardiac W/U continued today. Hyperoxia test\ncompleted by RRT . Score 311. EKG done this\nAm. Team aware of all tests. Mom called x1. Updated by tele.\nWill come to visit at 1245. Looking forward to team meeting.\n\nSee flowsheet and MD notes for additional details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924423, "text": "NICU Fellow PN\none spell overnight (HR 78, sat 83), mild stim needed. Continues with murmur\nweight 2080 (down 60g)\nPE: Asleep, pink and breathing easily, in NAD\nHEENT: AFOF, soft, OP clear, MMM\nChest: Clear BS bilaterally, no distress\nCV: RRR, III/VI systolic murmur heard throughout precordium, cap refill brisk\nAbd: Soft, NT, ND, no HSM, +BS\nExt: WWP\nPlan: dol 3 for this 34 weeker, now 34 4/7 weeks CGA. Spoke with cardiology on the phone today who would prefer to echo on Monday to allow pulmonary pressures to drop more which would allow better evaluation of VSD if one is present. Also would give additional time for PDA to close if this is the murmur we are hearing.\nFollow for spells, work on po feeding.\nSpoke with mom about cardiac workup today-informed her of the CXR and hyperoxia test results. EKG pending.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 1924424, "text": "NPN 1100-1900\n\n#1 Alt. in Resp. Function\nO: In RA with RR 30's-50's. Mild SC retractions. Breath sounds are clear and =. Sats 97-100. No spells.\nA: Doing well in RA, no spells this shift\nP: Continue close observation and monitoring.\n\n#2 Alt. in Development\nO: Temp borderline 97.8-98, in open crib, double swaddled with hat and extra blanket. Not waking for feeds but alert with cares. BF well X 5 min. Taking some PO but still needs gavage. Occasional spells.\nA: Immature feeding and breathing regulation, appropriate for GA\nP: Continue to support developmental needs.\n\n#3 Alt. in Parenting\nO: Parents and siblings in for 1300. Parents updated and mom spoke with Dr.. All questions answered. Mom put infant to breast and also offered her a bottle w/o assistance.\nA: Involved, loving family\nP: Keep informed and support.\n\n#4 Alt. in Nutrition\nO: TF increased to 120cc/kg=46cc BM or SpCare24 Q 4 hrs. Abd. exam is benign. Minimal aspirates. No spits. Voiding and stooling guaiac -. PO fed taking 25-35cc. Breastfed well X 5 min.\nA: Tolerating feeds, guaiac - stool\nP: Continue close observation and monitoring of feeding tolerance. Follow daily wts.\n\n#5 Alt. in C-V Function\nO: Loud murmur audible. HR 120's-150's. Pink in RA with sats 97-100. Lungs clear, easy respirations. No edema noted. Cardiac eval. completed. ECHO to be done on Monday if murmur persists.\nA: Non-compromising murmur present\nP: Continue close observation and monitoring for any change in C-V status.\n\n#6 Bili\nO: Color is mild/mod. jaundice. On 120cc/kg enteral feeds. Passing stool QS. Not under phototherapy for latest bili 8.2/0.3\nA: Physiologic jaundice not requiring treatment at present\nP: Continue close observation and monitoring for s/s increased jaundice.\n" }, { "category": "Nursing/other", "chartdate": "2193-10-05 00:00:00.000", "description": "Report", "row_id": 1924425, "text": "PCA NOTE\n\n\nRESP: O/A-No spells or desats noted. No drifts. Stable in\nRA. P-Continue to monitor.\n\nG/D: O/A-Temp remains borederline in OAC. Double swaddled,\nhat on and 2 blankets. Slowly waking for feeds. Alert and\nactive. Sleeps peacefully. MAE. AF-flat. Rooting. sweet\nnatured. AGA. P-Continue to support developmentally.\n\nPARENTS: No contact thus far this shift.\n\nFEN: O/A-Current weight 2.140, ^ 60gm. TF 120cc/k/d of\nBM/ 20. PO/PG. Infant is voiding, trace stool. Active\nbowel sounds. Benign abdomen. Minimal residuals. No spits.\nTolerating feeds. P-Continue to encourage PO intake.\n\nCV: O/A-Loud murmur present. + pulses. Well perfused.\nP-Continue to follow.\n\nBILI: O/A-Infant slightly jaundice. No plan for phototherapy\nlights at this time. Continue to assess.\n\n ***See flowsheet for further examination of shift**\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2193-10-04 00:00:00.000", "description": "Report", "row_id": 183246, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2200-04-26 00:00:00.000", "description": "Report", "row_id": 1571687, "text": "CONDITION UPDATE\nD: NEURO: SEDATED ON PROPOFOL. PROPOFOL INTERMITTENTLY STOPPED TO ALLOW FOR NEURO ASSESSMENT. PT OPENS EYES TO NAME, MAE ON BED, INCONSISTENTLY FOLLOWS COMMANDS. PUPILS 3-4 MM WITH BRISK REACTION.\nCV: T MAX 102. OTHER VSS- SEE CAREVUE FOR SPECIFICS. IV NTG TITRATED TO MAINTAIN SBP<140.\nRESP: ABD REMAIN FAIR- PEEP INCREASED TO 15 WITH IMPROVEMENT OF PO2. BS COARSE BILATERALLY. SX FOR THICK BLOOD TINGED TAN SECRETIONS.\nGI: NPO. ABD SOFT AND NON-TENDER, + BS, NO STOOL THIS SHIFT\nGU: LASIX 20 MG IV GIVEN WITH FAIR DIURESIS\nA: NEURO STATUS MONITORED, STARTED ON IV VANCOMYCIN FOR GM + COCCI IN BLOOD CX REPORTS.\nR: STABLE NEURO STATUS, CONTINUE TO RECHECK ABG AS ORDERED, SX PRN\n" }, { "category": "Nursing/other", "chartdate": "2200-04-26 00:00:00.000", "description": "Report", "row_id": 1571688, "text": "Respiratory Care Note:\n Patient remains intubated and sedated. With an increase in PEEP to 15, FIO2 of 50% his PaO2=97. BS=bilat with rales LLL, LUL and occassinally coarse with scattered rhonchi, mild exp wheezing. MDI albuterol given. Suctioned for blood tinged and thick yellow sputum. One recrucitment manuever done this am per Dr with minimal effect on SaO2. BP tolerated well. See Carevue flowsheet for specifics. Blood cultures returned positive for gram pos cocci. He remains febrile. Plan to maintain and wean FIO2 as able.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-27 00:00:00.000", "description": "Report", "row_id": 1571689, "text": "focus hemodynics\ndata: neuro: on iv propofol gtt. off for neuro checks. moves all extremities on the bed. opens eyes to verbal stimuli.\n\nresp: suctioned for large amt of white-yellow sputum. plug x1. peep decreased this am. o2sats 95-100%. lg amt of yellow drainage from nares. culture obtained and sent to the lab.\n\ncardiac: continues on the iv ngt gtt. no ectopy seen. k repleted x2. ion calicium repleted.\n\ngi: abd distended. lg amt of flatus with brown stool. ngt draining brown drainage.\n\ngu: foley patent and draining light greeen urine.\n\naction: propofol gtt continues. iv ntg gtt continues. vent settings weaning slowly. ngt. k and calicium repleted. na level 135. update to\nwife. culture of nares. iv vanco tonite.\n\nresponse: monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-27 00:00:00.000", "description": "Report", "row_id": 1571690, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN SIMV/PS MODE. PT OVERBREATHING VENT, GROSSLY IN SYNCH, ADEQUATE SPONT TIDAL VOLUMES. TEMP SPIKE OVERNOC W/NOTED INCR IN RR, PLEASE SEE CAREVUE FOR DETAILS. BS OCCAS SL COARSE, FREQ SXN FOR SM-MOD AMTS LOOSE WHITE SEC. PURULENT YELLOW DRAINAGE FROM NARES NOTED. AM AB REFLECTS SL METABOLIC ALKALOSIS W/HYPEROXIA, PEEP WEANED FROM 15 TO 10CMH20. NO RSBI DUE TO HIGH PEEP. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-25 00:00:00.000", "description": "Report", "row_id": 1571682, "text": "Nursing note\nRemains neuro intact, headache's controlled with fiorecet. No headache excpet with movement and OOB. Nitro gtt titrated to keep sys <140. SR, no ectopy. Able to wean o2 to NC, PO2 an ABG wnl. LS diminished. lasix given and diuresed well.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-25 00:00:00.000", "description": "Report", "row_id": 1571683, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nPT ALERT, ORIENTED X3 THIS AM. SL CONFUSED, FORGETFUL. ON NITRO GTT FOR SBP <140.\nTO NEURO ANGIO AT 0900. PER REPORT, IN ANGIO, PT BECAME INCREASINGLY CONFUSED, COMBATIVE, HYPOXIC. RECEIVED IV LASIX WITH DIURESIS. INTUBATED AND SEDATED. HYPOTENSIVE WITH SEDATION. NITRO OFF AND NEO UP.\nRETURNED FROM ANGIO AT 1345, INTUBATED, SEDATED, R FEM SHEATH D/C'D (HEMOSTASIS AT 1315 PER REPORT). SBP ELEVATED WITH SEDATION OFF. NITRO GTT RESTARTED AND TITRATED UP TO MAINTAIN SBP <140. PROPOFOL GTT STARTED AND TITRATED UP TO MAINTAIN ADEQUATE SEDATION AND SBP <140. SEE FLOWSHEET FOR NEURO EXAM.\nREMAINS INTUBATED ON IMV, 8 PEEP. FIO2 DECREASED TO 60%. SEE FLOWSHEET FOR ABG'S.\nK AND CA REPLETED. NA DECREASED, NACL TABS STARTED, 750CC FLUID RESTRICTION.\nPLAN: CONT TO MONITOR. ?WEAN SEDATION AND VENT TO EXTUBATE. MAINTAIN SBP <140. MONITOR SERUM LYTES, ESP NA. ? CONT TO DIURESE. CONT PER CURRENG MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-26 00:00:00.000", "description": "Report", "row_id": 1571684, "text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings: SIMV/PS 700 * 12 50% 5 peep and 5 ps. Breathsounds are coarse to clear. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-26 00:00:00.000", "description": "Report", "row_id": 1571685, "text": "focus hemodynmics\ndata: neuro: perla #3 bilaterally and reacts briskly. propofol infusing and shut off for neuro assessment. pt bites on et tube and lifts head off the pillow to attempt to pull at the et tube. moves legs and arms on the bed. eyes open to verbal stimuli.\n\nresp: remains intubated. ph 7.49-7.50. po2 90. peep increased to 10 at the change of shift. sputum culture sent to the lab. suctioned for mod amt of white sputum. temp 102.5. tylenol given with repeat temp 101.5.\nblood cultures peripherally x2 given.\n\ncardiac: on iv ntg and bp to be kept < 140. k 3.7 and repleted with 40meq kcl down ngt. ion ca repleted with calicium carbonate 1 tab via ngt. no ectopy seen.\n\ngu: foley patent and u.o > 50cc/hr. urine amber-yellow in color.\n\ngi: abd distendend and soft. postive bowel sounds. ngt patent. 2 large loose brown stools.\nendocrine: blood sugars 130-155. sliding scale insulin(reg) sc given.\n\naction: on iv propofol gtt. off during neuro exam. pt does bite the et tube . on iv ngt gtt to keep bp < 140. k and calicium repleted. abg's drawn and vent settings readjusted per abg's. lasix 20mg ivp given. labs drawn.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-26 00:00:00.000", "description": "Report", "row_id": 1571686, "text": "update from previous note: r angio site intact with no ecchymosis. pedal pulses intact and strong.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-23 00:00:00.000", "description": "Report", "row_id": 1571677, "text": "Nursing note:\nNEURO: A/Ox3, MAE. PERRLA. No neuro deficits. C/O mild headache relieved by Tylenol.\nRESP: Lung sounds dim w/occ. expiratory wheezes. Sats 97-100% on 2L NC and 60% mask. DOE much better, pt. not c/o SOB overnight. Able to get OOB to chair or commode mult. times overnight w/o incident. Using I/S w/good technique. Non-productive cough.\nCV: Afebrile. SR in 70s, no ectopy. SBP <130, cont. on Nitro gtt. Palpable pulses. No cardiac c/o's.\nGI: Abdomen large and distended, soft. 3 loose BMs overnight, moderate amounts liquid stool. Cont. on fluid restricition. Pt. only taking in small amount liquids overnight. -N/V.\nGU: Foley patent adequate amounts amber urine, good response from Lasix.\nENDO: SSRI PRN.\nAct: OOB to commode/chair overnight w/standby assist, gait steady.\nA/P: Stable, neuro intact. Resp. status much improved.\nCont. neuro assessment, pulm hygeine, increase activity level, ? Tx. to floor.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-23 00:00:00.000", "description": "Report", "row_id": 1571678, "text": "NEURO; A&Ox3, FOLLOWS COMMANDS, MAE, PERL #3 BRISK, NO PRONATOR DRIFT, NO FACIAL ASYMMETRY, CAT SCAN OF HEAD TODAY, MEDIC WITH PERCOCET AND DILAUDID FOR PERSISTENT HA\n\nCARDIOVASCULAR; HR 70'S SR, SYS BP 130'S-PRESENTLY 140 RANGE, LOPRESSOR 75 KMGM GIVEN THIS PM AND WILL BE TID, NITROPASTE 2' STARTED THIS PM AND NITRO GTT AT 0.06 MCG/KG/MIN\n\nRESPIR; EXPIR WHEEZES THIS AM BUT FEWER THAN YESTERDAY, BB RALES THIS PM, REPORTED TO SICU HO, 02 SATS 93-95% ON 60% SHOVEL MASK AND N/C AT 2L/MIN, PT DOES TO 88-89% WHEN MASK OFF,\n\nGI; ABD REMAINS FIRM AND DISTENDED, BUT PT TAKING PO LIQUIDS AND STARTED WITH SMALL AMTS SOLIDS TONOC\n\nPLAN NPO AFTER MIDNOC, ? ANGIO TOMORROW, MONITOR BP,\n" }, { "category": "Nursing/other", "chartdate": "2200-04-23 00:00:00.000", "description": "Report", "row_id": 1571679, "text": "RESP CARE\nPATIENT GIVEN X 2 NEB TX'S THIS SHIFT. BS DECRESASED AND MILDLY COARSE WITH MILD EXP WHEEZES WITH CLEARING. COUGH STRONG RR 20-24 PTIENT PLACED ON HIGH FLOW AEROSOL TO KEEP SAT'S >92%. SEE CAREVUE FOR SPECIFICS. CONTINUE TO FOLLOW.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-24 00:00:00.000", "description": "Report", "row_id": 1571680, "text": "NURSING NOTE\n SNEURO INTACT, SOME MILD TREMORS NOTED BILAT TO HANDS. DILAUDID AND PERCOET PRN FOR HEADACHE. HEADACHE INCREASING WITH MOVMENT. OOB TO CHAIR AND SLEPT WELL IN CHAIR, +DIZZINESS INTO CHAIR. LS WITH EXP WHEEZING, ALB NEBS GIVEN BY RT. SOME BIBASILAR CRACKLES. TO 88%, MD AWARE. NRB APPLIED. ? SLEEP APNEA. NPO AFTER MN FOR ANGIO\n" }, { "category": "Nursing/other", "chartdate": "2200-04-24 00:00:00.000", "description": "Report", "row_id": 1571681, "text": "CONDITION UPDATE\nD.LOW GRADE TEMP,SR 80-90-,RR=16-24 WITH PERIODS OF APNEA WHILE SLEEPING WHICH THEN CAUSES PT TO AWAKEN..DUE TO 100% O2 REBREATHER MASK ON AT ALL TIMES WHEN SLEEPING,O2 SATS 97-100.O2 SAT DROPPED TO 88 ON ROOM AIR WHEN PT PERIODICALLY REMOVES IT.\n NEW A-LINE INSERTED AND SBP 170-190/60-70..PT C/O OF CONTINUOUS HA'S OF VARYING DEGREES.VERY SHORT TERM RELIEF WITH DILAUDID IV AND NO RELIEF WITH PER PT. IV NTG INCREASED TO 3MCQ WITH SL DECREASE IN SBP BUT THIS PM PT WAS GIVEN FIORECET AFTER HE STATED HE IS USED TO DRINKING CUPS OF COFFEE/DAY...WITHIN 1 HR SBP DOWN TO 140 AND PT STATED HA MUCH LESS AND THAT HE CAN NOW TURN HIS HEAD AND MOVE HIS EYES..\n NEURO SIGNS STABLE..PT OOB TO COMMODE WITHOUT DIFFICULTY.\n PT ACTIVELY DIURESED WITH LASIX X2 AND FLUID RESTRICTION MAINTAINED.\nA.CT SCAN THIS AM DONE..ANGIO. FOR TODAY CANCELLED FOR FURTHER DIURESIS OVER NITE.\nR.NO CHANGE IN HEAD CT PER DR..FIORICET EFFECTIVE FOR HA.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-21 00:00:00.000", "description": "Report", "row_id": 1571674, "text": "Condition Update A:\nPlease refer to careview and remarks for details.\nNEURO: Neuro signs intact. Denied c/o HA, N/V. Pos BUE tremors, R>L. Did c/o HA w/ coughing. Tylenol x1 admin with good effect. Dr. up to speak with pt. need CT angio before d/c to home for follow up.\nCV: Afeb. Labetalol gtt to keep SBP <130. Lopressor PO dose increased today, and attempted to keep Gtt off and used PRN lopressor and one time dose of hydralazine with poor effect. Generalzied 1+ pit edema.\nRESP: LS CTA with dim bases most of shift. Pox began decreaseing to 93%. Pt noted with SOB, posterior BLL and BML crackles. Dr. notified. When pt desated to 91% and anterior LS noted with crckles ABG done(PaO2 54%) and CXR which verified CHF. Non-rebreather placed, Lasix 20mg IVP x1 admin with good effect. ABG's improving.\nGI/GU: Pt stated nimodipine initaially made pt nausea, but cleared quckly. However after 1600 dose pt commented he cont to feel nauseas. Zofran 2mg IV admin with good effect. SKIN: W/D/I.\nSOCIAL: Emotional support provided to pt, wife, and daughter. Pt's pastor, Pastor into visit this morning.\n\nPLAN: Monitor respstatus, I/O. Monitor neuro signs q1h. Monitor SBP to keep <130. Provide emotional support to pt and family as needed. Cont with ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-22 00:00:00.000", "description": "Report", "row_id": 1571675, "text": "Nursing note:\nNEURO: A/Ox3, PERRLA. No drift, smile symmetrical. No neuro deficits. MAE. Cont. w/fine tremors. Mild headache relieved by Tylenol.\nRESP: Lung sounds dim to bases, encouraged to cough and deep breathe. Occ exp. wheezing. Using I/S w/good technique. Desatting to 88-low 90s on 5L NC d/t mouth breathing. Sats 100% when NRB replaced. +DOE. Nebs PRN w/effect.\nCV: Afebrile. SR in 80s, no ectopy. SBP <130 w/Labetolol gtt at 1.5mg/hr. Palpable pulses. No cardiac c/o's.\nGI: Abdomen soft, non-tender. Tolerating liquids w/o incident. -Stool. Pt. c/o feeling constipated. No N/V.\nGU: Foley patent adequate amount amber urine.\nENDO: SSRI PRN.\nA/P: Stable , neuro intact. Cont. to be SOB w/any activity and desats when off NRB.\nCont. to monitor neuro status, encourage pulm. hygiene, increase activity level, support. ? Tx to floor today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-22 00:00:00.000", "description": "Report", "row_id": 1571676, "text": "NEURO; A&Ox3,PERL 33 AND BRISK, NO FACIAL ASYMMETRY, MAE, STRONG BILAT HANDGRASP, MEDIC WITH TYLENOL X 1 FOR HA,\n\nCARDIOVASCULAR; TEMP MAX 99.6, HR 70'S SR, LABETOL WEANED DOWN AND OFF AT 1800 FOR SYS 105-110 (GOAL IS < 130 SYS), STARTED ON NTG GTT TO DECREASE PRELOAD, PRESENTLY AT 0.6 MCG/KG/MIN, LASIX 20 MGM IV X 2 THIS SHIFT (HAD RECEIVED 20 MGM IV PRIOR TO START OF DAY SHIFT, TOTAL 60 MGM THUS FAR), STARTED ON 1 LITER FLUID RESTRICTION,\n\nRESPIR; EXPIR WHEEZES THIS PM, GIVEN NEB RX WITH SOME GOOD EFFECT, PT HAS EXPERIENCED DYSPNEA WITH MINIMAL EXERTION, AND 02 SATS 91-94 THIS AM, ON 60% FACE MASK, PRESENTLY USING FACE MASK WITH NASAL PRONGS AT 2L/MIN AND 02 SATS 97%, PT TO 88-89% WHEN MASK OFF,\n\nGI; UP TO COMMODE FOR SMALL FORMED BM, ABD REMAINS TAUT AND DISTENDED, GIVEN MOM THIS PM, (PT HAD REFUSED SUPPOS THIS AM),\n\nGU; GOOD-FAIR DIURESIS WITH LASIX, NEURO EXPECTATION WAS 1 LITER NEG BY NOON WHICH DID NOT OCCUR, WILL CONTINUE TO ASSESS AND RX\n" }, { "category": "Nursing/other", "chartdate": "2200-04-29 00:00:00.000", "description": "Report", "row_id": 1571696, "text": "condition update\nD: neuro: pt alert and oriented. c/o headache and medicated with tylenol with relief. moves all extremities to commands. normal strength in arm. pupils are equal and reactive to light.\ncardiac: sbp 130-150/60 aline is positional and flushed several time. nsr with no ectopy. pt with several episodes of hr down to 50's. sbp unchanged. abgs sent and unchanged see flowsheet. lytes repleated. pt remains on lopressor and nimodipine. Dr. aware.\nresp: pt extubated today and remains on fio2 70% facetent. repeat abg good and see flowsheet. pt coughing and raising thick yellow sputum. bs are coarse and diminished in the bases. o2 sat remains 98%. pt appears comfortable and has good cough.\ngi: pt tolerating clears well. pt on 1 liter fluid restrictionl. fecal bag intact. pt has positive bowel sounds.\ngu: foley patent and draining clear yellow urine. i and o approrximately 700cc negative.\nskin: fem site clean and dry and no bleeding or hematoma. no areas of breakdown.\na: continue with neuro checks. medicate with tylenol for pain as needed. continue to monitor hr and sbp. pt tolerated nimodipine after hr dropping to the 50's. sbp and hr remains the same after nimodipine.\nr: no change in neuro status. tylenol effective in relieving headache. pt able to sleep in naps. pt breathing comfortablely extubated and pt continues to have a good cough.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-29 00:00:00.000", "description": "Report", "row_id": 1571697, "text": "Nursing note:\nNEURO: A/Ox3, slightly more lethargic this afternoon. C/O feeling tired and not sleeping well last night. c/o headache relieved by Tylenol/Fiorocet. MAE w/normal strength. PERRLA. Speech slightly thick , slow to respond to ?s at times but appropriate. No other neuro issues.\nRESP: Lung sounds w/few crackles at bases, dim to LLL. Sats 97-100% on 50% FT. Coughing and deep breathing well w/encouragement. Using I/S w/good technique.\nCV: Afebrile. SR in 70s, no ectopy. SBP 140-150s. Palpable pulses. No cardiac c/o's.\nGI: Abdomen softly distended. +BS. FIB intact for minimal amounts liquid stool. Tolerating clears, pt. declining diet today. 1L fluid restriction in place d/t sodium levels.\nGU: Foley patent adequate amount amber urine, diuresed well after Lasix this am.\nENDO: SSRI PRN.\n\nA/P: Stable neurologically, resp. status improved. Cont. w/mild headache.\n\n" }, { "category": "Nursing/other", "chartdate": "2200-04-20 00:00:00.000", "description": "Report", "row_id": 1571671, "text": "nursing addend\nPt called RN and c/o CP. Pt states \"like my angina pain\", immediate diaphorsesis, nausea/vomiting followed. MD , EKG done, subligual nitro given. Over next few minutes pain began to resolve, pt c/o worsening headache with vomiting. dilaudid 1mg iv given. o2 up to 4lnc. o2 sat slow 90's. Upon vomiting, blocked down to 54- ? vagal. Seizure like syptoms occured invollving R sided arm twitching, pt eyes rolled back and looked as if was going to go unconcious. Episode lasted only few seconds. No post-ictal like behavior. Pt immed coherent, A+O x3. Diaphoresis followed by chills. MD aware of event. Cardiac enzymes sent and dialntin level. Pt states has angina at home that is relieved by nitro SL.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-20 00:00:00.000", "description": "Report", "row_id": 1571672, "text": "Neuro: pt remains alert and oriented X3, MAE, pupils 3mm brisk. Speech much improved. NO difficulty swallowing. occasional C/O headache. med with dilaudid X1 with good effect. To angio this am for diagnostic information.\nCV: tmax 99.1. HR 70's nsr with no ectopy, sbp 110-120's most of day. titrated labetalol to 1.0mg/min to keep sbp <130. extremities warm with palpable periferal pulses. R groin sheath inplace and + pulses.\nRESP: lungs clear with O2 sats >95% on 4 liter via N/C.\nGI: tol clears with meds and sips of H20. Having 2 episodes of nausea med with zofran with good effect.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars remains slightly elevated. requiring coverage per RISS.\nPt recieved Xray of orbitals ? of metal in eyes. MRI this eve.\nPlam: ? of angio on tuesday with Dr. \n" }, { "category": "Nursing/other", "chartdate": "2200-04-27 00:00:00.000", "description": "Report", "row_id": 1571691, "text": "CONDITION UPDATE\nD: NEURO: REMAINS SEDATED ON PROPOFOL. WHEN PROPOFOL OFF FOR NEURO PT OPENS EYES TO NAME AND INTERMITTENTLY FOLLOWS SIMPLE COMMANDS. MAE ON BED. PUPILS 3-4 MM WITH BRISK REACTION.\nCV: T MAX 101.8- PAN CX'D AND TYLENOL GIVEN. IV NTG WEANED TO OFF. NTG PASTE AND HYDRALAZINE (PRN) GIVEN TO MAINTAIN SBP<140.\nRESP: PEEP DECREASED TO 10 THIS AM WITH GOOD ABG'S= SEE CAREVUE FOR SPECIFICS. BS REMAIN COARSE. SX FOR THICK YELLOW SPUTUM (C&S SENT).\nGI: ABD OBESE BUT SOFT. SM LOOSE STOOL THIS AFTERNOON. NGT PATENT AND DRAINING MOD-LARGE AMT OF GREEN FLUID.\nGU: EXCELLENT DIURESIS FROM LASIX 20 MG IV X 1\nSOCIAL: FAMILY IN TO VISIT PT. WIFE HAD \" ANXIETY ATTACK\" AND WAS ESCORTED OUT OF UNIT BY FAMILY. DAUGHTER AND WIFE SPOKE WITH DR RE: PT'S CONDITION. FAMILY ALSO GIVEN DR OFFICE NUMBER SO THEY ALSO SPEAK TO HIM.\nA: HEMODYNAMICS MONITORED, RESP PARAMETERS MONITORED\nR: IMPROVED RESP STATUS, CONTINUE TO MONITOR TEMP- ASSESS CX REPORTS WHEN AVAILABLE\n" }, { "category": "Nursing/other", "chartdate": "2200-04-27 00:00:00.000", "description": "Report", "row_id": 1571692, "text": "RESPIRATORY CARE NOTE\nPT. REMAINS ON SAME SIMV SETTINGS. ABG 747/36/93/27/2/98 . RSBI THIS AM 55.5\n" }, { "category": "Nursing/other", "chartdate": "2200-04-28 00:00:00.000", "description": "Report", "row_id": 1571693, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, WELL SEDATED, COMFORTABLE. VENT CHANGED FROM SIMV/PS TO CPAP/PS, TOL WELL BY PT, HOWEVER WHEN PEEP WAS WEANED, PULM DEVELOPED W/IN 1.5HRS, INCR PEEP BACK TO 10CMH2O. NO TACHYPNEA, TACHYCARDIA ALTHOUGH HTN WAS NOTED. BS W/RALES & RHONCHI T.O., SXN FOR MOD AMTS THICK YELLOW SEC, LATER CHANGING TO PINK FROTHY SEC. MDI ALBUTEROL GIVEN X3. AM ABG REFLECTS SL METABOLIC ALKALOSIS W/NORMOXIA. NO RSBI DUE TO HIGH PEEP. PLEASE SEE RESP FLOWSHEET FOR DETAILS OF MDI ADMIN, VENT CHANGES, ABG'S. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-28 00:00:00.000", "description": "Report", "row_id": 1571694, "text": "NEURO: A&O X3, APPROPRIATE CONVERSATION, MAE SPONT/PURP, FOLLOWING COMMANDS. PERL.\n\nCV: HR 72-90, NSR NO ECTOPY, SBP 115-155. HAD ONE EPISODE OF SUST SBP TO 170'S, MEDICATED W/ HYDRALAZINE 10MG IV W/ GOOD EFFECT.\n\nRESP: PROPPOFOL GTT D/, PT EXTUBATED AT 12PM, RR 14-26, NO SOB, EXPECTORATING AND SELF SXNING FOR THICK YELLOW SPUTUM, O2 SAT 97-100% ON FACE TENT 70%.\n\nGI: ABD SOFTLY DIST, +BS, PT TOLERATING LIQUIDS, DR. AWARE.\n\nGU: FOLEY DRAINING ADEQ U/OCLEAR AMBER URINE, GOOD DIURESIS W/ LASIX FOR CLEAR YELLOW URINE.\n\nPLAN: MONITOR VS, LABS, I/O, RESP STATUS, NEURO STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-28 00:00:00.000", "description": "Report", "row_id": 1571695, "text": "RESPIRATORY CARE: PT. EXTUBATED TO A 70 % AEROSOL\nMASK AFTER SBT. DOING WELL.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2200-04-21 00:00:00.000", "description": "Report", "row_id": 1571673, "text": "nursing update\nRemains neuro intact with slightly garbled speech. Family states this is not his normal speech. PERLA. Headache comes on suddenly with movement and assoc with n/v (dry heaves). Dilaudid/zofran PRN. Sheath removed by MD and R groin remians benign with good distal pulses. + tremors noted R>L. Pt states he cannot control them. Mood labile, anxious at times, states depressed at others, lethargic at other times. Pt worried about family and care of wife/children. Also worried about job/ children he drives for. Labetolol gtt off. SBP <130 on PO loprssor/nimodipine. Briefly turned on with assoc h/a. Tol water/juice. abd large.soft/nt. +flatus. Attempt on bedpan for BM unsuccessful and pt upset wiht not being able to use bathroom. foley patent yellow urine adeq amounts.\nWife called for update. Daughter and son-in-law in to visit.\n" }, { "category": "Nursing/other", "chartdate": "2200-04-20 00:00:00.000", "description": "Report", "row_id": 1571670, "text": "Nursing admite note\n60 y.o. male admitted from ER s/p SAH dx after \"worst headache of life\" at 1415 this afternoon. Pt first to and then transferred here for further treatment. CT angio negative. Plan for angio AM.\n\nPMH:gout, cardiac stent , borderline diabetic, COPD, multiple hernia's (inguinal and hiatal).\n\nAllergies:morphine, calan, diltiazem.\n\nNeuro:A+O x3. Neuro intact. Sleeping unless awakened, however-arouse easily to voice. Speech slightly dysarthric. Headache present, increased with movement and lgith. pt able to sleep. dilaudid in ew.\nCV: SR to ST. Lopressor given IV and PO, nipride gtt to keep sys <130. DIfficult controlling MD aware and hydralazine started. IV periph x2 present- ns with 20kcl at 100cc/hour.\nRESP:LS clear. O2 sat low 90's-md aware. Pt states COPD- o2 sat normally 96-97%. CXR done. C+DB encouraged.\nGI:NPO, swabs given. Abd obese, soft, nt. Nausea, vomiting, zofran given with effect.\nGU: foley patent clear yellow urine adeq amounts.\nskin:intact.\nsocial: wife at home.\n" }, { "category": "Radiology", "chartdate": "2200-04-25 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 820955, "text": " 7:37 AM\n CAROT/CEREB Clip # \n Reason: S/P HEADACHES\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 265\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE SEL EA ADD'L *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1769 GUID WIRES INFU/PERF *\n * C1769 GUID WIRES INFU/PERF C1887 CATH GUIDING INFUS/PERF *\n * C1887 CATH GUIDING INFUS/PERF C1887 CATH GUIDING INFUS/PERF *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n Patient with intracranial hemorrhage in the prepontine cistern and the\n posterior fossa. The patient is here for a cerebral angiogram.\n\n This patient had a cerebral angiogram performed on which did not\n demonstrate any aneurysm in the posterior circulation. The patient is here for\n a repeat angiogram before discharge.\n\n The following blood vessels were selectively catheterized and arteriograms\n were performed from these locations:\n\n left vertebral artery;\n left internal carotid artery;\n right thyrocervical artery;\n right vertebral artery;\n right internal carotid artery.\n\n FINDINGS\n\n RIGHT INTERNAL CAROTID ARTERY:\n There is good opacification of the anterior and middle cerebral artery\n branches noted. No definite aneursym noted. There is good opacification of the\n proximal and distal right internal carotid artery noted.\n\n LEFT INTERNAL CAROTID ARTERY:\n There is good opacification of the anterior and middle cerebral artery\n branches noted. On the left side a tiny 2.5 mm aneurysm noted arising from the\n anterior communicating artery which has a broad base.\n\n LEFT VERTEBRAL ARTERY:\n There is good opacification of the proximal and distal left vertebral artery,\n basilar artery and both posterior cerebral arteries.\n\n RIGHT VERTEBRAL ARTERY:\n (Over)\n\n 7:37 AM\n CAROT/CEREB Clip # \n Reason: S/P HEADACHES\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 265\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is good opacification of the proximal and distal right vertebral artery,\n basilar artery and posterior cerebral arteries on both sides.\n\n RIGHT THYROCERVICAL TRUNK:\n There is good opacification of the thyrocervical branches without evidence of\n vascular malformation.\n\n IMPRESSION:\n 1. Evaluation of the anterior circulation demonstrates a tiny 2.5 mm broad-\n based aneurysm arising from the anterior communicating artery. Given the\n distribution of hemorrhage this is less likely the cause of hemorrhage.\n 2. Evaluation of both vertbral arteries and posterior circulation demonstrates\n no evidence of aneurysm.\n 3. A followup angiogram is recommended in six to eight weeks to exclude subtle\n thrombosed aneurysm.\n\n ADDENDUM:\n The left thyrocervical trunk was selectively catheterized. There is good\n opacification of the branches. No aneurysm or vascular malformation noted.\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 820864, "text": " 9:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: SAH - asses for interval change\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH\n REASON FOR THIS EXAMINATION:\n SAH - asses for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT SCAN:\n\n HISTORY: Subarachnoid hemorrhage. Assess for interval change.\n\n TECHNIQUE: Noncontrast head CT scan was obtained.\n\n FINDINGS: Comparison with the prior study of reveals persistent\n hyperdensity within the prepontine and medullary portions of the subarachnoid\n space. There does not appear to be any new areas of hemorrhage or\n hydrocephalus detected. There is no interval development of a minor or major\n vascular territorial infarct.\n\n CONCLUSION: Persistent posterior fossa hemorrhage as noted above.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 820704, "text": " 6:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subarachnoid hemorrhage with low oxygen saturation. Wheeze and\n crackles.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST: There are hazy opacities in the perihilar\n regions, though there is improved definition of the upper lobe vasculature.\n There may be layering effusions posteriorly bilaterally. Cardiac and\n mediastinal contours are unchanged.\n\n IMPRESSION: Slight improvement of CHF.\n\n" }, { "category": "Radiology", "chartdate": "2200-05-01 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 821602, "text": " 3:35 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: To assess location of PICC tip inserted in patient's left ar\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with subarachnoid hemorrhage. Beta strep bacteremia on Vanco.\n REASON FOR THIS EXAMINATION:\n To assess location of PICC tip inserted in patient's left arm. Please notify\n IV nurse at beeper number 9-2442. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with subarachnoid hemorrhage. S/P PICC line\n placement\n\n COMPARISON: \n\n FINDINGS: Single view of the chest. There is interval placement of left-\n sided PICC line with the tip in the low SVC. Cardiac, mediastinal and hilar\n contours are unchanged allowing for differences in technique. Interval\n removal of the NG tube. The lung fields are clear. There are no focal\n consolidations or pleural effusions. There is improvement of bibasilar\n atelectasis.\n\n IMPRESSION: Picc line in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821027, "text": " 3:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage with wheezing and crackles.\n\n VIEWS: Semi-erect AP view compared with semi-upright AP view from .\n\n FINDINGS: There has been interval placement of an endotracheal tube with tip\n in appropriate position approximately 3.7 cm from the carina. A nasogastric\n tube is seen which looped within the esophagus, and a tip located at the level\n of the clavicles, pointing cephalad. The cardiac and mediastinal contours\n remain stable. There is increased perihilar haziness and vascular\n indistinctness, findings consistent with interval worsening of congestive\n heart failure. Additionally small layering bilateral pleural effusions are\n present. No pneumothorax is identified.\n\n IMPRESSION:\n 1) NG tube looped within the esophagus with tip at the level of the\n clavicles, pointing cephalad. These findings were discussed with the surgical\n resident caring for the patient at the time of interpretation.\n 2) Satisfactory placement of endotracheal tube.\n 3) Interval worsening of congestive heart failure.\n 4) Small bilateral layering pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-23 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 820773, "text": " 3:10 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: eval progression\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Subarachnoid hemorrhage from OSH\n\n REASON FOR THIS EXAMINATION:\n eval progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up for subarachnoid hemorrhage and to see progression.\n\n Multiple axial images were obtained from base to vertex without intravenous\n contrast administration. Comparison is made to the prior head CT from , . There has been partial resolution of the previously seen subdural\n hemorrhage anterior to the cerebellar hemispheres and pontomedullary junction.\n There is a round oval residual blood clot seen anterior to the left aspect of\n the medulla which would represent a small organizing hematoma without mass\n effect. There is also some residual hemorrhage along the tentorium. The\n overall appearance, however, has improved. No hydronephrosis is seen. There\n is no sulcal effacement or midline shift. Continued follow up would be helpfu\n based on clinical grounds.\n\n IMPRESSION: Partial resolution of the previously seen subarachnoid\n hemorrhage which is mostly along the posterior fossa and the tentorium as\n described.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 820539, "text": " 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm process\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n r/o pulm process\n ______________________________________________________________________________\n FINAL REPORT\n Portable supine chest of compared to 1 day earlier.\n\n CLINICAL INDICATION: Low oxygen saturation.\n\n The heart is mildly enlarged. There has been interval development of vascular\n engorgement, perihilar haziness, and numerous thickened septal lines. A small\n right pleural effusion is evident, extending into the fissures.\n\n IMPRESSION: Interval development of congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-20 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 820363, "text": " 8:30 AM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 280\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * C1769 GUID WIRES INFU/PERF C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n Patient with subarachnoid hemorrhage predominantly in the region of the\n prepontine cistern extending inferiorly into the cerebellar pontine angle on\n the left side. Patient is here for a cerebral angiogram.\n\n TECHNIQUE:\n Informed consent was obtained from the patient and the patient's family after\n explaining the risks, indications and alternative management. Risks explained\n included stroke, loss of vision and speech, temporary or permanent, with\n possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr Berenstein catheter was introduced\n and connected to continuous saline infusion (with mixture of 1000 units of\n heparin in 1000 cc of saline).\n\n The following blood vessels were selectively catherized, and arteriograms were\n performed from these locations:\n\n left subclavian artery;\n left vertebral artery;\n right vertebral artery;\n right common carotid artery;\n right internal carotid artery;\n right external carotid artery;\n left common carotid artery;\n left internal carotid artery;\n left external carotid artery.\n\n (Over)\n\n 8:30 AM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 280\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS\n\n RIGHT COMMON CAROTID ARTERY:\n No significant atherosclerotic disease noted in the carotid bulb.\n\n RIGHT INTERNAL CAROTID ARTERY:\n There is good opacification of the anterior and middle cerebral artery\n branches noted. The posterior communicating artery appears prominent.\n\n RIGHT EXTERNAL CAROTID ARTERY:\n There is good opacification of all external carotid artery branches. No\n abnormal vascular malformation noted.\n\n LEFT COMMON CAROTID ARTERY:\n The common carotid artery is tortuous proximally. No atherosclerotic disease\n noted in the carotid bulb.\n\n LEFT INTERNAL CAROTID ARTERY:\n There is good opacification of the proximal and distal left internal carotid\n artery and left anterior and middle cerebral artery branches. There is a small\n posterior communicating artery noted. There is a tiny broad-based aneurysm\n noted arising from the anterior communicating artery oriented onto the right\n and inferiorly and measures approximately 2.5 mm in diameter.\n\n LEFT EXTERNAL CAROTID ARTERY:\n There is good opacification of the external carotid artery branches without\n evidence of aneurysm or vascular malformation.\n\n RIGHT VERTEBRAL ARTERY:\n There is good opacification of the proximal and distal right vertebral\n arteries, basilar artery, posterior-inferior cerebellar artery and both\n posterior cerebellar arterires. No evidence of aneurysm noted.\n\n LEFT SUBCLAVIAN ARTERY:\n There is tortuosity with minimal stenosis noted at the origin of the left\n vertebral artery.\n\n LEFT VERTEBRAL ARTERY:\n There is good opacification of the proximal and distal left vertebral artery,\n left posterior-inferior cerebellar artery, basilar artery and both posterior\n cerebral arteries. No evidence of aneurysm noted.\n\n IMPRESSION: There is no aneurysm noted in the region of the posterior\n circulation.\n 2. A tiny 2.5 mm broad based aneurysm noted arising from the anterior\n (Over)\n\n 8:30 AM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 280\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n communicating artery which is oriented inferiorly and medially. Given the\n distribution of the hemorrhage on the CAT scan this aneurysm does not appear\n to be the cause of the hemorrhage.\n\n These findings were discussed with Dr. , the referring neurosurgeon.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-20 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 820407, "text": " 3:57 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: MRI w/and w/o gadolinium. Please evaluate for source of suba\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 21\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with h/o HTN, p/w peripontine SAH.\n REASON FOR THIS EXAMINATION:\n MRI w/and w/o gadolinium. Please evaluate for source of subarachnoid hemorrhage\n (AVM, tumor, etc).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subarachnoid hemorrhage.\n\n COMPARISON: Head CT and head CT angiogram of .\n\n TECHNIQUE: Multiplanar T1-weighted, T2-weighted, gradient echo, and\n gadolinium-enhanced images of the brain were performed.\n\n FINDINGS: This report is redictated on . There is a notation\n in the PACS archiving system that the original report has been deleted.\n\n The cerebellar tonsils terminate 5 mm below the foramen magnum, consistent\n with a Chiari space I anomaly. There are foci of increased susceptibility\n artifact in the peripontine cisterns and in the dependent portions of the\n lateral ventricles on the gradient echo images, corresponding to the foci of\n subarachnoid and intraventricular hemorrhage demonstrated on the previous CT\n scan. There is a right subdural fluid collection without any increased\n susceptibility artifact to suggest blood, corresponding to the isodense fluid\n collection seen in this location on the previous CT scan. There is no\n hydrocephalus. There is no shift of normally midline structures. Diffusion-\n weighted images demonstrate focus of slow diffusion in the inferior left\n cerebellar hemisphere, consistent with a small acute infarction. The\n visualized extracranial soft tissues appear unremarkable.\n\n IMPRESSION:\n 1. Small area of acute infarction in the left cerebellar hemisphere.\n 2. Right subdural fluid collection without evidence of hemorrhage.\n 3. Peripontine subarachnoid hemorrhage and intraventricular hemorrhage as seen\n on previous CT scan.\n 4. Chiari I malformation.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821162, "text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n eval progression\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Wheezing, crackles and low oxygen saturations in patient with\n subarachnoid hemorrhage.\n\n Endotracheal tube is 2 cm above the carina with neck flexed. NG tube extends\n below the diaphragm. There is upper zone redistribution with small bilateral\n pleural effusions and bibasilar atelectases. The atelectasis in the left\n upper lobe noted on prior study of has resolved. No pneumothorax.\n\n IMPRESSION: CHF with small bilateral pleural effusions and bibasilar\n atelectases. Resolution of left upper lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-20 00:00:00.000", "description": "ORBITS (WATERS, CALDWELL & LAT)", "row_id": 820403, "text": " 3:40 PM\n ORBITS (WATERS, & LAT) Clip # \n Reason: pre-MRI (r/o foreign body, metal)\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60yoM h/o SAH, needs MRI head w/and w/o gadolinium. Metal worker.\n REASON FOR THIS EXAMINATION:\n pre-MRI (r/o foreign body, metal)\n ______________________________________________________________________________\n FINAL REPORT\n ORBITS ON :\n\n INDICATION: Foreign body evaluation for MRI.\n\n FINDINGS: There are no radiopaque foreign bodies visualized. The visualized\n osseous structures and paranasal sinuses appear within normal limits though\n the Waters' view is not optimally imaged.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821042, "text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check NGT postition - replaced\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n check NGT postition - replaced\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Oxygen saturation, check for NG tube placement.\n\n CHEST, AP: Comparison is made to a film obtained two hours earlier. The tip\n of the endotracheal tube is about 3 cm above the carina. The tip of the\n nasogastric tube is in the body of the stomach. There is unchanged perihilar\n haziness and vascular congestion. The heart size is enlarged. Small layering\n bilateral pleural effusions are present. There is interval\n development of atelectasis involing the left upper and middle zones. Left\n lower lobe consolidation/ atelectasis is also noted.\n\n IMPRESSION: Appropriate position of the endotracheal and nasogastric tube.\n Stable congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-28 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 821202, "text": " 4:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: HIGH KUB TO eval ngt\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man intubated, resp fail\n\n REASON FOR THIS EXAMINATION:\n HIGH KUB TO eval ngt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Replacement of previously malpositioned NG tube, reassess.\n\n TWO SUPINE RADIOGRAPHS OF THE CHEST AND ABDOMEN: An NG tube is now clearly\n seen coursing below the diaphragm and terminating in the region of the gastric\n antrum. The lungs are unchanged in appearance.\n\n IMPRESSION: Satisfactory position of NG tube. These findings were\n communicated to Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2200-04-19 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 820344, "text": " 9:13 PM\n CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Eval SAH for source with CT ANGIO of brain\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: There are a few areas of lucencies within the skull nonspecific in\n nature. If clinically warranted, a bone scan may be performed.\n\n\n 9:13 PM\n CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: Eval SAH for source with CT ANGIO of brain\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Subarachnoid hemorrhage from OSH\n REASON FOR THIS EXAMINATION:\n Eval SAH for source with CT ANGIO of brain\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SADk SUN 5:45 AM\n subarachnoid hemorrhage\n no aneurysm identified\n WET READ VERSION #1 SADk SAT 11:08 PM\n subarachnoid hemorrhage in circle of \n no aneurysm identified\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Subarachnoid hemorrhage from an outside hospital.\n\n TECHNIQUE: CT of the head prior to and following the administration of IV\n contrast. Multiplanar reformatted images were obtained.\n\n CT WITHOUT CONTRAST: There is high attenuation within the pre\n pontine cistern and extends inferior on to the left overlying the\n left vertebral artery region consistent with subarachnoid hemorrhage. No\n extraaxial hemorrhage. No midline shift or mass effect. No hydrocephalus. The\n - white matter differentiation is within normal limits. The paranasal\n sinuses are normal. No fractures are identified.\n\n CTA OF THE HEAD WITH 3D RECONS: The vertebral, basilar, internal carotid, and\n circle of arteries are well visualized and appear unremarkable. There\n is no stenosis or aneurysm.\n\n IMPRESSION: Findings consistent with known subarachnoid hemorrhage. No\n definite aneurysm identified. The anterior communicating artery appears\n minimally bulbous..\n\n" }, { "category": "Radiology", "chartdate": "2200-04-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 820356, "text": " 1:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for copd, ? aspiration\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats\n REASON FOR THIS EXAMINATION:\n eval for copd, ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 01:05:\n\n INDICATION: Neurologic injury with low oxygenation - possible aspiration.\n\n There is a shallow level of inspiration which creates a crowded appearance to\n the pulmonary vessels but no definite evidence for focal consolidation. Due\n to the shallow inspiration assessment of the heart and mediastinum are\n inaccurate.\n\n IMPRESSION: No definite evidence for aspiration on this film limited by\n shallow inspiration.\n\n" }, { "category": "Radiology", "chartdate": "2200-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 821200, "text": " 1:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ngt replacement, eval progression pulm process\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, low o2 sats, wheeze, crackles,\n\n REASON FOR THIS EXAMINATION:\n eval ngt replacement, eval progression pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess NG tube placement.\n\n PORTABLE SEMI-ERECT FRONTAL RADIOGRAPH OF THE CHEST:\n\n Comparison is made to .\n\n The patient remains intubated. An NG tube is present, though its tip is not\n well seen. It appears to course below the diaphragm. The lung fields are\n unchanged compared to the prior study.\n\n IMPRESSION:\n\n NG tube is seen below the diaphragm, though tip is not well seen. Unchanged\n appearance of the lungs compared to 1 day prior. These findings were\n communicated to Dr. . A repeat film or radiograph of the abdomen may be\n obtained to help clarify tube positioning.\n\n\n" }, { "category": "Radiology", "chartdate": "2200-04-28 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 821201, "text": " 3:23 AM\n PORTABLE ABDOMEN Clip # \n Reason: HIGH KUB for ngt placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man intubated, resp fail\n REASON FOR THIS EXAMINATION:\n HIGH KUB for ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess NG tube placement.\n\n UPRIGHT RADIOGRAPH OF THE ABDOMEN:\n\n Comparison is made to chest radiograph of one hour prior.\n\n No feeding tube is seen below the diaphragm within the abdomen. In the medial\n portion of the right hemithorax, there is a coiled structure. This may\n represent an overlying external wire or possibly a malpositioned NG tube.\n Repeat evaluation of the prior chest x-ray does not definitively show proper\n placement of the NG tube. Removal of the tube and replacement is recommended\n with repeat radiographs to document proper positioning. These findings were\n communicated to Dr. .\n\n\n" }, { "category": "Echo", "chartdate": "2200-04-30 00:00:00.000", "description": "Report", "row_id": 75940, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nBP (mm Hg): 110/70\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 11:30\nTest: TEE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe aortic arch and descending aorta were not visualized.\nLEFT ATRIUM: The left atrium is dilated. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium/left atrial appendage or the\nbody of the right atrium/right atrial appendage. All four pulmonary veins were\nidentified and found to enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. No atrial\nseptal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. No masses or vegetations are seen on the aortic valve.\nMild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. No mass or vegetation is seen on the mitral valve.\nModerate (2+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. There is no mass or\nvegetation detected on the tricuspid valve. Mild tricuspid [1+] regurgitation\nis seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\nThe echocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient. The physician caring for the patient was notified of\nthe echocardiographic results by e-mail.\n\nConclusions:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. No masses or vegetations are seen on the aortic valve. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. There is no mitral valve prolapse. No mass or vegetation is seen on\nthe mitral valve. Moderate (2+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Mild aortic regurgitation and moderate mitral regurgitation with\nnormal valve morphology. No echocardiographic evidence of endocarditis.\n\n\n" }, { "category": "Echo", "chartdate": "2200-04-23 00:00:00.000", "description": "Report", "row_id": 75941, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 237\nBSA (m2): 2.18 m2\nBP (mm Hg): 116/53\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 09:24\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: There is lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to\nmoderate (+) mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Preserved global biventricular systolic function. Mild-moderate\nmitral regurgitation. Mild aortic regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2200-04-22 00:00:00.000", "description": "Report", "row_id": 187643, "text": "Sinus rhythm\nNormal ECG\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2200-04-20 00:00:00.000", "description": "Report", "row_id": 187644, "text": "Sinus rhythm\nST junctional depression is nonspecific\n\n" } ]

[ { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 340477, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Sepsis from impacted renal stone s/p IR guided nephrostomy tube\n Prelim Cx at pseudomonas\n 24 Hour Events:\n ULTRASOUND - At 10:00 AM\n kidneys, bladder\n STOOL CULTURE - At 02:51 PM\n sent for ? c-diff\n URINE CULTURE - At 04:00 PM\n during left nephrostomy red and greq top tubes of urine sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 08:24 AM\n Linezolid - 10:04 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (67 - 81) bpm\n BP: 157/85(103) {106/64(71) - 158/92(107)} mmHg\n RR: 8 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (6 - 16)mmHg\n Total In:\n 4,109 mL\n 1,086 mL\n PO:\n 380 mL\n TF:\n IVF:\n 4,109 mL\n 706 mL\n Blood products:\n Total out:\n 1,825 mL\n 1,045 mL\n Urine:\n 1,825 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Gen sittin gin chair, NAD< notes swelling of hands and feet\n HEENTo/p clear\n CV: RR\n ChestCTa ant\n Abd soft NT + BS serosang drainage from perc nephrostomy\n Ext: dry and scaling skin\n Neuro conversant and appropriate\n Labs / Radiology\n 12.8 g/dL\n 418 K/uL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n A/P: 61 yo M with MMP including prior CVA, neurogenic bladder with\n chronic indwelling suprapubic catheter and recurrent UTIs, lypmphoma,\n sle with sepsis-- transient hypotension, fevers, leukocytosis,\n with grossly positive\n 1. Sepsis: due to impacted renal stone s/p perc drain by IR yesterday\n and now additional data that he also has by C diff.\n Cover broadly with Linezolid (hx of VRE), zosyn (Pseudomonas at ).\n F/u cx data from with sensi\n C. diff: rx with Flagyl, watch stool output from stoma and low\n threshold for KUB is stops output\n 2. ARF: ATN and post obstructive, improving slowly\n may sig more\n improvement with time as drains.\n 3. Hyperglycemia: insulin drip held this AM and given glargine\n ICU Care\n Nutrition: diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n from , d/c work with 2 PIV\n we have, in for IR guided PICC\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: with pt and daughter\n status: Full code\n Disposition : possible tx later if stable BP and off insulin drip\n Total time spent: 35\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340558, "text": "TITLE:\n Chief Complaint: septic shock\n 24 Hour Events:\n Left percutaneous nephrostomy placed. Cultures sent GS with many polys\n Confirmation from sister that patient does not normally refuse medical\n care\n Ordered for PICC but not placed\n Linezolid replaced Vanc for h/o VRE\n Stopped insulin gtt. Started glargine 18u and SSI\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 10:09 PM\n Piperacillin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 76 (67 - 94) bpm\n BP: 139/83(97) {90/46(57) - 150/92(105)} mmHg\n RR: 12 (8 - 17) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 8 (5 - 16)mmHg\n Total In:\n 4,109 mL\n 246 mL\n PO:\n TF:\n IVF:\n 4,109 mL\n 246 mL\n products:\n Total out:\n 1,825 mL\n 465 mL\n Urine:\n 1,825 mL\n 465 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n Gen: Pleasant, alert male resting in bed in NAD\n HEENT: NCAT, PERRL, right ptosis and facial droop, MM dry but intact\n Neck: right triple lumen CDI\n CV: RRR no MRG, nl S1, S2\n Lungs: CTA b/l\n Abd: distended, soft, +BS, beefy healthy appearing stoma site draining\n greenish-brown stool\n Ext: UE 1+ nonpitting edema, mild clubbing\n Neuro: A and O times 3.\n Labs / Radiology\n 418 K/uL\n 12.8 g/dL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Imaging: Renal US: Moderate hydronephrosis of the left kidney. Large\n stone seen in\n the left UPJ. Smaller bilateral renal stones.\n Head CT: Left maxillary sinus opacification. Otherwise normal study.\n Microbiology: Nephrostomy GS: 4+ PML\n Urine CX () > suspected pseudomonas\n Culture HX from , (+) h/o VRE. Pseudomonas UTI (Pip-tazo, tobra,\n Imipenem, Cefepime, Amikasin sensitive)\n C.diff +\n Assessment and Plan\n 61 YO male with complicated PMH admitted as tx from OSH with presumed\n septic shock found to have left obstructive nephropathy \n nephrolithiasis s/p precut nephrostomy tube placement found to be Cdiff\n +.\n #. UTI/urosepsis\n Grew pseudomonas at OSH. Cultures pending here.\n Largely improved. Normotensive and mentating appropriately today.\n -cont linezolid, zosyn, and flagyl\n -f/u cultures\n -PICC line ordered and pending\n #. Cdiff\n Fair amount of stool output.\n -continue to monitor, if stool output becomes very high, may require\n rehydration\n -continue flagyl\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Likely \n obstruction along with pre-renal etiology. Improving. Euvolemic to\n mildly hypervolemic today.\n -continue to monitor.\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. be Cdiff but also noted on prior exams\n during other hospitalizations.\n - monitor serial abd exams\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - as mental status improved, will restart gabapentin and oxycodone\n - continue to monitor\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - monitor\n # DM: -well controlled\n -d/c insulin gtt\n -restart lantus and SSI\n #. FEN\n Advance as tolerated.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (d/c today), PICC to be placed\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo\n call out to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340091, "text": "61y/o male admitted to micu-6 from & Women\ns ED after\n presenting with unresponsiveness, temp spike and hypotension. Pt\n treated with 3liters NS fluid, received vanco, ceftazadine, & flagyl ,\n 125mg solumedrol, blood cultures sent, kub (-), (2) peripheral IV\n placed &\n IJ TLC. Pt\ns potassium ^6.5, pt treated with 10units\n insulin, 25gm dextrose, & 50meq bicarbonate. Pt arrived to unit\n arouses to verbal stimuli, sbp^ 150-169/100\ns, 02sats >95%, suprapubic\n catheter draining large amounts clear yellow urine. Repeat labs sent,\n ua & urine cx sent, IV flagly started as ordered, awaiting ID approval\n for vanco & Zosyn. Pt to CT scan to r/o cva, results (p). Pt\n potassium returned 5.8, pt treated with 10units insulin IV x1 & 2gms\n calcium gluconate.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, arouses to verbal & tactile stimuli, able to\n articulate needs & respond to verbal commands\n Action:\n Pt to ct scan to r/o cva,\n Response:\n Ct scan (-) bleeds, pt remains lethargic, sleeping, arouses to stimuli,\n cooperative with care\n Plan:\n Continue to monitor neuro status, monitor electrolytes, treat for\n urosepsis\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars remain >300 since admission to micu-6, pt sleepy &\n lethargic\n Action:\n Pt covered with regular insulin IV & sq every two hours.\n Response:\n Blood sugars remain elevated, insulin infusion initiated.\n Plan:\n Monitor blood glucose every hour and adjust insulin infusion per\n insulin guidelines\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340094, "text": "61y/o male admitted to micu-6 from & Women\ns ED after\n presenting with unresponsiveness, temp spike and hypotension. Pt\n treated with 3liters NS fluid, received vanco, ceftazadine, & flagyl ,\n 125mg solumedrol, blood cultures sent, kub (-), (2) peripheral IV\n placed &\n IJ TLC. Pt\ns potassium ^6.5, pt treated with 10units\n insulin, 25gm dextrose, & 50meq bicarbonate. Pt arrived to unit\n arouses to verbal stimuli, sbp^ 150-169/100\ns, 02sats >95%, suprapubic\n catheter draining large amounts clear yellow urine. Repeat labs sent,\n ua & urine cx sent, IV flagly started as ordered, awaiting ID approval\n for vanco & Zosyn. Pt to CT scan to r/o cva, results (p). Pt\n potassium returned 5.8, pt treated with 10units insulin IV x1 & 2gms\n calcium gluconate.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, arouses to verbal & tactile stimuli, able to\n articulate needs & respond to verbal commands\n Action:\n Pt to ct scan to r/o cva,\n Response:\n Ct scan (-) bleeds, pt remains lethargic, sleeping, arouses to stimuli,\n cooperative with care\n Plan:\n Continue to monitor neuro status, monitor electrolytes, treat for\n urosepsis\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars remain >300 since admission to micu-6, pt sleepy &\n lethargic\n Action:\n Pt covered with regular insulin IV & sq every two hours.\n Response:\n Blood sugars remain elevated, insulin infusion initiated.\n Plan:\n Monitor blood glucose every hour and adjust insulin infusion per\n insulin guidelines\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt noted with elevated potassium 5.8 upon admission, with cr 2.0, pt\n suprapubic tube noted with good amounts yellow urine\n Action:\n Pt given 10units IV insulin x1 and 2gms IV calcium gluconate X1\n Response:\n Pt\ns potassium 4.9, urine output remains sufficient, creatine unchanged\n Plan:\n Continue to monitor electrolytes, and urine output\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340003, "text": "61y/o male admitted to micu-6 from & Women\ns ED after\n presenting with unresponsiveness, temp spike and hypotension. Pt\n treated with 3liters NS fluid, received vanco, ceftazadine, & flagyl ,\n 125mg solumedrol, blood cultures sent, kub (-), (2) peripheral IV\n placed &\n IJ TLC. Pt\ns potassium ^6.5, pt treated with 10units\n insulin, 25gm dextrose, & 50meq bicarbonate. Pt arrived to unit\n arouses to verbal stimuli, sbp^ 150-169/100\ns, 02sats >95%, suprapubic\n catheter draining large amounts clear yellow urine. Repeat labs sent,\n ua & urine cx sent, IV flagly started as ordered, awaiting ID approval\n for vanco & Zosyn. Pt to CT scan to r/o cva, results (p). Pt\n potassium returned 5.8, pt treated with 10units insulin IV x1 & 2gms\n calcium gluconate.\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340089, "text": "61y/o male admitted to micu-6 from & Women\ns ED after\n presenting with unresponsiveness, temp spike and hypotension. Pt\n treated with 3liters NS fluid, received vanco, ceftazadine, & flagyl ,\n 125mg solumedrol, blood cultures sent, kub (-), (2) peripheral IV\n placed &\n IJ TLC. Pt\ns potassium ^6.5, pt treated with 10units\n insulin, 25gm dextrose, & 50meq bicarbonate. Pt arrived to unit\n arouses to verbal stimuli, sbp^ 150-169/100\ns, 02sats >95%, suprapubic\n catheter draining large amounts clear yellow urine. Repeat labs sent,\n ua & urine cx sent, IV flagly started as ordered, awaiting ID approval\n for vanco & Zosyn. Pt to CT scan to r/o cva, results (p). Pt\n potassium returned 5.8, pt treated with 10units insulin IV x1 & 2gms\n calcium gluconate.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, arouses to verbal & tactile stimuli, able to\n articulate needs & respond to verbal commands\n Action:\n Pt to ct scan to r/o cva,\n Response:\n Ct scan (-) bleeds, pt remains lethargic, sleeping, arouses to stimuli,\n cooperative with care\n Plan:\n Continue to monitor neuro status, monitor electrolytes, treat for\n urosepsis\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars remain >300 since admission to micu-6, pt sleepy &\n lethargic\n Action:\n Pt covered with regular insulin IV & sq every two hours.\n Response:\n Blood sugars remain elevated, insulin infusion initiated.\n Plan:\n Monitor blood glucose every hour and adjust insulin infusion per\n insulin guidelines\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-09-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340373, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n He is now admitted to MICU-6 from & Women\ns ED after\n presenting from NH with unresponsiveness, temp spike and hypotension,\n and K+ 6.5. Pt rec\nd total of 3 liters NS in ED, as well as Vancomycin,\n Ceftazadine, Flagyl, and 125mg Solumedrol. Blood and urine cultures\n sent, kub (-). Head CT done, neg for new bleed.\n H/O altered mental status (not Delirium)\n Assessment:\n Easily arouseable. Unable to assess orientation d/t language barrier,\n however, able to make needs known, speaking English. Follows commands.\n Slept most of night.\n Action:\n Able to communicate with pt in English.\n Response:\n Mental status clearing.\n Plan:\n Continue to assess mental status. Interpreter if needed.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars on insulin gtt 101-171. NPO.\n Action:\n Titrate insulin gtt to FSBS.\n Response:\n Good control of blood sugars.\n Plan:\n Insulin gtt, ? convert to insulin regime today. ? may start diet again\n as MS is clearing.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n . Suprapubic draining cloudy yellow urine occ bloody tinged\n 40-50cc/hr. Nephrostomy tube draining pink urine 40cc/hr. Creatinine\n decreasing\n1.6 this AM. WBC 19. Lytes all WNL. Afebrile.. BP\n 130s-140s/70s-80s. NSR 70s.\n Action:\n Vanco changed to linezolid, also on flagyl and zosyn.\n Response:\n Nephrostomy tube patent, decreasing creatinine.\n Plan:\n Anibx.Monitor UOP, renal function. VS.\n" }, { "category": "Nursing", "chartdate": "2125-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 340512, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n He was admitted to MICU-6 from & Women\ns ED after\n presenting from NH with unresponsiveness, temp spike and hypotension,\n and K+ 6.5. Pt rec\nd total of 3 liters NS in ED, as well as Vancomycin,\n Ceftazadine, Flagyl, and 125mg Solumedrol. Blood and urine cultures\n sent, + for urosepsis. Head CT and KUB neg.\n On US showed bilat kidney stones L>R with moderate hydronephrosis\n on Left. Pt subsequently had a perc nephrostomy tube placement on left.\n He rec\nd total of 2.5liters NS for BP/CVP management.\n Pt is a Jehovah\ns Witness. Pt remains full code, with sister /proxy.\n Pt on contact precautions for stool + for c-diff and previous dx VRE.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt sleeping soundly in am, but easily woken and appropriate. Oriented X\n 2 in English, and talking easily with translator. Cooperative with all\n care. Gag and cough intact. He C/O chronic bilat LE pain, but denied\n abdominal or nephrostomy site pain.\n Action:\n Pt freq oriented. Translator/coworker available for freq translations.\n Pt rec\nd PRN Oxycodone IR 10mg X 1, and Gabapentin restarted. OOB to\n chair via slideboard, remaining in chair for several hrs. Started on\n clear liqs.\n Response:\n Per patient, after taking pain med, leg pain went from ->.\n Tolerated chair well, but C/O back pain and desire to lie on his side\n in bed after several hrs. Diet progressed to full liqs.\n Plan:\n Cont freq reorientation of pt, with translator as available. Cont PRN\n pain med, observing for oversedation/somulence. Cont to increase\n activity as tolerated. ? PT consult. Cont to increase diet as\n tolerated, aspiration precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n VSS with HR 70-80\ns SR without VEA, SBP 130-150\ns, RR 6-12 and regular\n on 3l NC with O2 sat 93-97%. Afebrile. Mild periph edema of hands,\n feet. Suprapubic tube draining 40-60ml/hr of yellow urine with occas\n sed. Left Nephrostomy tube draining avg 50ml/hr pink-tinged urine which\n is clearing as day progresses. Nephrostomy tube site with DSD intact.\n AM creat 2->1.6.\n Action:\n VS and output monitored Q1hr. Nephrostomy tubing/site monitored.\n Response:\n Urine drainage tubes cont to drain well. VS remain stable.\n Plan:\n Pt to transfer to floor. Cont to monitor urine drainage tubes, VS with\n temp.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Rec\nd pt on Insulin qtt @ 2units/hr with FSG 104-110.\n Action:\n Insulin qtt stopped @ 0745. Pt rec\nd Galrgine 18units @ 0800 per\n sliding scale. Diet advanced from NPO to clear ligs.\n Response:\n FSG 143, 158. Pt has not rec\nd additional insulin per sliding scale. Pt\n taking juice, jello, and requested oatmeal for dinner.\n Plan:\n Cont to monitor FSG with insulin per sliding scale. Cont to advance\n diet as tolerated.\n" }, { "category": "Physician ", "chartdate": "2125-09-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 339985, "text": "Chief Complaint: hypotension, altered mental status\n HPI:\n Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n Per notes from the nursing home, the patient had low grade fevers since\n discharge of 99-100.8. He completed vancomycin and cefepime on \n (prior admission). In the morning of , the patient was noted to have\n altered mental status (details unclear). His temp at that time was\n 101.8, P 124, BP 98/78, RR 18, O2 86-88% on RA up to 91-92% on 2L NC.\n His FS was 304 at that time. He was started on doxycycline 100 mg \n (with planned 10 day course). CXR was performed and tylenol was\n administered. Temp decreased to 98.4, HR 104, BP 108/76, O2 95% on 2L\n prior to transfer.\n .\n He presented to the ED on with altered mental\n status from his nursing facility. In their ED, initial vitals T 96.5, P\n 96, BP 86/64-->79/57, 100% on NRB. He received 3 L NS with improvement\n of BPs to 100s-130s systolic. A R IJ central venous line was placed. He\n had evidence of a UTI on UA. cultures were sent X 2. He was\n treated with vancomycin 1 g IV (given at on ), ceftazadime 1 g\n IV (given at 1700 on ) and flagyl 500 mg IV (given at 1715 on ).\n His hyperkalemia was treated with D50/insulin and bicarb. He also\n received solumedrol 125 mg IV X 1 and morphine 2 mg IV X 1. He made 300\n cc of urine in their ICU.\n On arrival to the MICU, the patient is complaining of bilateral leg\n pain which is longstanding per his report. He denies cough, vomiting,\n abdominal pain, and diarrhea. He denies headache, neck pain, and\n fevers. He denies chest pain.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Friend, Interpreter\n unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds at nursing home:\n folate 1 mg daily\n citalopram 20 mg daily\n thiamine 100 mg daily\n asa 81 mg daily\n senna 2 tabs three times weekly at bedtime\n calcium 600 with vitamin D \n gabapentin 1200 mg TID\n ferrous sulfate 325 mg TID\n oxycodone 10 mg TID\n kaopectate 30 mL po Q6h prn diarrhea\n oxycodone 5 mg q6h prn\n lactulose 30 mL po daily prn constipation\n dulcolax suppository prn\n lantus 12 U SC QHS\n humalog 8 U SC TID and humalog sliding scale\n doxycycline 100 mg TID X 10 days (start date )\n tylenol prn\n Past medical history:\n Family history:\n Social History:\n (per OMR)\n * s/p CVA\n * Neurogenic bladder s/p suprapubic cath\n * Recurrent UTIs with Klebsiella/Pseudomonas & enterococcus\n * Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p\n R-CHOP x 6 cycles)\n * Bells Palsy\n * BPH\n * Hypertension\n * Partial Bowel obstruction s/p colostomy ()\n * Hepatitis C\n * Cryoglobulinemia\n * SLE with transverse myelitis, anti-dsDNA Ab+\n * Insulin Dependant Diabetes mellitus\n * Fungal Esophagitis Stage IV?\n unable to obtain mental status\n Occupation: unable to obtain\n Drugs:\n Tobacco: unable to obtain\n Alcohol:\n Other: Jehovah's witness (confirmed with sister, no products\n without discussing with sister)\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: suprapubic catheter\n Endocrine: Hyperglycemia\n Neurologic: No(t) Headache\n Flowsheet Data as of 01:06 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 73 (73 - 85) bpm\n BP: 169/105(121) {165/101(116) - 172/106(122)} mmHg\n RR: 9 (9 - 16) insp/min\n SpO2: 96%\n Height: 68 Inch\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n products:\n Total out:\n 180 mL\n 0 mL\n Urine:\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n 1 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n VS - Temp 95.9 F, BP 167/107, HR 84, R 14, O2-sat 98% 2L NC\n GENERAL - somnolent male, responsive to voice & sternal rub, answers\n questions appropriate (via interpreter), no acute distress\n HEENT - L facial droop, pupils small but reactive 3-->2 mm bilaterally,\n EOMI, sclerae anicteric, dry MM\n NECK - supple, no thyromegaly / LAD / JVD, R IJ cath in place\n LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory\n effort\n HEART - RRR, normal S1 & S2, no murmur appreciated\n ABDOMEN - normoactive bowel sounds, distended but soft, no appreciable\n tenderness to palpation, no masses or HSM, no rebound/guarding\n EXTREMITIES - WWP, no peripheral edema, 1+ DP pulses bilaterally, 2+\n bilateral radial pulses\n NEURO - arousable to voice/sternal rub, moves left arm easily with\n prompting, able to hold right arm to gravity, hand grip \n bilaterally, moves both legs on command, no clonus, toes equivocal\n bilaterally, + rigidity of hip flexors bilaterally, withdraws both\n hands to pain\n Labs / Radiology\n 405 mg/dL\n 2.0 mg/dL\n 11 mg/dL\n 29 mEq/L\n 101 mEq/L\n 5.8 mEq/L\n 135 mEq/L\n [image002.jpg]\n \n 2:33 A9/4/ 11:30 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 2.0\n Glucose\n 405\n Other labs: ALT / AST:15/17, Alk Phos / T Bili:97/0.9, Albumin:4.0\n g/dL, LDH:164 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.4 mg/dL\n Other labs:\n From :\n WBC 18.5 (9%L, 85%N, 5%M, < 5% bands)\n Hgb 14.9, Hct 46.6, Plt 400\n Na 132, K 6.5, Cl 97, CO2 29, glucose 356\n Ca 9.2, PO4 2.5, M 1.9\n lactate 2.2\n ammonia 25\n ALT 14, AST 18\n CK 26, CKMB 0.4, trop I < 0.04\n total protein 6.1, albumin 3.8\n Alk phos 94\n Total bili 1.1\n lipase 19\n PT 14.7, PTT 34.3, INR 1.1\n UA: SG 1.017, pH 5.5, 2+ protein, negative glucose, trace ketones, bili\n negative, > 200 WBCs, RBCs, 1+ bacteria, 3+ leuk esterase,\n positive nitrites\n serum tox negative for salicylates, alcohol, acetaminophen, benzos,\n barbs, tricyclics\n urine tox negative for amphetamines, barbs, benzos, cannabis, cocaine,\n methadone, PCP; POSITIVE for opiates\n Labs from NH ():\n WBC 9.1 (58%N, 27%L, 10%M, 5% eos), Hct 45.8, Plt 256\n Na 137, K 4.5, Cl 96, CO2 32, BUN 5, Cr 1.1, glucose 206\n Calcium 8.7\n CXR (, from outside facility): slight left lower lobe atelectasis,\n cath tip in SVC\n Imaging: CXR: right-shifted mediastinum, R IJ CVL in SVC/atrial\n junction\n Microbiology: cx at B&W X 2\n ECG: sinus rhythm at 75, normal axis, signs of LVH, < \n elevation in II, III, aVF & V4-6. No Q waves.\n Assessment and Plan\n 61 y/o M with PMH of prior CVA, indwelling catheter and multiple prior\n UTIs admitted with shock, likely septic and urinary tract\n infection.\n #. Altered mental status: Appears similar to prior episode per review\n of discharge summary and patient is clinically infected. He is oriented\n and appropriate when answering questions and neurologic examination is\n not focal to point to an intracranial process (though somewhat limited\n by language barrier & patient's mental status). The patient also is on\n chronic narcotic pain medications at his NH and received morphine IV at\n the OSH, which could cause somnolence.\n - close monitoring of mental status\n - continue to treat infections\n - obtain non-contrast head CT this PM given h/o CVA and current\n somnolence\n - check ABG to ensure not retaining CO2\n - avoid sedating medications\n #. Hypotension, likely septic in etiology UTI, improved: The\n patient is now hypertensive after IV fluids. Hypertension could be\n related to autonomic instability (given his neurologic diagnoses)\n though not documented in prior d/c summary.\n - Treat UTI with vancomycin, zosyn\n - repeat UA & urine culture here\n - if urine culture positive, will likely need suprapubic cath replaced\n by urology during admission\n - follow up on B&W culture results on \n - Continue flagyl for potential C diff/abd process\n - Monitor BP closely & check BP in opposite arm\n - consider arterial line if BP labile or does not correlate\n - check CVP to assess volume status, though clinically currently\n euvolemic\n - if hypotension recurs, consider stim given prior prednisone\n course\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Repeat here 2.\n Likely secondary to hypotension/hypovolemia from infectious process as\n above. He has fair urine output at present.\n - If not improved, consider renal ultrasound in AM\n - Obtain urine lytes if Cr not improved\n #. Respiratory distress: The patient was hypoxic prior to transfer to\n B&W earlier though no apparent distress currently and lung exam/CXR not\n indicative of pneumonia. Apparently finished course of vanc/cefepime on\n for aspiration pneumonia.\n - continue supplemental oxygen to maintain sat > 92% and wean as\n tolerated\n - cycle cardiac enzymes given ? prior cardiac ischemia last admission\n - repeat EKG in AM\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. Given recent abx, concern for C diff with elevated\n WBC count.\n - cover intra-abdominal source with zosyn & flagyl\n - monitor serial abd exams\n - send C diff if has stool output\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - avoid sedating meds\n - continue to monitor\n - tylenol when taking POs, may resume gabapentin at that time as well\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - consider contact surgery in the AM for evaluation\n # DM: On lantus & humalog (with meals & sliding scale) at baseline.\n Will give sliding scale for now and resume prior regimen when taking\n POs.\n #. FEN - NPO for now given mental status. Lyte repletion prn.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (will need replacement within 24 hours if\n still necessary as placed at OSH)\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo - MICU for now\n , MD\n PGY-3, pager #\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2125-09-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 340189, "text": "Ht: 68\n Wt: 79.4Kg\n IBW: 69.9 Kg\n %IBW: 113 %\n Comments:\n 61 y/o male p/w shock, likely septic UTI. Pt currently NPO x 1 day\n decreased MS, on insulin gtt for elevated BG's. Pt was on\n Diabetic/consistent diet c/ SF shakes on last admission. Will\n follow ability to advance to po diet.\n" }, { "category": "Physician ", "chartdate": "2125-09-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 340122, "text": "Chief Complaint: hypotension, altered mental status\n HPI:\n Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n Per notes from the nursing home, the patient had low grade fevers since\n discharge of 99-100.8. He completed vancomycin and cefepime on \n (prior admission). In the morning of , the patient was noted to have\n altered mental status (details unclear). His temp at that time was\n 101.8, P 124, BP 98/78, RR 18, O2 86-88% on RA up to 91-92% on 2L NC.\n His FS was 304 at that time. He was started on doxycycline 100 mg \n (with planned 10 day course). CXR was performed and tylenol was\n administered. Temp decreased to 98.4, HR 104, BP 108/76, O2 95% on 2L\n prior to transfer.\n .\n He presented to the ED on with altered mental\n status from his nursing facility. In their ED, initial vitals T 96.5, P\n 96, BP 86/64-->79/57, 100% on NRB. He received 3 L NS with improvement\n of BPs to 100s-130s systolic. A R IJ central venous line was placed. He\n had evidence of a UTI on UA. cultures were sent X 2. He was\n treated with vancomycin 1 g IV (given at on ), ceftazadime 1 g\n IV (given at 1700 on ) and flagyl 500 mg IV (given at 1715 on ).\n His hyperkalemia was treated with D50/insulin and bicarb. He also\n received solumedrol 125 mg IV X 1 and morphine 2 mg IV X 1. He made 300\n cc of urine in their ICU.\n On arrival to the MICU, the patient is complaining of bilateral leg\n pain which is longstanding per his report. He denies cough, vomiting,\n abdominal pain, and diarrhea. He denies headache, neck pain, and\n fevers. He denies chest pain.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Friend, Interpreter\n unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds at nursing home:\n folate 1 mg daily\n citalopram 20 mg daily\n thiamine 100 mg daily\n asa 81 mg daily\n senna 2 tabs three times weekly at bedtime\n calcium 600 with vitamin D \n gabapentin 1200 mg TID\n ferrous sulfate 325 mg TID\n oxycodone 10 mg TID\n kaopectate 30 mL po Q6h prn diarrhea\n oxycodone 5 mg q6h prn\n lactulose 30 mL po daily prn constipation\n dulcolax suppository prn\n lantus 12 U SC QHS\n humalog 8 U SC TID and humalog sliding scale\n doxycycline 100 mg TID X 10 days (start date )\n tylenol prn\n Past medical history:\n Family history:\n Social History:\n (per OMR)\n * s/p CVA\n * Neurogenic bladder s/p suprapubic cath\n * Recurrent UTIs with Klebsiella/Pseudomonas & enterococcus\n * Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p\n R-CHOP x 6 cycles)\n * Bells Palsy\n * BPH\n * Hypertension\n * Partial Bowel obstruction s/p colostomy ()\n * Hepatitis C\n * Cryoglobulinemia\n * SLE with transverse myelitis, anti-dsDNA Ab+\n * Insulin Dependant Diabetes mellitus\n * Fungal Esophagitis Stage IV?\n unable to obtain mental status\n Occupation: unable to obtain\n Drugs:\n Tobacco: unable to obtain\n Alcohol:\n Other: Jehovah's witness (confirmed with sister, no products\n without discussing with sister)\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: suprapubic catheter\n Endocrine: Hyperglycemia\n Neurologic: No(t) Headache\n Flowsheet Data as of 01:06 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 73 (73 - 85) bpm\n BP: 169/105(121) {165/101(116) - 172/106(122)} mmHg\n RR: 9 (9 - 16) insp/min\n SpO2: 96%\n Height: 68 Inch\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n products:\n Total out:\n 180 mL\n 0 mL\n Urine:\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n 1 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n VS - Temp 95.9 F, BP 167/107, HR 84, R 14, O2-sat 98% 2L NC\n GENERAL - somnolent male, responsive to voice & sternal rub, answers\n questions appropriate (via interpreter), no acute distress\n HEENT - L facial droop, pupils small but reactive 3-->2 mm bilaterally,\n EOMI, sclerae anicteric, dry MM\n NECK - supple, no thyromegaly / LAD / JVD, R IJ cath in place\n LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory\n effort\n HEART - RRR, normal S1 & S2, no murmur appreciated\n ABDOMEN - normoactive bowel sounds, distended but soft, no appreciable\n tenderness to palpation, no masses or HSM, no rebound/guarding\n EXTREMITIES - WWP, no peripheral edema, 1+ DP pulses bilaterally, 2+\n bilateral radial pulses\n NEURO - arousable to voice/sternal rub, moves left arm easily with\n prompting, able to hold right arm to gravity, hand grip \n bilaterally, moves both legs on command, no clonus, toes equivocal\n bilaterally, + rigidity of hip flexors bilaterally, withdraws both\n hands to pain\n Labs / Radiology\n 405 mg/dL\n 2.0 mg/dL\n 11 mg/dL\n 29 mEq/L\n 101 mEq/L\n 5.8 mEq/L\n 135 mEq/L\n [image002.jpg]\n \n 2:33 A9/4/ 11:30 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 2.0\n Glucose\n 405\n Other labs: ALT / AST:15/17, Alk Phos / T Bili:97/0.9, Albumin:4.0\n g/dL, LDH:164 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.4 mg/dL\n Other labs:\n From :\n WBC 18.5 (9%L, 85%N, 5%M, < 5% bands)\n Hgb 14.9, Hct 46.6, Plt 400\n Na 132, K 6.5, Cl 97, CO2 29, glucose 356\n Ca 9.2, PO4 2.5, M 1.9\n lactate 2.2\n ammonia 25\n ALT 14, AST 18\n CK 26, CKMB 0.4, trop I < 0.04\n total protein 6.1, albumin 3.8\n Alk phos 94\n Total bili 1.1\n lipase 19\n PT 14.7, PTT 34.3, INR 1.1\n UA: SG 1.017, pH 5.5, 2+ protein, negative glucose, trace ketones, bili\n negative, > 200 WBCs, RBCs, 1+ bacteria, 3+ leuk esterase,\n positive nitrites\n serum tox negative for salicylates, alcohol, acetaminophen, benzos,\n barbs, tricyclics\n urine tox negative for amphetamines, barbs, benzos, cannabis, cocaine,\n methadone, PCP; POSITIVE for opiates\n Labs from NH ():\n WBC 9.1 (58%N, 27%L, 10%M, 5% eos), Hct 45.8, Plt 256\n Na 137, K 4.5, Cl 96, CO2 32, BUN 5, Cr 1.1, glucose 206\n Calcium 8.7\n CXR (, from outside facility): slight left lower lobe atelectasis,\n cath tip in SVC\n Imaging: CXR: right-shifted mediastinum, R IJ CVL in SVC/atrial\n junction\n Microbiology: cx at B&W X 2\n ECG: sinus rhythm at 75, normal axis, signs of LVH, < \n elevation in II, III, aVF & V4-6. No Q waves.\n Assessment and Plan\n 61 y/o M with PMH of prior CVA, indwelling catheter and multiple prior\n UTIs admitted with shock, likely septic and urinary tract\n infection.\n #. Altered mental status: Appears similar to prior episode per review\n of discharge summary and patient is clinically infected. He is oriented\n and appropriate when answering questions and neurologic examination is\n not focal to point to an intracranial process (though somewhat limited\n by language barrier & patient's mental status). The patient also is on\n chronic narcotic pain medications at his NH and received morphine IV at\n the OSH, which could cause somnolence.\n - close monitoring of mental status\n - continue to treat infections\n - obtain non-contrast head CT this PM given h/o CVA and current\n somnolence\n - check ABG to ensure not retaining CO2\n - avoid sedating medications\n #. Hypotension, likely septic in etiology UTI, improved: The\n patient is now hypertensive after IV fluids. Hypertension could be\n related to autonomic instability (given his neurologic diagnoses)\n though not documented in prior d/c summary.\n - Treat UTI with vancomycin, zosyn\n - repeat UA & urine culture here\n - if urine culture positive, will likely need suprapubic cath replaced\n by urology during admission\n - follow up on B&W culture results on \n - Continue flagyl for potential C diff/abd process\n - Monitor BP closely & check BP in opposite arm\n - consider arterial line if BP labile or does not correlate\n - check CVP to assess volume status, though clinically currently\n euvolemic\n - if hypotension recurs, consider stim given prior prednisone\n course\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Repeat here 2.\n Likely secondary to hypotension/hypovolemia from infectious process as\n above. He has fair urine output at present.\n - If not improved, consider renal ultrasound in AM\n - Obtain urine lytes if Cr not improved\n #. Respiratory distress: The patient was hypoxic prior to transfer to\n B&W earlier though no apparent distress currently and lung exam/CXR not\n indicative of pneumonia. Apparently finished course of vanc/cefepime on\n for aspiration pneumonia.\n - continue supplemental oxygen to maintain sat > 92% and wean as\n tolerated\n - cycle cardiac enzymes given ? prior cardiac ischemia last admission\n - repeat EKG in AM\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. Given recent abx, concern for C diff with elevated\n WBC count.\n - cover intra-abdominal source with zosyn & flagyl\n - monitor serial abd exams\n - send C diff if has stool output\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - avoid sedating meds\n - continue to monitor\n - tylenol when taking POs, may resume gabapentin at that time as well\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - consider contact surgery in the AM for evaluation\n # DM: On lantus & humalog (with meals & sliding scale) at baseline.\n Will give sliding scale for now and resume prior regimen when taking\n POs.\n #. FEN - NPO for now given mental status. Lyte repletion prn.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (will need replacement within 24 hours if\n still necessary as placed at OSH)\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo - MICU for now\n , MD\n PGY-3, pager #\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU staff admit addendum\n I saw and examined this patient and was physically present with the\n MICU resident for the key portions of the service provided. I agree\n with the above note including the assessment and plan. I would\n emphasize the following points:\n Briefly this pt is a 61 yo Jehova's witness, French Creole speaking M\n NH resident,with MMP--including h/o partial SBO s/p R colectomy with\n ostomy, SLE with transverse myelitis, lymphoma, HTN (not on meds), DM,\n ? fungal esophagitis, prior CVA with L-sided deficits, neurogenic\n bladder w/ chronic indwelling suprapubic cath with recurrent UTIS\n (kleb, enterococcus) transferred from ED with altered MS \n, probably from UTI.\n Pt was recently admit to from -/ with septic shock \n aspiration pna. Sepsis from UTI was of concern but urine\n cx neg. Suprapubic cath was changed. Was d/c to NH to complete course\n of vacno/cefepime on . Since d/c has had low grade temps and today\n became more lethargic/ less responsive. Noted to be febrile to 101.8,\n hypoxic to 86-88% on RA, hyperglycemic to 304, started on doxycycline\n and sent to ED where he had temp of 96.5, transient hypotension to\n systolic 79 which improved with 3 L NS, RIJ placed, u/a grossly pos,\n received empiric broad antibx (ceftaz, vanco, and flagyl). Also\n hyperkalemic (treated with kayexalate) and in arf with cr 2.0 (1.0\n b/l). Also received dose of morphin and solumedrol. Noted mild abd\n distention without abd tenderness with KUB performed--nonspecific bowel\n gas pattern with no evidence of obstruction. --> transferred to for\n further care. On arrival to , pt HD stable, hypertensive to\n 160/110. Somnolent but easily arousable. With help of interpretor, pt\n noted only chronic le extremet pain and weakness, denies other\n complaints.\n Exam notable for: oral temp 95.9, BP 167/107, HR 84, RR 14, SAT 98%\n 2L, somnolent but arousable, slight L facial droop, NAD, conversant\n with interpretor on phone and cooperative with exam, perrla, but\n sluggish, MMD, r IJ site clean, lungs CTA, decreased at bases, no r/r,\n RR, no M, distended abd, tympanitic, NT, stoma prolapsed, soft, NT,\n beefy red, warm ext with diminshed but palpable distal pulses,\n rigidity, cogwheeling of upper ext, moves all 4 ext\n Labs () notable for 18 wbc, 46.6 hct, 400 plt, 132 na, K 6.5-->4.5\n cr 2.1 (1.0), lactate 2.2, ammonia 24, ast/alt lipase wnl, trop < 0.04,\n u/a pos, urine tox + optiates (takes oxycodone), serum tox neg\n CXR--rotated, mediastinum shifted R (stable from prior), slightly\n widened trachea, L base with streaky infiltrate--on comaprison with\n film from this appears to be clearing--infiltrate vs persistent\n atelectasis.\n ECG--T waves in 11, 111, F more pronounced than prior, 1mm st elevation\n upsloping, no acute changes\n A/P: 61 yo M with MMP including prior CVA, neurogenic bladder with\n chronic indwelling suprapubic catheter and recurrent UTIsm lypmphoma,\n sle with sepsis--\n transient hypotension, fevers, leukocytosis, with grossly positive\n u/a, AMS, ARF, mild abd distention, and hyponatremia, hyperglycemia,\n and hypoxia\n --Suspect sepsis uti, though bowel source such as c diff on ddx\n given abd distention (also noted on last admit). CXR less impressive\n and now with improved sats on minimal o2.\n Cover broadly with vanco, zosyn. F/u cx data from out ED and recx\n here. Although highest suspicion for urinary source, given some\n concern for c diff would continue IV flagyl opending cx data.Will need\n urology c/s for suprapubic cath change. Received dose solumedrol at\n OSH ed, but given improvement in bp will hold on continuing this as no\n suggestion of adrenal insufficiency, chronic steroids were d/c'd at\n last admit.\n --Hypotension resolved with fluids and now hypertensive. ? component\n of automonmic dysregulation given prior cva/transverse myelitis.\n Monitor for now, recheck manually, consider a-line.\n --ARF is likely prerenal--recheck after hydration. Send urine lytes.\n if no improvement would check renal us.\n --Altered MS likely from infection/sepsis--now appears more\n awake/alert. Would check head CT to r/u SDH or CVA given his hx. Hold\n sedating meds/narcotics which may have further contribributed insetting\n of renal failure.\n --Abd distention with benign exam- follow serial exams, send c diff,\n osh KUB unimpressive, consider surgical input on ostomy appearance (?\n prolapsed)\n --ICU prophylaxis, insulin gtt if unable to control BS with SSI\n --remainder as per ICU resident note.\n Pt is critically ill\n CC time spent--60 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 08:20 ------\n" }, { "category": "Physician ", "chartdate": "2125-09-07 00:00:00.000", "description": "ICU Attending", "row_id": 340164, "text": "CRITICAL CARE STAFF ADDENDUM\n 12 noon\n I saw and examined Mr. with the ICU team, whose note reflects my\n input. I would add/emphasize that he is a 61 y/o man with a\n complicated prior medical history (including admissions for septic\n shock) now admitted with severe sepsis. Since Dr. \ns note from\n this morning, events include:\n Gradually rising HR and falling BP, associated with decline in UOP\n [image002.gif]\n Development/continuation of delirium (interviewed with interpreter)\n Ultrasound showing moderate left hydronephrosis and large UPJ stones in\n the left kidney.\n On examination he follows some commands but seems quite confused and a\n bit paranoid. His chest is clear and his abdomen (with SP tube) is\n soft. There are no signs of meningismus. Stoma looks pink and\n well-perfused.\n Labs are reviewed in OMR/Metavision and are especially notable for Cr\n 2.0, WBC 21, and glucose 387\n 141\n Medications are as noted in the (reviewed on rounds)\n Assessment and Plan\n 61 year-old man with complicated prior medical history now with\n apparent severe sepsis (acute renal failure, altered mental status).\n The most likely source is urinary: in particular, I am concerned about\n obstructing hydronephrosis with pus under pressure. C difficile is\n possible, as is pneumonia.\n Severe sepsis\n Vanco to cover MRSA and non-VRE enterococcus\n o Call : if any prior VRE, change vanco to linezolid or\n dapto. If decompensates, change to linezolid or daptomycin.\n Zosyn to cover for resistant GNR\n o Though ESBL Klebs is possible, other GNRs are probable\n as/more likely\n Flagyl to cover for C diff\n Volume resuscitation as needed\n presently responding to\n volume challenge and normotense\n Urology consultation regarding best path for relief of\n ureteral obstruction (stent vs. percutaneous nephrostomy)\n Ask urology to change SP tube in days\n stim test since he was on chronic steroids within the\n past few months\n Does not meet criteria for APC\n Acute renal failure\n Likely hypoperfusion and post-renal (from stone)\n Hemodynamic management and relief of ureteral obstruction\n Altered mental status\n Likely related to severe sepsis +/- medications\n No signs suggested meningitis at present. Follow\n clinically.\n Diabetes\n On SQ insulin for now. need infusion if hard to control\n Blood products\n Pt is Jehovah\ns witness. Discuss with sister before ANY blood products\n Access\n CVL was placed at . Will try to get PICC.\n Full code\n Critical Care time: 50 min\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340248, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n He is now admitted to MICU-6 from & Women\ns ED after\n presenting from NH with unresponsiveness, temp spike and hypotension,\n and K+ 6.5. Pt rec\nd total of 3 liters NS in ED, as well as Vancomycin,\n Ceftazadine, Flagyl, and 125mg Solumedrol. Blood and urine cultures\n sent, kub (-). Head CT done, neg for new bleed.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt sleeping soundly through day, waking only to repeated verbal\n stimulation. Per Haitian/Creole translator in am, pt felt staff was\n trying to harm him and that antibiotic therapy would not help him. O X\n 1. He intermit C/O his chronic LE pain, but not grimacing or other\n evidence pain.\n Action:\n Pt freq reassured and reoriented in English and by sister/translator.\n Rec\nd Fentanyl 100mcg total for IR procedure.\n Response:\n Pt O X 2 in afternoon and cooperative, less resistant to care. Pt alert\n after rec\ning Fentanyl.\n Plan:\n Cont freq reorientation and reassurance. Translator as necessary. Pt to\n remain NPO while somulent.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine from suprapubic tube initially yellow/clear in am, becoming more\n coudy/milky. Urine output 100->25ml/hr. BP generally 106/59-142/89, but\n @ 0930 BP 90/46 with CVP 8->5. Afebrile. K+ WNL @ 4.3.\n Action:\n Pt rec\nd total 2.5liters NS fluid boluses. Pt on Vancomycin, Zosyn,\n Flagyl. US done which showed kidney stones bilat with partial blockage\n on L. Pt subsequently went for Left nephrostomy tube placement in IR.\n Response:\n BP has stabilized with SBP in 140\ns, CVP 12. Suprapubic foley cont to\n drain milky urine, nephrostomy tube draining mod amts pink-tinged\n urine.\n Plan:\n Cont to monitor urine output closely. Fluid boluses to maintain CVP\n ~12.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Rec\nd pt on continuous Insulin drip @ 8units/hr. NPO. FSG in 200\n Action:\n Insulin qtt adjusted per sliding scale. Requested that pharmacy not put\n Vancomycin in D5W.\n Response:\n Insulin qtt weaned down to present rate 2units/hr with latest FSG 100.\n Plan:\n Cont to wean Insulin qtt to off while reinstating intermit sliding\n scale.\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340365, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Percutaneous nephrostomy. Cultures sent GS with many polys\n Confirmation from sister that patient does not normally refuse medical\n care\n Ordered for PICC but not placed\n Linazolid replaced Vanc for h/o VRE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 10:09 PM\n Piperacillin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 76 (67 - 94) bpm\n BP: 139/83(97) {90/46(57) - 150/92(105)} mmHg\n RR: 12 (8 - 17) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 8 (5 - 16)mmHg\n Total In:\n 4,109 mL\n 246 mL\n PO:\n TF:\n IVF:\n 4,109 mL\n 246 mL\n products:\n Total out:\n 1,825 mL\n 465 mL\n Urine:\n 1,825 mL\n 465 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 418 K/uL\n 12.8 g/dL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Imaging: Renal US: Moderate hydronephrosis of the left kidney. Large\n stone seen in\n the left UPJ. Smaller bilateral renal stones.\n Head CT: Left maxillary sinus opacification. Otherwise normal study.\n Microbiology: Nephrostomy GS: 4+ PML\n Assessment and Plan\n 61 y/o M with PMH of prior CVA, indwelling catheter and multiple prior\n UTIs admitted with shock, likely septic and urinary tract\n infection.\n #. Altered mental status: Appears similar to prior episode per review\n of discharge summary and patient is clinically infected. He is oriented\n and appropriate when answering questions and neurologic examination is\n not focal to point to an intracranial process (though somewhat limited\n by language barrier & patient's mental status). The patient also is on\n chronic narcotic pain medications at his NH and received morphine IV at\n the OSH, which could cause somnolence.\n - close monitoring of mental status\n - continue to treat infections\n - obtain non-contrast head CT this PM given h/o CVA and current\n somnolence\n - check ABG to ensure not retaining CO2\n - avoid sedating medications\n #. Hypotension, likely septic in etiology UTI, improved: The\n patient is now hypertensive after IV fluids. Hypertension could be\n related to autonomic instability (given his neurologic diagnoses)\n though not documented in prior d/c summary.\n - Treat UTI with vancomycin, zosyn\n - repeat UA & urine culture here\n - if urine culture positive, will likely need suprapubic cath replaced\n by urology during admission\n - follow up on B&W culture results on \n - Continue flagyl for potential C diff/abd process\n - Monitor BP closely & check BP in opposite arm\n - consider arterial line if BP labile or does not correlate\n - check CVP to assess volume status, though clinically currently\n euvolemic\n - if hypotension recurs, consider stim given prior prednisone\n course\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Repeat here 2.\n Likely secondary to hypotension/hypovolemia from infectious process as\n above. He has fair urine output at present.\n - If not improved, consider renal ultrasound in AM\n - Obtain urine lytes if Cr not improved\n #. Respiratory distress: The patient was hypoxic prior to transfer to\n B&W earlier though no apparent distress currently and lung exam/CXR not\n indicative of pneumonia. Apparently finished course of vanc/cefepime on\n for aspiration pneumonia.\n - continue supplemental oxygen to maintain sat > 92% and wean as\n tolerated\n - cycle cardiac enzymes given ? prior cardiac ischemia last admission\n - repeat EKG in AM\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. Given recent abx, concern for C diff with elevated\n WBC count.\n - cover intra-abdominal source with zosyn & flagyl\n - monitor serial abd exams\n - send C diff if has stool output\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - avoid sedating meds\n - continue to monitor\n - tylenol when taking POs, may resume gabapentin at that time as well\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - consider contact surgery in the AM for evaluation\n # DM: On lantus & humalog (with meals & sliding scale) at baseline.\n Will give sliding scale for now and resume prior regimen when taking\n POs.\n #. FEN - NPO for now given mental status. Lyte repletion prn.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (will need replacement within 24 hours if\n still necessary as placed at OSH)\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo - MICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 340368, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Percutaneous nephrostomy. Cultures sent GS with many polys\n Confirmation from sister that patient does not normally refuse medical\n care\n Ordered for PICC but not placed\n Linazolid replaced Vanc for h/o VRE\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Linezolid - 10:09 PM\n Piperacillin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 76 (67 - 94) bpm\n BP: 139/83(97) {90/46(57) - 150/92(105)} mmHg\n RR: 12 (8 - 17) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 8 (5 - 16)mmHg\n Total In:\n 4,109 mL\n 246 mL\n PO:\n TF:\n IVF:\n 4,109 mL\n 246 mL\n products:\n Total out:\n 1,825 mL\n 465 mL\n Urine:\n 1,825 mL\n 465 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 418 K/uL\n 12.8 g/dL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Imaging: Renal US: Moderate hydronephrosis of the left kidney. Large\n stone seen in\n the left UPJ. Smaller bilateral renal stones.\n Head CT: Left maxillary sinus opacification. Otherwise normal study.\n Microbiology: Nephrostomy GS: 4+ PML\n Urine CX () > suspected pseudomonas\n Culture HX from , (+) h/o VRE. Pseudomonas UTI (Pip-tazo, tobra,\n Imipenem, Cefepime, Amikasin sensitive)\n Assessment and Plan\n 61 y/o M with PMH of prior CVA, indwelling catheter and multiple prior\n UTIs admitted with shock, likely septic and urinary tract\n infection.\n Note: No Citalopram while on Vanc\n Needs to change right IJ\n Call to f/u sensitivities\n #. Altered mental status: Appears similar to prior episode per review\n of discharge summary and patient is clinically infected. He is oriented\n and appropriate when answering questions and neurologic examination is\n not focal to point to an intracranial process (though somewhat limited\n by language barrier & patient's mental status). The patient also is on\n chronic narcotic pain medications at his NH and received morphine IV at\n the OSH, which could cause somnolence.\n - close monitoring of mental status\n - continue to treat infections\n - obtain non-contrast head CT this PM given h/o CVA and current\n somnolence\n - check ABG to ensure not retaining CO2\n - avoid sedating medications\n #. Hypotension, likely septic in etiology UTI, improved: The\n patient is now hypertensive after IV fluids. Hypertension could be\n related to autonomic instability (given his neurologic diagnoses)\n though not documented in prior d/c summary.\n - Treat UTI with vancomycin, zosyn\n - repeat UA & urine culture here\n - if urine culture positive, will likely need suprapubic cath replaced\n by urology during admission\n - follow up on B&W culture results on \n - Continue flagyl for potential C diff/abd process\n - Monitor BP closely & check BP in opposite arm\n - consider arterial line if BP labile or does not correlate\n - check CVP to assess volume status, though clinically currently\n euvolemic\n - if hypotension recurs, consider stim given prior prednisone\n course\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Repeat here 2.\n Likely secondary to hypotension/hypovolemia from infectious process as\n above. He has fair urine output at present.\n - If not improved, consider renal ultrasound in AM\n - Obtain urine lytes if Cr not improved\n #. Respiratory distress: The patient was hypoxic prior to transfer to\n B&W earlier though no apparent distress currently and lung exam/CXR not\n indicative of pneumonia. Apparently finished course of vanc/cefepime on\n for aspiration pneumonia.\n - continue supplemental oxygen to maintain sat > 92% and wean as\n tolerated\n - cycle cardiac enzymes given ? prior cardiac ischemia last admission\n - repeat EKG in AM\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. Given recent abx, concern for C diff with elevated\n WBC count.\n - cover intra-abdominal source with zosyn & flagyl\n - monitor serial abd exams\n - send C diff if has stool output\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - avoid sedating meds\n - continue to monitor\n - tylenol when taking POs, may resume gabapentin at that time as well\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - consider contact surgery in the AM for evaluation\n # DM: On lantus & humalog (with meals & sliding scale) at baseline.\n Will give sliding scale for now and resume prior regimen when taking\n POs.\n #. FEN - NPO for now given mental status. Lyte repletion prn.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (will need replacement within 24 hours if\n still necessary as placed at OSH)\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo - MICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 340462, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Sepsis from impacted renal stone s/p IR guided nephrostomy tube\n Prelim Cx at pseudomonas\n 24 Hour Events:\n ULTRASOUND - At 10:00 AM\n kidneys, bladder\n STOOL CULTURE - At 02:51 PM\n sent for ? c-diff\n URINE CULTURE - At 04:00 PM\n during left nephrostomy red and greq top tubes of urine sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 08:24 AM\n Linezolid - 10:04 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (67 - 81) bpm\n BP: 157/85(103) {106/64(71) - 158/92(107)} mmHg\n RR: 8 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (6 - 16)mmHg\n Total In:\n 4,109 mL\n 1,086 mL\n PO:\n 380 mL\n TF:\n IVF:\n 4,109 mL\n 706 mL\n Blood products:\n Total out:\n 1,825 mL\n 1,045 mL\n Urine:\n 1,825 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 12.8 g/dL\n 418 K/uL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n A/P: 61 yo M with MMP including prior CVA, neurogenic bladder with\n chronic indwelling suprapubic catheter and recurrent UTIsm lypmphoma,\n sle with sepsis-- transient hypotension, fevers, leukocytosis,\n with grossly positive\n 1. Sepsis: due to impacted reanl stone s/p perc drain by IR yesterday.\n Cover broadly with vanco, zosyn. F/u cx data from out ED and recx here\n 2. ARF is likely prerenal--recheck after hydration. Send urine lytes.\n if no improvement would check renal us.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2125-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 340490, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n He was admitted to MICU-6 from & Women\ns ED after\n presenting from NH with unresponsiveness, temp spike and hypotension,\n and K+ 6.5. Pt rec\nd total of 3 liters NS in ED, as well as Vancomycin,\n Ceftazadine, Flagyl, and 125mg Solumedrol. Blood and urine cultures\n sent, + for urosepsis. Head CT and KUB neg.\n On US showed bilat kidney stones L>R with moderate hydronephrosis\n on Left. Pt subsequently had a perc nephrostomy tube placement on left.\n He rec\nd total of 2.5liters NS for BP/CVP management.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt sleeping soundly in am, but easily woken and appropriate. Oriented X\n 2 in English, and talking easily with translator. Cooperative with all\n care. Gag and cough intact. He C/O chronic bilat LE pain, but denied\n abdominal or nephrostomy site pain.\n Action:\n Pt freq oriented. Translator/coworker available for freq translations.\n Pt rec\nd PRN Oxycodone IR 10mg X 1, and Gabapentin restarted. OOB to\n chair via slideboard, remaining in chair for several hrs. Started on\n clear liqs.\n Response:\n Per patient, after taking pain med, leg pain went from ->.\n Tolerated chair well, but C/O back pain and desire to lie on his side\n in bed after several hrs. Diet progressed to full liqs.\n Plan:\n Cont freq reorientation of pt, with translator as available. Cont PRN\n pain med, observing for oversedation/somulence. Cont to increase\n activity as tolerated. ? PT consult. Cont to increase diet as\n tolerated, aspiration precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n VSS with HR 70-80\ns SR without VEA, SBP 130-150\ns, RR 6-12 and regular\n on 3l NC with O2 sat 93-97%. Afebrile. Mild periph edema of hands,\n feet. Suprapubic tube draining 40-60ml/hr of yellow urine with occas\n sed. Left Nephrostomy tube draining avg 50ml/hr pink-tinged urine which\n is clearing as day progresses. Nephrostomy tube site with DSD intact.\n AM creat 2->1.6.\n Action:\n VS and output monitored Q1hr. Nephrostomy tubing/site monitored.\n Response:\n Urine drainage tubes cont to drain well. VS remain stable.\n Plan:\n Pt to transfer to floor. Cont to monitor urine drainage tubes, VS with\n temp.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Rec\nd pt on Insulin qtt @ 2units/hr with FSG 104-110.\n Action:\n Insulin qtt stopped @ 0745. Pt rec\nd Galrgine 18units @ 0800 per\n sliding scale. Diet advanced from NPO to clear ligs.\n Response:\n FSG 143, 158. Pt has not rec\nd additional insulin per sliding scale. Pt\n taking juice, jello, and requested oatmeal for dinner.\n Plan:\n Cont to monitor FSG with insulin per sliding scale. Cont to advance\n diet as tolerated.\n" }, { "category": "Physician ", "chartdate": "2125-09-07 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 339977, "text": "Chief Complaint: hypotension, altered mental status\n HPI:\n Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n Per notes from the nursing home, the patient had low grade fevers since\n discharge of 99-100.8. He completed vancomycin and cefepime on \n (prior admission). In the morning of , the patient was noted to have\n altered mental status (details unclear). His temp at that time was\n 101.8, P 124, BP 98/78, RR 18, O2 86-88% on RA up to 91-92% on 2L NC.\n His FS was 304 at that time. He was started on doxycycline 100 mg \n (with planned 10 day course). CXR was performed and tylenol was\n administered. Temp decreased to 98.4, HR 104, BP 108/76, O2 95% on 2L\n prior to transfer.\n .\n He presented to the ED on with altered mental\n status from his nursing facility. In their ED, initial vitals T 96.5, P\n 96, BP 86/64-->79/57, 100% on NRB. He received 3 L NS with improvement\n of BPs to 100s-130s systolic. A R IJ central venous line was placed. He\n had evidence of a UTI on UA. cultures were sent X 2. He was\n treated with vancomycin 1 g IV (given at on ), ceftazadime 1 g\n IV (given at 1700 on ) and flagyl 500 mg IV (given at 1715 on ).\n His hyperkalemia was treated with D50/insulin and bicarb. He also\n received solumedrol 125 mg IV X 1 and morphine 2 mg IV X 1. He made 300\n cc of urine in their ICU.\n On arrival to the MICU, the patient is complaining of bilateral leg\n pain which is longstanding per his report. He denies cough, vomiting,\n abdominal pain, and diarrhea. He denies headache, neck pain, and\n fevers. He denies chest pain.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient, Family / Friend, Interpreter\n unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds at nursing home:\n folate 1 mg daily\n citalopram 20 mg daily\n thiamine 100 mg daily\n asa 81 mg daily\n senna 2 tabs three times weekly at bedtime\n calcium 600 with vitamin D \n gabapentin 1200 mg TID\n ferrous sulfate 325 mg TID\n oxycodone 10 mg TID\n kaopectate 30 mL po Q6h prn diarrhea\n oxycodone 5 mg q6h prn\n lactulose 30 mL po daily prn constipation\n dulcolax suppository prn\n lantus 12 U SC QHS\n humalog 8 U SC TID and humalog sliding scale\n doxycycline 100 mg TID X 10 days (start date )\n tylenol prn\n Past medical history:\n Family history:\n Social History:\n (per OMR)\n * s/p CVA\n * Neurogenic bladder s/p suprapubic cath\n * Recurrent UTIs with Klebsiella/Pseudomonas & enterococcus\n * Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p\n R-CHOP x 6 cycles)\n * Bells Palsy\n * BPH\n * Hypertension\n * Partial Bowel obstruction s/p colostomy ()\n * Hepatitis C\n * Cryoglobulinemia\n * SLE with transverse myelitis, anti-dsDNA Ab+\n * Insulin Dependant Diabetes mellitus\n * Fungal Esophagitis Stage IV?\n unable to obtain mental status\n Occupation: unable to obtain\n Drugs:\n Tobacco: unable to obtain\n Alcohol:\n Other: Jehovah's witness (confirmed with sister, no products\n without discussing with sister)\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: suprapubic catheter\n Endocrine: Hyperglycemia\n Neurologic: No(t) Headache\n Flowsheet Data as of 01:06 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 73 (73 - 85) bpm\n BP: 169/105(121) {165/101(116) - 172/106(122)} mmHg\n RR: 9 (9 - 16) insp/min\n SpO2: 96%\n Height: 68 Inch\n CVP: 7 (7 - 7)mmHg\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n products:\n Total out:\n 180 mL\n 0 mL\n Urine:\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n -180 mL\n 1 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n VS - Temp 95.9 F, BP 167/107, HR 84, R 14, O2-sat 98% 2L NC\n GENERAL - somnolent male, responsive to voice & sternal rub, answers\n questions appropriate (via interpreter), no acute distress\n HEENT - L facial droop, pupils small but reactive 3-->2 mm bilaterally,\n EOMI, sclerae anicteric, dry MM\n NECK - supple, no thyromegaly / LAD / JVD, R IJ cath in place\n LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory\n effort\n HEART - RRR, normal S1 & S2, no murmur appreciated\n ABDOMEN - normoactive bowel sounds, distended but soft, no appreciable\n tenderness to palpation, no masses or HSM, no rebound/guarding\n EXTREMITIES - WWP, no peripheral edema, 1+ DP pulses bilaterally, 2+\n bilateral radial pulses\n NEURO - arousable to voice/sternal rub, moves left arm easily with\n prompting, able to hold right arm to gravity, hand grip \n bilaterally, moves both legs on command, no clonus, toes equivocal\n bilaterally, + rigidity of hip flexors bilaterally, withdraws both\n hands to pain\n Labs / Radiology\n 405 mg/dL\n 2.0 mg/dL\n 11 mg/dL\n 29 mEq/L\n 101 mEq/L\n 5.8 mEq/L\n 135 mEq/L\n [image002.jpg]\n \n 2:33 A9/4/ 11:30 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 2.0\n Glucose\n 405\n Other labs: ALT / AST:15/17, Alk Phos / T Bili:97/0.9, Albumin:4.0\n g/dL, LDH:164 IU/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL, PO4:2.4 mg/dL\n Other labs:\n From :\n WBC 18.5 (9%L, 85%N, 5%M, < 5% bands)\n Hgb 14.9, Hct 46.6, Plt 400\n Na 132, K 6.5, Cl 97, CO2 29, glucose 356\n Ca 9.2, PO4 2.5, M 1.9\n lactate 2.2\n ammonia 25\n ALT 14, AST 18\n CK 26, CKMB 0.4, trop I < 0.04\n total protein 6.1, albumin 3.8\n Alk phos 94\n Total bili 1.1\n lipase 19\n PT 14.7, PTT 34.3, INR 1.1\n UA: SG 1.017, pH 5.5, 2+ protein, negative glucose, trace ketones, bili\n negative, > 200 WBCs, RBCs, 1+ bacteria, 3+ leuk esterase,\n positive nitrites\n serum tox negative for salicylates, alcohol, acetaminophen, benzos,\n barbs, tricyclics\n urine tox negative for amphetamines, barbs, benzos, cannabis, cocaine,\n methadone, PCP; POSITIVE for opiates\n Labs from NH ():\n WBC 9.1 (58%N, 27%L, 10%M, 5% eos), Hct 45.8, Plt 256\n Na 137, K 4.5, Cl 96, CO2 32, BUN 5, Cr 1.1, glucose 206\n Calcium 8.7\n CXR (, from outside facility): slight left lower lobe atelectasis,\n cath tip in SVC\n Imaging: CXR: right-shifted mediastinum, R IJ CVL in SVC/atrial\n junction\n Microbiology: cx at B&W X 2\n ECG: sinus rhythm at 75, normal axis, signs of LVH, < \n elevation in II, III, aVF & V4-6. No Q waves.\n Assessment and Plan\n 61 y/o M with PMH of prior CVA, indwelling catheter and multiple prior\n UTIs admitted with shock, likely septic and urinary tract\n infection.\n #. Altered mental status: Appears similar to prior episode per review\n of discharge summary and patient is clinically infected. He is oriented\n and appropriate when answering questions and neurologic examination is\n not focal to point to an intracranial process (though somewhat limited\n by language barrier & patient's mental status). The patient also is on\n chronic narcotic pain medications at his NH and received morphine IV at\n the OSH, which could cause somnolence.\n - close monitoring of mental status\n - continue to treat infections\n - obtain non-contrast head CT this PM given h/o CVA and current\n somnolence\n - check ABG to ensure not retaining CO2\n - avoid sedating medications\n #. Hypotension, likely septic in etiology UTI, improved: The\n patient is now hypertensive after IV fluids. Hypertension could be\n related to autonomic instability (given his neurologic diagnoses)\n though not documented in prior d/c summary.\n - Treat UTI with vancomycin, zosyn\n - repeat UA & urine culture here\n - if urine culture positive, will likely need suprapubic cath replaced\n by urology during admission\n - follow up on B&W culture results on \n - Continue flagyl for potential C diff/abd process\n - Monitor BP closely & check BP in opposite arm\n - consider arterial line if BP labile or does not correlate\n - check CVP to assess volume status, though clinically currently\n euvolemic\n - if hypotension recurs, consider stim given prior prednisone\n course\n #. Acute renal failure: Creatinine up to 2.1 at OSH. Repeat here 2.\n Likely secondary to hypotension/hypovolemia from infectious process as\n above. He has fair urine output at present.\n - If not improved, consider renal ultrasound in AM\n - Obtain urine lytes if Cr not improved\n #. Respiratory distress: The patient was hypoxic prior to transfer to\n B&W earlier though no apparent distress currently and lung exam/CXR not\n indicative of pneumonia. Apparently finished course of vanc/cefepime on\n for aspiration pneumonia.\n - continue supplemental oxygen to maintain sat > 92% and wean as\n tolerated\n - cycle cardiac enzymes given ? prior cardiac ischemia last admission\n - repeat EKG in AM\n #. Abdominal distension: The patient's abdomen is distended but no\n vomiting or abd pain by report. KUB and LFTs/lipase at unrevealing. Given recent abx, concern for C diff with elevated\n WBC count.\n - cover intra-abdominal source with zosyn & flagyl\n - monitor serial abd exams\n - send C diff if has stool output\n # Leg pain: Patient states pain is bilateral and longstanding. On\n gabapentin & oxycodone at nursing facility. Patient complains of pain\n upon waking but does not appear in distress.\n - avoid sedating meds\n - continue to monitor\n - tylenol when taking POs, may resume gabapentin at that time as well\n # Stoma protrusion: Likely benign given that stoma appears pink and is\n soft. No abd tenderness.\n - consider contact surgery in the AM for evaluation\n # DM: On lantus & humalog (with meals & sliding scale) at baseline.\n Will give sliding scale for now and resume prior regimen when taking\n POs.\n #. FEN - NPO for now given mental status. Lyte repletion prn.\n #. PPx - Hep SC TID. PPI (recent gastritis). Bowel meds when taking\n POs.\n # Access: 2 PIVs, R IJ CVL (will need replacement within 24 hours if\n still necessary as placed at OSH)\n #. Code - Full, confirmed with patient's sister, HCP. products\n without speaking with sister as patient is witness.\n # Communication: With patient and sister, .\n #. Dispo - MICU for now\n , MD\n PGY-3, pager #\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-09-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 340232, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n .H/O altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type I\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 340461, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Sepsis from impacted renal stone s/p IR guided nephrostomy tube\n Prelim Cx at pseudomonas\n 24 Hour Events:\n ULTRASOUND - At 10:00 AM\n kidneys, bladder\n STOOL CULTURE - At 02:51 PM\n sent for ? c-diff\n URINE CULTURE - At 04:00 PM\n during left nephrostomy red and greq top tubes of urine sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 08:24 AM\n Linezolid - 10:04 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (67 - 81) bpm\n BP: 157/85(103) {106/64(71) - 158/92(107)} mmHg\n RR: 8 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (6 - 16)mmHg\n Total In:\n 4,109 mL\n 1,086 mL\n PO:\n 380 mL\n TF:\n IVF:\n 4,109 mL\n 706 mL\n Blood products:\n Total out:\n 1,825 mL\n 1,045 mL\n Urine:\n 1,825 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 12.8 g/dL\n 418 K/uL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2125-09-08 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 340465, "text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Sepsis from impacted renal stone s/p IR guided nephrostomy tube\n Prelim Cx at pseudomonas\n 24 Hour Events:\n ULTRASOUND - At 10:00 AM\n kidneys, bladder\n STOOL CULTURE - At 02:51 PM\n sent for ? c-diff\n URINE CULTURE - At 04:00 PM\n during left nephrostomy red and greq top tubes of urine sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Piperacillin - 08:24 AM\n Linezolid - 10:04 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 04:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Pantoprazole (Protonix) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 77 (67 - 81) bpm\n BP: 157/85(103) {106/64(71) - 158/92(107)} mmHg\n RR: 8 (8 - 17) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 7 (6 - 16)mmHg\n Total In:\n 4,109 mL\n 1,086 mL\n PO:\n 380 mL\n TF:\n IVF:\n 4,109 mL\n 706 mL\n Blood products:\n Total out:\n 1,825 mL\n 1,045 mL\n Urine:\n 1,825 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,284 mL\n 41 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 12.8 g/dL\n 418 K/uL\n 103 mg/dL\n 1.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 142 mEq/L\n 40.1 %\n 19.0 K/uL\n [image002.jpg]\n 11:30 PM\n 12:18 AM\n 01:23 AM\n 04:15 AM\n 11:45 AM\n 05:25 PM\n 02:52 AM\n WBC\n 21.0\n 20.4\n 19.0\n 19.0\n Hct\n 46.2\n 45.6\n 41.3\n 40.1\n Plt\n 374\n 368\n 426\n 418\n Cr\n 2.0\n 2.0\n 2.0\n 1.7\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 29\n Glucose\n 08\n 103\n Other labs: PT / PTT / INR:13.7/28.6/1.2, CK / CKMB /\n Troponin-T:20/5/0.02, ALT / AST:15/17, Alk Phos / T Bili:97/0.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:3.5 %, Eos:0.1 %, Lactic\n Acid:1.2 mmol/L, Albumin:4.0 g/dL, LDH:164 IU/L, Ca++:8.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n A/P: 61 yo M with MMP including prior CVA, neurogenic bladder with\n chronic indwelling suprapubic catheter and recurrent UTIs, lypmphoma,\n sle with sepsis-- transient hypotension, fevers, leukocytosis,\n with grossly positive\n 1. Sepsis: due to impacted renal stone s/p perc drain by IR yesterday\n compounded by C diff.\n Cover broadly with Linezolid (hx of VRE), zosyn. F/u cx data from \n with sensi\n C. diff: rx with Flagyl\n 2. ARF: ATN and post obstructive, improving slowly\n 3. Hyperglycemia: insulin drip held this AM and given glargine\n ICU Care\n Nutrition: diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:29 PM\n from , d/c work with 2 PIV\n we have, in for IR guided PICC\n 20 Gauge - 09:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and daughter\n status: Full code\n Disposition : call out\n Total time spent: 35\n" }, { "category": "Nursing", "chartdate": "2125-09-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 340547, "text": "Mr. is a 61 y/o M with PMH notable for prior CVA, neurogenic\n bladder with indwelling suprapubic catheter with multiple prior UTIs\n admitted with altered mental status. He was recently admitted to \n from for septic shock secondary to aspiration pneumonia which\n improved rapidly with fluid boluses. There was concern for UTI at that\n time, but urine culture was negative and his suprapubic catheter was\n changed on . He also was diagnosed with gastritis (biopsies\n negative) and acute renal failure (Cr to 2) which resolved prior to\n discharge.\n He was admitted to MICU-6 from & Women\ns ED after\n presenting from NH with unresponsiveness, temp spike and hypotension,\n and K+ 6.5. Pt rec\nd total of 3 liters NS in ED, as well as Vancomycin,\n Ceftazadine, Flagyl, and 125mg Solumedrol. Blood and urine cultures\n sent, + for urosepsis. Head CT and KUB neg.\n On US showed bilat kidney stones L>R with moderate hydronephrosis\n on Left. Pt subsequently had a perc nephrostomy tube placement on left.\n He rec\nd total of 2.5liters NS for BP/CVP management.\n Pt is a Jehovah\ns Witness. Pt remains full code, with sister next of\n /proxy. Pt on contact precautions for stool + for c-diff and\n previous dx VRE.\n .H/O altered mental status (not Delirium)\n Assessment:\n Pt sleeping soundly in am, but easily woken and appropriate. Oriented X\n 2 in English, and talking easily with translator. Cooperative with all\n care. Gag and cough intact. He C/O chronic bilat LE pain, but denied\n abdominal or nephrostomy site pain.\n Action:\n Pt freq oriented. Translator/coworker available for freq translations.\n Pt rec\nd PRN Oxycodone IR 10mg X 1, and Gabapentin restarted. OOB to\n chair via slideboard, remaining in chair for several hrs. Started on\n clear liqs.\n Response:\n Per patient, after taking pain med, leg pain went from ->.\n Tolerated chair well, but C/O back pain and desire to lie on his side\n in bed after several hrs. Diet progressed to full liqs.\n Plan:\n Cont freq reorientation of pt, with translator as available. Cont PRN\n pain med, observing for oversedation/somulence. Cont to increase\n activity as tolerated. ? PT consult. Cont to increase diet as\n tolerated, aspiration precautions.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n VSS with HR 70-80\ns SR without VEA, SBP 130-150\ns, RR 6-12 and regular\n on 3l NC with O2 sat 93-97%. Afebrile. Mild periph edema of hands,\n feet. Suprapubic tube draining 40-60ml/hr of yellow urine with occas\n sed. Left Nephrostomy tube draining avg 50ml/hr pink-tinged urine which\n is clearing as day progresses. Nephrostomy tube site with DSD intact.\n AM creat 2->1.6.\n Action:\n VS and output monitored Q1hr. Nephrostomy tubing/site monitored.\n Response:\n Urine drainage tubes cont to drain well. VS remain stable.\n Plan:\n Pt to transfer to floor. Cont to monitor urine drainage tubes, VS with\n temp.\n Diabetes Mellitus (DM), Type I\n Assessment:\n Rec\nd pt on Insulin qtt @ 2units/hr with FSG 104-110.\n Action:\n Insulin qtt stopped @ 0745. Pt rec\nd Galrgine 18units @ 0800 per\n sliding scale. Diet advanced from NPO to clear ligs.\n Response:\n FSG 143, 158. Pt has not rec\nd additional insulin per sliding scale. Pt\n taking juice, jello, and requested oatmeal for dinner.\n Plan:\n Cont to monitor FSG with insulin per sliding scale. Cont to advance\n diet as tolerated.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n UROSEPSIS\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact, Additional Precautions\n PMH: Diabetes - Insulin, Renal Failure\n CV-PMH: CVA, PVD\n Additional history: neurogenic bladder s/p suprapubic cath, lymphoma,\n SLE, and partial bowel obstruction s/p colostomy. Septic shock due to\n pna, aspiration, acute encephalopathy, ARF - last cr 1.0, chronic LLE\n pain, gastritis\n Surgery / Procedure and date: L perc nephrostomy \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:158\n D:91\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 1,763 mL\n 24h total out:\n 1,785 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 02:52 AM\n Potassium:\n 4.3 mEq/L\n 02:52 AM\n Chloride:\n 106 mEq/L\n 02:52 AM\n CO2:\n 28 mEq/L\n 02:52 AM\n BUN:\n 15 mg/dL\n 02:52 AM\n Creatinine:\n 1.6 mg/dL\n 02:52 AM\n Glucose:\n 103 mg/dL\n 02:52 AM\n Hematocrit:\n 40.1 %\n 02:52 AM\n Finger Stick Glucose:\n 129\n 04:00 PM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with: sister.\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-6\n Transferred to: CC619\n Date & time of Transfer: 1900\n" }, { "category": "Radiology", "chartdate": "2125-09-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1032174, "text": " 12:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? head bleed\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with prior CVA, altered mental status.\n REASON FOR THIS EXAMINATION:\n ? head bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with prior CVA and altered mental status. Please\n evaluate for hemorrhage.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: There is no evidence of infarction, hemorrhage,\n edema, mass effect, or shift of normally midline structures. The ventricles\n and sulci are normal in size and configuration for the patient's age. The\n left maxillary sinus demonstrates extensive opacification consistent with\n chronic sinus disease. The visualized soft tissues are unremarkable.\n\n IMPRESSION: Left maxillary sinus opacification. Otherwise normal study.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-07 00:00:00.000", "description": "INTRO CATH RENAL PELVIS FOR DRAINAGE", "row_id": 1032324, "text": " 3:15 PM\n PERC NEPHROSTO Clip # \n Reason: perc nephrostomy for drainage and culture\n Admitting Diagnosis: UROSEPSIS\n Contrast: VISAPAQUE Amt: 30\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe sepsis, mod left hydronephrosis and large renal\n stone in pelvis. UA OSH from yesterday psudomonas\n REASON FOR THIS EXAMINATION:\n perc nephrostomy for drainage and culture\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb FRI 6:46 PM\n Left-sided percutaneous nephrostomy for drainage and culture. No immediate\n complications.\n ______________________________________________________________________________\n FINAL REPORT\n Patient is a 61-year-old man with severe sepsis, moderate left hydronephrosis,\n and large renal stone in the pelvis. Request was made for percutaneous\n nephrostomy for drainage and culture.\n\n OPERATORS: Dr. , Dr. , and Dr. , the attending radiologist\n who present and supervised during the whole procedure.\n\n PROCEDURE: Left percutaneous nephrostomy for drainage and culture.\n\n ANESTHESIA: Lidocaine was applied locally.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure as well\n as anesthesia were explained, informed consent was obtained. The patient was\n brought to the angiography suite and placed prone on the imaging table. The\n left flank side was prepared and draped in the usual sterile fashion.\n Lidocaine was applied locally for anesthesia. Accustick introducer system was\n applied to get access to the left kidney and pelvis. A 0.016 Headliner wire\n was passed through the puncture needle and advanced into the left ureter.\n Then, a 5 French Cobra catheter was placed, and the Headliner wire was\n exchanged for a 0.35 Glidewire which was passed all the way down to the\n ureter. The catheter was removed and an 8 French 25-cm Flexima nephrostomy\n catheter was placed in the left pelvic system. The final position of the tip\n of the catheter is in the left pelvis, and the patency of the catheter was\n verified with contrast medium. The catheter was sutured to the skin and a\n sterile dressing was applied. The draining catheter was connected to a\n draining bag. There were no immediate complications.\n\n IMPRESSION: Placement of 8 French 25-cm Flexima nephrostomy catheter in the\n left pelvis.\n (Over)\n\n 3:15 PM\n PERC NEPHROSTO Clip # \n Reason: perc nephrostomy for drainage and culture\n Admitting Diagnosis: UROSEPSIS\n Contrast: VISAPAQUE Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2125-09-07 00:00:00.000", "description": "INTRO CATH RENAL PELVIS FOR DRAINAGE", "row_id": 1032325, "text": ", D. MED MICU 3:15 PM\n PERC NEPHROSTO Clip # \n Reason: perc nephrostomy for drainage and culture\n Admitting Diagnosis: UROSEPSIS\n Contrast: VISAPAQUE Amt: 30\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe sepsis, mod left hydronephrosis and large renal\n stone in pelvis. UA OSH from yesterday psudomonas\n REASON FOR THIS EXAMINATION:\n perc nephrostomy for drainage and culture\n ______________________________________________________________________________\n PFI REPORT\n Left-sided percutaneous nephrostomy for drainage and culture. No immediate\n complications.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1032158, "text": " 10:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: positioning of right IJ\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MMP tx to ICU for hypotension and AMS. Now, hypertensive.\n With right IJ\n REASON FOR THIS EXAMINATION:\n positioning of right IJ\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld 11:25 AM\n PFI: Right IJ catheter tip is in the mid to lower SVC. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n REASSON FOR EXAM: Line placement\n\n Right IJ catheter tip is in the mid to lower SVC. The aorta is elongated.\n Mild elevation of the left hemidiaphragm is persistent. There is no\n pneumothorax or enlarging pleural effusion, minimal atelectases are in the\n bases. Cardiac size is normal. Persistently, the cardiomediastinum is\n slightly shifted towards the right side.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2125-09-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1032159, "text": ", D. MED MICU 10:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: positioning of right IJ\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MMP tx to ICU for hypotension and AMS. Now, hypertensive.\n With right IJ\n REASON FOR THIS EXAMINATION:\n positioning of right IJ\n ______________________________________________________________________________\n PFI REPORT\n PFI: Right IJ catheter tip is in the mid to lower SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2125-09-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1032390, "text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid balance\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with extensive PMH septic shock thought to have urosepsis\n largely resolved after aggressive treatment with fluids now with hypertension.\n REASON FOR THIS EXAMINATION:\n fluid balance\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Septic shock, urosepsis.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a right IJ line with tip at the SVC/RA junction. There is\n ill definition of both hemidiaphragms consistent with volume\n loss/consolidation in these regions. There is probably bilateral layering\n effusions. There is pulmonary vascular re-distribution.\n\n IMPRESSION: Likely fluid overload, cannot totally exclude small bilateral\n lower lobe effusion, infiltrates.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-07 00:00:00.000", "description": "RENAL U.S.", "row_id": 1032251, "text": " 9:31 AM\n RENAL U.S. Clip # \n Reason: obstructive uropathy, hydronephrosis\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with multiple medical problems incl neurogenic bladder req\n suprapubic catheter who presents with UTI and elev Cr.\n REASON FOR THIS EXAMINATION:\n obstructive uropathy, hydronephrosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 11:12 AM\n Moderate left hydronephrosis. Large UPJ stones in the left kidney. One small\n right renal stone.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with UTI and elevated creatinine.\n\n COMPARISON: No previous exams for comparison.\n\n FINDINGS: The left kidney measures 13.0 cm. There is a moderate\n hydronephrosis seen in this kidney. A large obstructing stone is seen in the\n pelvis of the left kidney measuring about 2.5 cm. A smaller stone is seen in\n the lower pole of the left kidney measuring 0.6 cm. No solid masses are\n identified in the left kidney.\n\n The right kidney measures 11.8 cm. A non-obstructing stone is seen in the\n lower pole of the right kidney measuring 2.1 cm. There is no hydronephrosis\n on the right kidney, and no solid masses are identified. Some cortical\n thinning is noted in the right kidney. The bladder is not identified on this\n exam, as the patient has a urinary catheter.\n\n IMPRESSION: Moderate hydronephrosis of the left kidney. Large stone seen in\n the left UPJ. Smaller bilateral renal stones.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-07 00:00:00.000", "description": "RENAL U.S.", "row_id": 1032252, "text": ", D. MED MICU 9:31 AM\n RENAL U.S. Clip # \n Reason: obstructive uropathy, hydronephrosis\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with multiple medical problems incl neurogenic bladder req\n suprapubic catheter who presents with UTI and elev Cr.\n REASON FOR THIS EXAMINATION:\n obstructive uropathy, hydronephrosis\n ______________________________________________________________________________\n PFI REPORT\n Moderate left hydronephrosis. Large UPJ stones in the left kidney. One small\n right renal stone.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1032552, "text": " 9:38 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 39cm\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n r picc 39cm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Right-sided PICC line.\n\n FINDINGS: There is new right-sided PICC line with tip at the SVC/RA junction.\n The right IJ line has been removed. There is no pneumothorax. It is a\n rotated film. There is ill definition of both hemidiaphragms suggesting some\n volume loss and small effusion with some mild perihilar haze suggesting an\n element of fluid overload. A left-sided drain is visualized.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-09-09 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1032594, "text": " 5:05 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Evaluate for obstruction, constipation\n Admitting Diagnosis: UROSEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ostomy, left nephrostomy with UTI with ab pain, nausea\n REASON FOR THIS EXAMINATION:\n Evaluate for obstruction, constipation\n ______________________________________________________________________________\n WET READ: DSsd SUN 9:41 PM\n no definite evidence of obstruction, but multiple nonspecific loops of gas-\n filled nondilated small bowel.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old male with ostomy, left nephrostomy, urinary tract\n infection, now with abdominal pain and nausea. Concern for obstruction or\n constipation.\n\n COMPARISON: Renal ultrasound .\n\n FINDINGS: Supine and left lateral decubitus radiographs of the abdomen were\n obtained. A percutaneous nephrostomy tube is present on the left with\n termination projecting in the expected region of the left renal pelvis. The\n known large right lower pole renal stone is again noted. Due to the presence\n of bowel gas the known left renal stones are not well seen. Gas is present\n throughout non-dilated colon. There is also a small amount of gas in\n non-dilated small bowel. There are no air-fluid levels or dilated loops.\n Stomach is non-distended. There is no evidence of pneumatosis or\n pneumoperitoneum. A few small tubular metallic densities measuring 1 cm in\n length each in addition to a smaller metallic density are noted in the central\n pelvis possibly within the bladder or rectum of uncertain significance. A\n mobile lobulated area of intermediate density is noted of the right abdomen.\n This probably external to the patient, may be related to the ostomy.\n\n IMPRESSION:\n 1. No evidence of obstruction or significant amount of retained colonic\n stool.\n 2. Known large right renal stone re-demonstrated. Other known left renal\n stones not well seen due to overlying bowel gas.\n 3. A few small metallic densities projecting over the central pelvis could be\n present in bladder or rectum however may be external to the patient and\n clinical correlation recommended.\n\n\n" }, { "category": "ECG", "chartdate": "2125-09-07 00:00:00.000", "description": "Report", "row_id": 222384, "text": "Sinus rhythm. ST-T wave changes are suggestive of early repolarization.\nCompared to the previous tracing there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2125-09-06 00:00:00.000", "description": "Report", "row_id": 222385, "text": "Sinus rhythm. The P-R interval is prolonged. ST-T wave changes suggestive\nof early repolarization. Compared to the previous tracing the rate is slower.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2167-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947031, "text": " 2:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: .\n\n PORTABLE CHEST: There has been marked interval increase in poorly defined\n opacities within the right lower lobe as well as in the visualized portions of\n the left lung. Again seen is evidence of left apical opacity, consistent with\n patient's known lung cancer. Persistent elevation of the left hemidiaphragm\n is noted. Median sternotomy wires again noted. Cardiac contours are not well\n evaluated secondary to new opacities.\n\n IMPRESSION: Interval development of poorly defined opacities in the lungs\n bilaterally, most consistent with pneumonia. Acute chemotherapy reaction\n could have a similar appearance.\n\n" }, { "category": "Radiology", "chartdate": "2167-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 947202, "text": " 9:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old woman with nonSm cell lung ca now with worsening shortness of\n breath\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Nonsmall cell lung cancer. Increasing shortness of breath.\n\n CHEST\n\n Diffuse bibasilar infiltrates are again noted, not significantly changed since\n the prior chest x-ray consistent with pneumonia.\n\n IMPRESSION: Bilateral basilar infiltrates, suggesting pneumonia.\n\n\n" }, { "category": "Echo", "chartdate": "2167-12-28 00:00:00.000", "description": "Report", "row_id": 64970, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Shortness of breath. AVR\nHeight: (in) 63\nWeight (lb): 124\nBSA (m2): 1.58 m2\nBP (mm Hg): 140/52\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 15:16\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Hyperdynamic LVEF >75%.\nNo resting LVOT gradient. LVOT gradient increases with Valsalva.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Severe PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. There is symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF>75%). The gradient increased with the\nValsalva manuever. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild to moderate (+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is severe pulmonary\nartery systolic hypertension. There is a small pericardial effusion. There are\nno echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , estimated\npulmonary artery systolic pressure is now higher.\n\n\n" }, { "category": "ECG", "chartdate": "2167-12-27 00:00:00.000", "description": "Report", "row_id": 130586, "text": "Sinus rhythm\nAnterolateral ST changes are nonspecific\nSince previous tracing, no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2167-12-29 00:00:00.000", "description": "Report", "row_id": 1494291, "text": "MICU Nursing Note 1900-0700\nEvents: Stable overnight, less anxious, awaiting transfer to heme/onc floor\n\nNeuro: Pleasant and cooperative, Follows all commands and moves all extremities, ambulating around room with supervision, PEARL, denies pain, less anxious--no ativan overnight, received ambien and slept most of night, verbalizing distress about having had such a bad day.\n\nCardiac: HR= 70-80's SR with no ectopy noted, no tachycardic and no hypertensive episodes overnight, started on po lopressor with good effect\n\nResp: Lungs clear upper lobes with rales at bilat bases, some scattered rhonchi with increased activity--clears with coughing, prod cough of small amt of blood-tinged sputum x 1, RR= 14-25, increased SOB with activity, received 1 atrovent neb overnight when C/O dyspnea after ambulating to commode---symptoms subsided with neb, 02 remains at 3 L NC with Sats= 93-98%.\n\nGI: Abd softly distended with + bowel sounds all quads, taking sips of water during night. No BM\n\nGU: Foley to CD draining pink urine with clots visible---Foley D/C'd at 9pm without incident. Pt voided 350ml amber urine x 1\n\nSkin: Grossly intact. Minimal assist with ADL's.\n\nID: Afebrile, WBC= 8.3, continues on IV Unasyn\n\nSocial: pt's husband visited until 8pm---no further contact overnight\n\nPlan: Awaiting bed to be available on Heme/onc service, Increase activity as tolerated and provide freq. rest periods, ? if pt needs scheduled doses of ativan during the day to alleviate anxiety, continue nebs prn---? if should albuterol d/t tachycardia yesterday following treatment, Med for pain prn, Support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2167-12-29 00:00:00.000", "description": "Report", "row_id": 1494292, "text": "npn 0700-1500;\nbetter day today. no episodes of sob today. gauging activity and periods of rest better.\nneuro ; neuro intact less anxious today taking sedation and pain killers when needed.mae equally yo command steady on feet.\n\nresp; lungs upper rt.inp wheeze, diminished at bases strong productive cough. of thick blood tinged sputum small nose bleed this am with bowel movement.sats 97-98% desats to 90 off o2 weaned from 5l-3l n/c maintaining sats rr 16-30 sob with activity but recovers quickly.\n\ncvs; tmax 99.8 po nsr 70-85 tolerated lopressor at 8 am and cozaar 12.5 mgs at 12md. bp 117/65.\n\ngu;voiding good amounts of clear yellow urine with slight odour culture sent.\n\ngi; taking adequate amounts o0f food needs encouragement to increase fluids. no c/o of nausea this am. belly soft pos bs mod formed bm this am guiaic neg.\n\nskin in good condition ambulating around room in better spirits today\n\npain; c/o of lower back pain taking roxicet 10 mgs po..\n\nsoc; family into visit and updated with pts current condition and plan to transfer to floor.\n stable and transferred to floor by ambulance at 1545.\ncontinue to encourage pulonary toilet increase ambulation as tolerarted.\noffer emotional support to pt and family .\npt is dnr/dni.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-12-27 00:00:00.000", "description": "Report", "row_id": 1494286, "text": "Nursing Progress Note 0700-1900\n\nNeuro: A&Ox3. OOB ambulating around room without inncident. Pt with c/o nausea after breakfast given Zofran with good effect. Pt with C/o back pain this afternoon medicated with Roxicet 10 ml with good effect.\n\nResp: Lung sounds coarse with bibasilar crackles at bases. Sats 95-97 on 3 LNC. RR up to 30 with activity Sats remain stable at 94-96 with activity. RR 18-24 while resting. Pt with c/o SOB at 1300, given neb with good effect. Started on Q 6 neb treatments. + Non productive cough that increases after eating, pt patient chronic cough since thyroidectomy.\n\nCardiac: SR 70-80's without ectopy. BP stable ranging from 100-130/40-50's. No edema noted + 2 pt/dp bilaterally. Pt to have Echo in AM\n\nGI: Tolerating regular diet. + BS in 4 quadrents. Abdomen soft, non tender. No BM this shift\n\nRenal: Foley patient draining clear yellow urine. At this writing -200 cc for day\n\nFEN: K 4.5 after repletion. Mg down to 1.7 repleted with 2 GM IV.\n\nID: WBC up to 23.2. T max 100. Urine sample sent for leginella. Started on Unasyn for ? PNA. Awaiting sputum sample\n\nSocial: Husband in to visit most of afternoon\n\nPlan:\n\n1. C/O to heme/onc service\n2. Monitor resp status, nebs as ordered, wean 02 as pt tolerates\n3. Follow temp curve, WBC, culture data, IVANBX as ordered\n4. Medicated PRN for nausea, pain, anxiety etc\n5. Routine Monitoring and care\n6. Emotional support to patient and family\n" }, { "category": "Nursing/other", "chartdate": "2167-12-28 00:00:00.000", "description": "Report", "row_id": 1494287, "text": "MICU Nursing Note 1900-0700\nEvents: Uneventful night, remains hemodynamically stable, awaiting transfer out to heme/onc service.\n\nNeuro: A+Ox3, pleasant and cooperative, follows all commands and moves all extremities, oob to commode with minimal assist, no sig. acute changes, C/O back pain---med with roxicet 10ml with good effect.\n\nCardiac: HR= 70-80's SR with no ectopy noted, BP= 99-129/40-50's, no hypotensive epidsodes overnight. Denies CP.\n\nResp: Lungs with rales at bilateral bases and scattered rhonchi in upper lobes, dry cough noted although able to produce cough of whitish sputum this am and specimen sent for culture and gr. stain, C/O mild SOB x 2 overnight---treated with nebs each time with good effect and resolution of symptoms, RR= 13-23, 02 at 3 L NC with Sats 88-99%, Sats down to 88-92% while asleep and mouth breathing.\n\nGI: Abd soft with + bowel sounds all quads, taking sips overnight---has bouts of coughing with taking fluids---states that this has been happening to her since her thyroidectomy over 40 yrs. ago, no c/o nausea overnight.\n\nGU: Foley to CD initially draining clear yellow urine and no draining amber urine this am, U/O borderline at 30-40ml/hr.\n\nSkin: grossly intact\n\nID: afebrile, remains on IV Unasyn, am WBC pending\n\nSocial: husband left around 8pm after visiting all day--no contact overnight.\n\nPlan: Transfer to heme/onc floor when bed becomes available, Medicate for back pain and for nausea prn, Continue nebs for episodes of SOB, Continue 02 via NC, encourage po fluid intake and monitor I+O, Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2167-12-28 00:00:00.000", "description": "Report", "row_id": 1494288, "text": "Resp Care: Pt seen x2 this shift for atrovent/albuterol for c/o sob: bs few crackles/occ exp wheeze with improvemnet with rx, will cont as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2167-12-28 00:00:00.000", "description": "Report", "row_id": 1494289, "text": "Respiratory Care Note\nCalled to pt's bedside, Pt c/o SOB with increased WOB. Pt started on Albuterol neb by RN. Atrovent added to neb. BS decreased bilaterally with expiratory wheezes before rx; after rx increased aeration throughout and expiratory wheezes persist, but are lessening. Pt states that her breathing feels better.\n" }, { "category": "Nursing/other", "chartdate": "2167-12-28 00:00:00.000", "description": "Report", "row_id": 1494290, "text": "npn 0700-1900;\nawaiting transfer to heme onc service.\nseveral episodes of sob on exertion with accompanying tachycardia and hypertension treated with nebs and restarted on pts oral meds. and some ativan with fair effect.\nmade dnr/dni today.\nneuro; aoox3 very pleasant but very anxious lady.cooperative with care\nimprovedwith ativan.\nresp; lung with insp/exp wheeze worse on rt upper responded to atrovent nebs sats maintained arpound 90-94% n/c increased to 4l /min.\ngiven ativan .5 mgs po and o5 mg i.v\n cvs;given cozaar 12.5 po and started on atenolol 25 mgs po with good effect hr sinus.from 120-85 bp from 187/67 after cardiac echo received .5 mgs ativan x2 with good effect . to 150/60, .\n\n\ngu; passing mod amounts blodd tinged urine via foley. foley to be removed later tonight.mrudolph aware.\n\ngi; taking small amounts po diet with encouragement c/o of nausea at 6pm received zofran with relief of symptoms. belly soft pos bs c/o constipation on commode x2 with no results.\n\nskin in good condition in and oob as tolerated.\n\nsoc; daughter and husband into visit and updated with pts current condition and plan of care discussed with team and made dnr/dni today.\n\na/p continue with pulmonary toilet as tolerated\ncontrol hr and bp atenolol d/c'd and to start lopressor .\n ducolax supoository fo constipation relief.\ncontiue to offer emotional suport to pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2167-12-27 00:00:00.000", "description": "Report", "row_id": 1494283, "text": "Resp Care\nremoved from niv @ 0610. Sating 95 @ room air\n" }, { "category": "Nursing/other", "chartdate": "2167-12-27 00:00:00.000", "description": "Report", "row_id": 1494284, "text": "Resp Care\nReceived from ed. Pt on mask ventilation for resp distess. Saring in the 100s. Abg pending. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2167-12-27 00:00:00.000", "description": "Report", "row_id": 1494285, "text": "MICU Admission Note 0600-0700\nPt is a 74 yo white female admitted into MICU 684 for Diagnosis pna vs. CHF. Pt presented to ED with 10 day history of increasing SOB. Pt recently diagnosed with nonsmall cell CA of left lower lobe and was undergoing first round of Chemo. Pt went to oncologist 48 hours ago and was placed on home 02 for increasing SOB and decreasing Sats. Pt presented to ED with Sats in 80's, labored, using accessory muscles and tachypneic. Pt treated with 30min. neb with fair result but symptoms returned quickly and pt placed on CPAP with improved Sats and more comfortable. pt admitted to MICU for further management. PMH includes: S/P CABG and AVR in , CHF, HTN, pna, Thyroid cancer---s/p radical thyroidectomy in , Recent diagnosis of nonsmall cell ca of left lung. Allergies, include: Cipro, darvocet, thiazides.\nPt arrived on CPAP and cardiac monitor in NAD, pleasant and cooperative, Sats 98% and nonlabored breathing, trial off of CPAP attempted and pt currently on 4L NC 02 with Sats= 93-93% with slight dyspnea with talking.\n\nNeuro: A+OX3, pleasant and , , moving all extremities, no acute deficits noted, oriented to environment, siderails up x 4.\n\nCardiac: HR= 90's SR with occas PVC noted, BP= 90's /40's.\n\nResp: upper lobes clear and diminished at bilat bases with scattered rhonchi in lower lobes, nonprod. dry cough noted, slight dyspnea with talking, currently on 4 L NC with Sats 93%, RR= 20-24.\n\nGI: Abd soft with + bowel sounds.\n\nGU: Foley to CD draining light yellow urine in large amts---diuresing from lasix received in ED\n\nSkin: grossly intact. Do not use left arm for IV's or blood draws---being saved for oncology access device.\n\nSocial: husband was with pt in and went home just prior to pt being transported to MICU---no contact yet.\n\nPlan: Monitor resp status closely, Possibility pt may need CPAP again or potential for intubation, Replace K as ordered, Await admission ordered at this time, Support pt and family.\n" } ]

[ { "category": "Echo", "chartdate": "2135-05-06 00:00:00.000", "description": "Report", "row_id": 64572, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 120\nBSA (m2): 1.56 m2\nBP (mm Hg): 129/38\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 10:02\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF. Mid-cavitary gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Complex (>4mm and/or mobile) atheroma in\naortic root. Focal calcifications in aortic root. Normal ascending aorta\ndiameter. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Left\nventricular systolic function is hyperdynamic (EF>75%). A mild mid-cavitary\ngradient is identified. No masses or thrombi are seen in the left ventricle.\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. There are complex (>4mm and/or mobile) atheroma in the\naortic root. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. The supporting structures of the tricuspid valve are\nthickened/fibrotic. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the tricuspid regurgitation is significantly reduced; otherwise no major\nchange.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866941, "text": " 7:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for ETT position.\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman post-op re-intubation.\n REASON FOR THIS EXAMINATION:\n Please assess for ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop reintubation. Evaluate endotracheal tube position.\n\n TECHNIQUE: Single portable AP view of the chest was obtained, compared with\n examination performed yesterday.\n\n FINDINGS: Endotracheal tube is positioned 3 cm above the carina. Cardiac and\n mediastinal silhouettes remain stable. Linear opacity at the left lung base\n and at the right mid peripheral lung probably represent changes of discoid\n atelectasis. Pleural thickening is seen on both sides. There appeared to be\n right-sided lateral third and fourth rib fractures of uncertain chronicity.\n\n IMPRESSION: ETT 3 cm above the carina. Bilateral atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-05-04 00:00:00.000", "description": "VEN DUP EXTEXT BIL (MAP/DVT)", "row_id": 867614, "text": " 2:37 PM\n DUP EXTEXT BIL (MAP/DVT); DUP EXTEXT BIL (MAP/DVT) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: vein mapping\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with PVD, need vein mapping\n REASON FOR THIS EXAMINATION:\n vein mapping\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Vein mapping pre-op for bypass.\n\n FINDINGS: The left cephalic and basilic veins are patent. No right basilic\n or cephalic veins were identified. The greater saphenous veins were patent\n bilaterally. Please see digitized data sheets for exact venous dimensions.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-27 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 866770, "text": " 4:11 PM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: r/o osteomyelitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with severe PVD presents with red/warm/swollen R foot, eval\n for signs of osteomyelitis\n REASON FOR THIS EXAMINATION:\n r/o osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old woman with severe pulmonary vascular disease, now\n with red swollen right foot, pain.\n\n COMPARISON: Right foot radiograph, .\n\n RIGHT FOOT, THREE VIEWS: As seen on previous studies, there is \n arthroplasty performed at the proximal interphalangeal joint of the second\n digit and partial resection of the same portion of the fifth digit. A\n cortical lucency at the tarsal-metatarsal joint was previously seen. Also,\n previously identified is cortical irregularity in the distal portion of the\n first metatarsal. No new regions of cortical irregularity to suggest new\n osteomyelitis are seen. Vascular calcifications are again noted. Bony\n mineralization is intact. Of note, there is soft tissue swelling in the\n plantar aspect of the forefoot.\n\n IMPRESSION: No radiographic evidence of osteomyelitis. New soft tissue\n swelling since , radiographed.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-04-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 867141, "text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for hemothorax, line placement, CHF.\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p left subclavian line change, mild wheezing.\n REASON FOR THIS EXAMINATION:\n Please assess for hemothorax, line placement, CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n PORTABLE CHEST: Comparison is made to film from 1 day earlier. The ET tube\n and Swan-Ganz catheter have been removed. There is a new left subclavian\n catheter, with the tip in the SVC. There is no evidence of pneumothorax.\n Midline structures are stable. Evaluation of the lungs is limited by\n submaximal inspiratory effort. There is still nonspecific increased density\n in the left base, without significant change.\n\n IMPRESSION: 1) New left subclavian catheter tip in SVC; no pneumothorax.\n 2) Persistent left retrocardiac density.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-27 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 866782, "text": " 5:56 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with R foot gangrene/cellulitis, plan for angio & probable\n debridement\n REASON FOR THIS EXAMINATION:\n pre-op eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for angiogram.\n\n PA and lateral radiograph. Comparison and .\n\n FINDINGS: Cardiac and mediastinal contours are stable. The aorta is unfolded\n and calcified. Pulmonary vasculature is likely within normal limits. There\n appears to be chronic pleural thickening on the lateral view. Patchy opacity\n is seen posteriorly on the lateral view of uncertain chronicity. There is no\n focal consolidation. Osseous structures are demineralized with degenerative\n changes in the thoracic spine. A right bipolar humeral prosthesis is present.\n\n IMPRESSION:\n Stable appearance of the chest with no radiographic evidence of acute\n cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2135-05-02 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 867350, "text": " 3:21 PM\n ART EXT (REST ONLY) Clip # \n Reason: ISCHEMIC FEET\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with 3rd toe ulcer\n REASON FOR THIS EXAMINATION:\n PVRs to level of forefoot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with nonhealing toe ulcer.\n\n COMPARISON: Lower extremity noninvasive arterial studies from .\n\n TECHNIQUE AND FINDINGS: Continuous Doppler ultrasound examination was\n performed at the level of the bilateral lower extremities, revealing triphasic\n signals at the bilateral femoral and popliteal levels with absent signals at\n the bilateral tibial levels and monophasic signals at the bilateral dorsalis\n pedis levels.\n\n Pulse volume recordings were then obtained, revealing amplitudes of 32 mm on\n the right at the level of the thigh, 8 mm at the calf, 20 mm at the ankle, and\n 3 mm at the metatarsum. On the left, the amplitudes measured 24 mm at the\n thigh, 14 mm at the calf, 6 mm at the ankle, and 1 mm at the metatarsum. The\n waveforms demonstrate evidence of widening at the bilateral calf and right\n ankle levels with severe dampening of the left ankle and bilateral metatarsal\n levels. The ankle-brachial indices could not be measured due to\n noncompressibility of the vessels.\n\n IMPRESSION: Significant bilateral infrapopliteal disease, left worse than\n right. The resting ankle brachial indices could not be measured due to vessel\n noncompressibility.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-28 00:00:00.000", "description": "TRANSLUMIN BAL ANGIOPLASTY, PERIPHERAL", "row_id": 866934, "text": " 6:43 PM\n OR VASCULAR A-GRAM Clip # \n Reason: R LEG ARTHRECTOMY\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ********************************* CPT Codes ********************************\n * TRANSLUMIN BAL ANGIOPLASTY, PE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb Clinical Lookup.\n\n" }, { "category": "Radiology", "chartdate": "2135-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 866966, "text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p left subclavian cordis and Swan placement\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman post-op re-intubation\n REASON FOR THIS EXAMINATION:\n s/p left subclavian cordis and Swan placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left subclavian Cordis and Swan placement.\n\n TECHNIQUE: Single portable AP view of the chest was obtained, compared with a\n chest x-ray performed 9 hours previous.\n\n FINDINGS: There has been interval placement of a left-sided subclavian Cordis\n sheath and Swan-Ganz catheter, but it appears that the tip of the catheter\n curls within the right atrium, and is abutting the edge of the right\n atrium/SVC. Endotracheal tube remains 3 cm from the carina. No evidence of\n pneumothorax. Cardiac and mediastinal silhouettes appear stable.\n Calcifications of the aortic valve were gain appreciated. Changes of\n bilateral atelectasis are again seen. No other significant change.\n\n IMPRESSION: Swan-Ganz catheter appears to curl within the right atrium, and\n the tip projects over the junction of the right atrium and superior vena cava.\n\n Findings were discussed with Dr. at 9:30 a.m., .\n\n" }, { "category": "Radiology", "chartdate": "2135-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 867923, "text": " 10:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for ETT position.\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p right leg bypass.\n REASON FOR THIS EXAMINATION:\n Please assess for ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right leg bypass. Assess ET tube position.\n\n COMPARISON: .\n\n FINDINGS: ET tube is at the level of the thoracic inlet. Left subclavian\n central venous line tip is within the proximal SVC. There are dense aortic\n calcifications. The heart size is within normal limits for this AP supine\n technique. There is opacity within the left lung, which may represent\n atelectasis, but more focal component in the left upper lobe may represent\n aspiration or pneumonia. Mild failure on the prior study has improved.\n Multiple bilateral healed rib fractures are present. There is a right humeral\n head prosthesis. The left clavicle has been partially resected.\n\n IMPRESSION: Opacity on the left may represent atelectasis, but upper lobe\n pneumonia or aspiration not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2135-05-13 00:00:00.000", "description": "R FOOT AP,LAT & OBL RIGHT", "row_id": 868701, "text": " 10:00 PM\n FOOT AP,LAT & OBL RIGHT Clip # \n Reason: assess post op changes s/p 3rd toe amputation\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with severe PVD presents with red/warm/swollen R foot, eval\n for signs of osteomyelitis\n REASON FOR THIS EXAMINATION:\n assess post op changes s/p 3rd toe amputation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Osteomyelitis. Status post third toe amputation.\n\n RIGHT FOOT, TWO VIEWS. Comparison is made to . The third toe has\n been amputated from the base of the proximal phalanx. There is\n demineralization and mottling of the distal first metatarsal head with several\n ossified fragments seen medial to the metatarsal head. There is also\n shortening of the proximal right first phalanx. The appearance appears\n slightly different than on , but findings could be due to positioning.\n Other metatarsals and phalanges also demonstrate minimal mottling which could\n be due to demineralization. Osteomyelitis cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2135-05-17 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 869049, "text": " 7:13 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: no bedside venous access. PICC for atbx.\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with pvd and rt. foot/leg wound,s/p bpg\n REASON FOR THIS EXAMINATION:\n no bedside venous access. PICC for atbx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: No bedside venous access. Requirement for ongoing IV antibiotics.\n\n PHYSICIANS: The procedure was performed by Dr. and Dr. , with\n Dr. present and supervising the procedure.\n\n TECHNIQUE/FINDINGS: A pre-procedure timeout was performed to verify the\n patient's identity. The left upper extremity was prepped and draped in usual\n sterile fashion. Ultrasound evaluation demonstrated a patent appearance of the\n brachial vein. A venous-appearing structure was entered with a 21-gauge\n micropuncture needle. However, after injection with IV contrast, this\n demonstrated arterial location. Therefore, the needle was removed and manual\n compression was applied until hemostasis was achieved.\n\n Subsequent to this, the left brachial vein was entered using son\n guidance with a 21-gauge micropuncture needle, and a 0.018 nitonol guide wire\n was advanced through the needle. However, there were regions of apparent\n holdup while advancing the guidewire. Hand- injection venogram at this time\n demonstrated areas of narrowing within the vein, consistent with venospasm, as\n this decrease in venous caliber waxed and waned with time. This likely also\n contributed to the difficulty in achieving venous access during the brachial\n puncture. The 0.018 nitinol guidewire was exchanged for a 0.018 Glidewire.\n Using fluoroscopic guidance, this was extended to the SVC, distance estimated\n at 47 cm from the skin surface. The PICC was trimmed to this length. The\n needle was exchanged for introducer sheath set, and the inner dilator. The\n PICC was then advanced over the glidewire into the sheath until reaching the\n SVC using fluoroscopic guidance. The catheter was flushed and Hep-Locked, and\n secured to the skin using a StatLock as well as the OpSite. Final fluoroscopic\n image was obtained, demonstrating the tip of the catheter to be at the lower\n SVC. Note was also made of marked vascular calcifications on this spot image.\n\n COMPLICATIONS: As mentioned above; no immediate post-procedure complications\n otherwise. Radiology nursing provided continuous hemodynamic monitoring during\n the procedure.\n\n IMPRESSION:\n 1) Successful left brachial vein PICC placement. This is a single-lumen\n Vaxcel 4-French catheter, with the tip in the lower SVC. This catheter is\n (Over)\n\n 7:13 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: no bedside venous access. PICC for atbx.\n Admitting Diagnosis: RIGHT FOOT ULCER W\\CELLULITIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ready for use.\n 2) Arterial puncture of the left brachial artery, as described above. Manual\n pressure was applied until hemostasis was achieved, and no hematoma was\n present at the completion of the procedure. Nonetheless, monitoring of\n puncture site including evaluation of peripheral pulses is suggested for \n hours after this procedure to monitor for potential formation of hematoma.\n\n" }, { "category": "ECG", "chartdate": "2135-04-28 00:00:00.000", "description": "Report", "row_id": 132012, "text": "Baseline artifact - probable sinus rhythm with atrial bigeminy\nLeft axis deviation\nPoor R wave progression - probable anteroseptal myocardial infarction\nNonspecific ST-T wave abnormalities\nSuggest repeat tracing\nSince previous tracing of , rhythm is difficult to ascertain and less\nsuggestive of left ventricular hypertrophy (aVL < 11mm)\n\n" }, { "category": "ECG", "chartdate": "2135-04-27 00:00:00.000", "description": "Report", "row_id": 132013, "text": "Sinus rhythm\nLong QTc interval\nLeft atrial abnormality\nLeft axis deviation\nPossible old septal infarct\nLeft ventricular hypertrophy\nSince previous tracing of ,junctional rhythm not seen\n\n" }, { "category": "ECG", "chartdate": "2135-05-14 00:00:00.000", "description": "Report", "row_id": 132009, "text": "Baseline artifact\nSinus rhythm\nQ-Tc interval appears prolonged but is difficult to measure\nLeft ventricular hypertrophy with ST-T abnormalities\nPoor R wave progression with late precordial QRS transition - is nonspecific\nST-T wave changes are diffuse\nClinical correlation is suggested\nSince previous tracing of , sinus bradycardia absent but otherwise\nbaseline artifact on prior tracing makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2135-05-07 00:00:00.000", "description": "Report", "row_id": 132010, "text": "Baseline artifact\nSinus bradycardia\nBorderline left axis deviation - is nonspecific\nConsider prior anteroseptal myocardial infarction\nQ-Tc interval appears prolonged but is difficult to measure\nDiffuse nonspecific low amplitude T waves\nClinical correlation is suggested for in part metabolic/drug effect\nSince previous tracing of , probably no significant change but baseline\nartifact makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2135-05-05 00:00:00.000", "description": "Report", "row_id": 132011, "text": "Regular narrow complex rhythm, possibly sinus, but P wave amplitude is low.\nSince the previous tracing of the rhythm is more regular. The\nQRS voltage is greater in leads I and aVL and the Q-T interval is more\nprolonged. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 1674149, "text": "Nursing Progress Note\n\nO: Please see FHP and flow sheet for objective data. 84yo man admitted from cath lab at approx 12n s/p IPSTEMI and placement of 2 BMS in RCA. Pt arrived pain free sinus rhythm stable BP. R groin sheath with oozing noted from suture site of sheath. Fem sheath dc'd by card fellow at 3p. RDP palpable other pulses are present by doppler. Integrilin bolus given and drip started dc'd in lab. Nl RH pressures. PCW 15.\n\nResp: Lungs clear sightly diminshed in bases. O2 sats >95% on room air.\n\nNeuro: Pt is alert and oriented x's. Able to MAE. Maintained on bedrest d/t sheath.\n\nGI/GU: Pt has been NPO since arrival Vomited a lg amt of old coffee ground material during sheath pull. House staff aware. Serial hcts and started on Protonix. Pt has h/o BPH, 1 kidney amd CRI(creat2.5). Sm meatus so unable to pass foley after several attempts. GU called do not wish to place foley at this point. Voiding in sm amts and inc of sm amts of urine. Pt received 300cc's of contrast. IV post NS at 125/hr x's 3liters.\n\nSocial: Pt is a widower and lives alone has several children who were in to visit and spoke to MD's.\n\nA&P: 84yo man S/P IPSTEMI with 2 BMS placed in RCA. Hemodynamically stable. cont to monitor cardiac status. Advance diet as tolerated. Serial hcts monitor lytes and renal fx.\n\n" }, { "category": "Nursing/other", "chartdate": "2147-09-04 00:00:00.000", "description": "Report", "row_id": 1674150, "text": "ccu npn 1900-0700\nS;\"Why is my stomach so upset.\"\nO: Please see carevue for VS and objective data\nCVS; Hemodynamically stable with HR 50-70's NSR/SB. No vea K+4.3. Transient drop in HR to 48 and SBP 89 when nauseous/vomiting, responding to 200cc NS bolus, without Atropine required. CCU team aware. Pt. denies CP, discomfort.EKG without ischemic changes, evolving IPMI. BP ranges 100-116/40-60. Right groin D/I without palp. hematoma, distal pulses palp. CPK trending up 1250//74 with troponin leak to 7.82. Hct stable 42.5-43.3. IVF NS at 125cc/hour for 6L post cath secondary to 320cc contrast given and 1 kidney.\nResp; Pt. requesting to remove 02, with great irritation to his nose. Sats>95% on RA, Lungs clear with diminished base dependently.\nGI;GU; Transient episode of nausea, vomited 150cc dark brown bile, guaic positive. CCU team aware. Hct stable as above, ordered q8hours.\nAbdomen large, active bowel sounds, no stool this shift. Voiding in small amounts yellow foul smelling urine. Urology had seen Pt. previous shift, recommended not putting in foley with pinhole size meatus. u/o 50-100cc at a time. Condom cath placed overnight with adequate u/o.\nID: Tmax 99.4 po, U/A, C/S sent with foul smelling urine.\nNeuro: Pt. A/A/0x3, pleasant and cooperative, appreciative of care. MAE, assisting with turning in bed. Bedrest maintained. Pt. admits to being forgetful. Bed alarms on. Visiting with son during evening.\nSlept well at intervals.\nA; hemodynamically stable s/p IPMI with thrombus, c/b nausea and guaic positive emesis.\nP: Cont to monitor hemodynamics, follow up with am labs, trend Hct, CPKS, assess renal function, cont IVF for 6L. Follow up with urine culture, monitor temp. Cont to monitor groin, increase activity as tolerated. Echo in am. Comfort and emotional support to Pt. and family\n\n" }, { "category": "Echo", "chartdate": "2147-09-04 00:00:00.000", "description": "Report", "row_id": 104939, "text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Right ventricular function. Left ventricular function.\nHeight: (in) 65\nWeight (lb): 205\nBSA (m2): 2.00 m2\nBP (mm Hg): 103/60\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with focal hypokinesis of the basal half of the inferior wall. The\nremaining segments contract normally (LVEF = 50%). Right ventricular chamber\nsize and free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Trace aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , basal inferior\nhypokinesis is now identified. The severity of aortic regurgitation and\npulmonary artery systolic hypertension are similar.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2147-09-04 00:00:00.000", "description": "Report", "row_id": 307511, "text": "Sinus rhythm. Continuing evolution of acute infero-posterolateral myocardial\ninfarction. There is Q-T interval prolongation. Clinical correlation is\nsuggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 307512, "text": "Sinus rhythm. Further evolution of inferoposterolateral myocardial infarction\nas compared with prior tracing of . In addition, the rate has slowed.\nFollowup and clinical correlation are suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 307513, "text": "Sinus rhythm. Baseline artifact. A-V conduction delay. Compared to the\nprior tracing of there has been evolution of acute inferior myocardial\ninfarction. The rate is increased. Followup and clinical correlation are\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-09-03 00:00:00.000", "description": "Report", "row_id": 307514, "text": "Sinus rhythm. A-V conduction delay. ST segment elevation in leads II, III, aVF.\nDownsloping ST segment depressions and T wave inversions in lead aVL.\nST segment depressions in leads V1-V3. Occasional ventricular ectopy. These\nfindings are consistent with acute infero-posterolateral myocardial infarction.\nFollowup and clinical correlation are suggested.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472757, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -on bypap for most of day with slight improvement in resp symptoms\n (wheezing present)\n -steroids, abx, nebs.\n -a-line placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 82 (74 - 88) bpm\n BP: 145/81(103) {87/67(-13) - 147/88(104)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 71 mL\n PO:\n 50 mL\n TF:\n IVF:\n 408 mL\n 71 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 182 K/uL\n 12.6 g/dL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C - stable, NTD\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens as above\n .\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472759, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -on bypap for most of day with slight improvement in resp symptoms\n (wheezing present)\n -steroids, abx, nebs.\n -a-line placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 82 (74 - 88) bpm\n BP: 145/81(103) {87/67(-13) - 147/88(104)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 71 mL\n PO:\n 50 mL\n TF:\n IVF:\n 408 mL\n 71 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), very tight with poor\n air movement especially at the bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 182 K/uL\n 12.6 g/dL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C - stable, NTD\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens as above\n .\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2153-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472860, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Somnolent this morning, however arousable to voice. Tolerating venti\n mask at 6L 31%.\n Action:\n pulm. Care, encouraged use of incentive spirometer, out of bed to chair\n and commode.\n Response:\n stable resp when on venti mask, however desats to 87% when placed on NC\n during meals. No resp complaints offered.\n Plan:\n OOB, Bipap overnight to optimize ventilation given OSA, cont incentive\n spirometry, nebs RTC, cont IV steroids.; wean O2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 472836, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated BiPAP intermittently yest pm.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace, Klonopin 1 , Mirtazipine 30 qhs, Paxil 20 am, Aripiprazole,\n Azithromycin, Solu-Medrol 125 q8, Atrovent, Albuterol, RISS, Heparin sc\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 86 (74 - 93) bpm\n BP: 140/79(99) {87/67(-13) - 153/88(108)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 400 mL\n PO:\n 50 mL\n 50 mL\n TF:\n IVF:\n 408 mL\n 350 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 28%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished:\n markedly decreased air mvmt)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 182 K/uL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Imaging: CXR- RML and LLL infiltrate\n Microbiology: cx pending or neg\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today but still off baseline\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV today; insulin while on steroids\n -azithro to help\n Probable OSA/OHV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: advance po diet today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n ------ Protected Section ------\n [image004.jpg]\n ------ Protected Section Addendum Entered By: , MD\n on: 15:36 ------\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 472837, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated BiPAP intermittently yest pm.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace, Klonopin 1 , Mirtazipine 30 qhs, Paxil 20 am, Aripiprazole,\n Azithromycin, Solu-Medrol 125 q8, Atrovent, Albuterol, RISS, Heparin sc\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 86 (74 - 93) bpm\n BP: 140/79(99) {87/67(-13) - 153/88(108)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 400 mL\n PO:\n 50 mL\n 50 mL\n TF:\n IVF:\n 408 mL\n 350 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 28%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished:\n markedly decreased air mvmt)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 182 K/uL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Imaging: CXR- RML and LLL infiltrate\n Microbiology: cx pending or neg\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today but still off baseline\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV today; insulin while on steroids\n -azithro to help\n Probable OSA/OHV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: advance po diet today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n ------ Protected Section ------\n [image004.jpg]\n ------ Protected Section Addendum Entered By: , MD\n on: 15:36 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473250, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.3 g/dL\n 213 K/uL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n OBSTRUCTIVE SLEEP APNEA (OSA)\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 472839, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated BiPAP intermittently yest pm.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace, Klonopin 1 , Mirtazipine 30 qhs, Paxil 20 am, Aripiprazole,\n Azithromycin, Solu-Medrol 125 q8, Atrovent, Albuterol, RISS, Heparin sc\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 86 (74 - 93) bpm\n BP: 140/79(99) {87/67(-13) - 153/88(108)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 400 mL\n PO:\n 50 mL\n 50 mL\n TF:\n IVF:\n 408 mL\n 350 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 28%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished:\n markedly decreased air mvmt)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 182 K/uL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Imaging: CXR- RML and LLL infiltrate\n Microbiology: cx pending or neg\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today but still off baseline\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV today; insulin while on steroids\n -azithro to help\n Probable OSA/OHV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: advance po diet today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n ------ Protected Section ------\n [image004.jpg]\n ------ Protected Section Addendum Entered By: , MD\n on: 15:36 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n [image005.jpg]\n I was present with MICU housestaff team for the key portions of\n services provided and agree with the history, physical, assessment and\n plan as outlined by Dr. above. I would add the following:\n 48 yo male with Hep C, hx of polysubstance abuse and COPD admitted\n yesterday with severe COPD exacerbation and severe hypercarbic failure.\n He has been on intermittent NIPPV. Physical exam today reveals slight\n improvement in aeration, though air movement still quite tight. pCO2\n slightly reduced on blood gases. He overall is improved, but remains\n critically ill. Will continue nebs, IV steroids, NIPPV. Drug screen was\n negative (aside from benzodiazepines which is part of his home\n regimen). Degree of emphysema seen on chest CT may reflect prior\n cocaine and heroin use, but it remains unclear why he\ns having\n recurrent COPD exacerbations.\n Total time spent on pt: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 15:50 ------\n" }, { "category": "Nursing", "chartdate": "2153-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472959, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Somnolent at times, however easily arousable to voice. Tolerating\n venti mask at 6L 31%. Pt. switched to Bipap for overnight.\n Action:\n pulm. Care, encouraged use of incentive spirometer, out of bed to\n utilize commode.\n Response:\n stable resp when on venti mask, however desats to 87% when placed on NC\n during meals. No resp complaints offered. PH improved with Bipap, but\n CO2 continues to climb. This am CO2 is 60. MD is aware.\n Plan:\n OOB, Bipap overnight to optimize ventilation given OSA, cont incentive\n spirometry, nebs RTC, cont IV steroids.; wean O2 as tolerated. Pt. is\n need a proper sleep study done at some point in the near future.\n" }, { "category": "Respiratory ", "chartdate": "2153-06-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 472940, "text": "Demographics\n Ideal body weight: 67.1\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea\n Non-invasive ventilation assessment: Tolerated well\n Plan\n Next 24-48 hours: : Intermittent non-invasive ventilation as needed.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473232, "text": "Chief Complaint:\n 24 Hour Events:\n - pCO2 improved during the day\n - BIPAP at night set as:\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: negative\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n Labs / Radiology\n 213 K/uL\n 12.3 g/dL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n OBSTRUCTIVE SLEEP APNEA (OSA)\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare and\n OSA. Treatment of COPD exaccerbation as below. Mental status much\n improved. His high CO2 this morning was likely contributable to his\n OSA more than a worsening COPD exaccerbation. Bipap overnight was used\n but not titrated up aggressively enough.\n - will pursue either more aggressive bipap titration overnight or a\n true sleep study and monitor CO2\n - CO2s in 60s again, likely from OSA last night\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - improved aeration in lungs today\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n has received 2 days of steroids, will try 3 days total for IV steroids\n and then consider transition to PO\n - cont azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n no new CXR, no clinical changes today;\n patient not coughing, WBC stable, no fevers. On azithro for COPD\n flare; if spikes or clinically worsens would broaden to levofloxacin or\n add ceftriaxone.\n .\n # Somnolence\n improving, likely was from hypercarbia, as tox screens\n neg; continues to have morning somnulence that improves as the day\n progresses.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines, anxiety symptoms stable\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals, art line R wrist\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement , ICU overnight for bipap\n titration/?sleep study\n .\n ICU Care\n Nutrition: PO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: pneumoboots, hep sc\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: likely floor\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473233, "text": "Chief Complaint:\n 24 Hour Events:\n - pCO2 improved during the day\n - BIPAP at night set as:\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: negative\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 213 K/uL\n 12.3 g/dL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n OBSTRUCTIVE SLEEP APNEA (OSA)\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare and\n OSA. Treatment of COPD exaccerbation as below. Mental status much\n improved. His high CO2 this morning was likely contributable to his\n OSA more than a worsening COPD exaccerbation. Bipap overnight was used\n but not titrated up aggressively enough.\n - will pursue either more aggressive bipap titration overnight or a\n true sleep study and monitor CO2\n - CO2s in 60s again, likely from OSA last night\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - improved aeration in lungs today\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n has received 2 days of steroids, will try 3 days total for IV steroids\n and then consider transition to PO\n - cont azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n no new CXR, no clinical changes today;\n patient not coughing, WBC stable, no fevers. On azithro for COPD\n flare; if spikes or clinically worsens would broaden to levofloxacin or\n add ceftriaxone.\n .\n # Somnolence\n improving, likely was from hypercarbia, as tox screens\n neg; continues to have morning somnulence that improves as the day\n progresses.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines, anxiety symptoms stable\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals, art line R wrist\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement , ICU overnight for bipap\n titration/?sleep study\n .\n ICU Care\n Nutrition: PO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: pneumoboots, hep sc\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: likely floor\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473338, "text": "Chief Complaint: COPD\n HPI: Did well on BiPap overnight\n 24 Hour Events:\n Titrated on bipap\n 16/8 with 2L O2\n Slept very well overnight- no AM somnolence this morning\n Continues on IV solumedrol x 3 days\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Atrovent\n Albuterol nebs\n Solumedrol 125 Q8\n Abilify\n Paxil\n Remeron\n Clonipin\n Colace\n Insulin sliding scale\n Heparin subcut\n Nicotine patch\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: no dyspnea, no chest pain, no abd pain\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n General\n NAD, no accessory muscle use\n HEENT\n EOMI, PERRL, OP clear\n Chest\n right basilar crackles, poor air movement overall\n better at\n apices, no wheezing\n Heart- RRR\n Abd\n benign\n Ext\n wwp, no edema\n Labs / Radiology\n 12.3 g/dL\n 213 K/uL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today clinically but w/ persistent am hypercarbia,\n suboptimal overnight NIPPV\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP at night settings are 16/8 with 2L O2, now satting well on 2L by\n day, could even get off supplemental O2 and tolerate Sats in low 90\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -transition to PO prednisone today; insulin while on steroids\n -azithro for possible CXR infiltrates/ exacerbation. No clinical signs\n of pna\n -pulm consult to continue following on floor\n will need sleep/pulm\n follow up upon discharge\n Probable OSA/OHV- suboptimal overnight NIPPV\n -BiPAP has been titrated, continue settings on floor\n will need sleep\n study as outpatient\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: heparin subcut\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2153-06-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 472565, "text": "TITLE:\n Chief Complaint: shortness of breath\n HPI:\n 48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day after stopping his long prednisone taper with about half day\n history of shortness of breath, wheezing and L sided chest \"tingling.\"\n Was not a pain in his chest, did not radiated. He denies hx of\n fevers, cough, body aches. No nausea, vomitting, diaphoresis.\n In the ED, initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on\n NRB. He had audible wheezes and was using his accessory muscles to\n breath. While on the NRB, he was noted to become increasingly\n somnulent and ABG was 7.24/83/262. He was switched to bipap 8/5 and\n 30%, and he improved slightly. His next ABG was 7.30/69/67. He was\n kept on bipap and admitted to the MICU. Patient was given solumedrol\n 125 mg IV x1 and Mag. He has 1 20g PIV.\n .\n On the floor, patient is somnulent but arousable to voice, speaks in\n full sentences but will sometimes fall asleep while talking. Says he\n is feeling better. Is complaining of headache that started last night\n around the time his breathing worsened. No vision changes, no\n dizziness, no fainting. He says his breathing is much improved than\n from when he first presented.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough. Denied chest pain or tightness, palpitations. Denied nausea,\n vomiting, diarrhea, constipation or abdominal pain. No recent change in\n bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Asthma/COPD. dx as an adult. Per his report, only has been\n on steroids twice in past, Hospitalized 4 times within the last\n 1.5 years, most recently to .\n Hepatitis C\n IBS\n \"Gastritis and Colitis\"\n h/o polysubstance abuse\n Anxiety and Panick Attacks\n Self Reported Bipolar\n strong FH of asthma/COPD\n Occupation: not working\n Drugs: past of cocaine and heroine, last usage 1+ yrs ago\n Tobacco: past hx, quit 2 weeks ago\n Alcohol: past hx of heavy etoh abuse, now sober, last drink months ago\n Other: recently moved to Bosotn to dual-dx house. brother, mom and\n friend whom helped him get into the program live on \n Review of systems:\n Cardiovascular: No(t) Chest pain, chest \"tingling\"\n Respiratory: Dyspnea, Wheeze\n Neurologic: Headache\n Flowsheet Data as of 01:54 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 84 (83 - 88) bpm\n BP: 127/69(84) {95/59(68) - 127/80(88)} mmHg\n RR: 21 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 454 mL\n PO:\n TF:\n IVF:\n 304 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 454 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (310 - 310) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.31/65/55//3\n Ve: 5.8 L/min\n PaO2 / FiO2: 157\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), very tight with poor\n air movement especially at the bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 191\n 13.4\n 1.1\n 23\n 33\n 104\n 4.4\n 144\n 41.7\n 15.8\n [image002.jpg]\n \n 2:33 A7/22/ 09:45 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 15.5\n Hct\n 41.7\n Plt\n 191\n Cr\n 1.1\n TropT\n <0.09\n TC02\n 34\n Glucose\n 107\n Other labs: PT / PTT / INR:10.8 / 22.1 / 0.9, Lactic Acid:1.8 mmol/L\n Imaging: CXR - hyperinflated lung fields, small opacity in the LLL\n Microbiology: blood cx pending\n ECG: NSR, non specific TW changes\n Assessment and Plan\n Assessment and Plan:\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C - stable, NTD\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens as above\n .\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Comments: NPO until mental status improved\n Glycemic Control: Comments: humalog sliding scale\n Lines:\n 20 Gauge - 08:30 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473013, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated vent mask through the day yesterday,\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Colace, Klonopin, Remeron, Paxil, Abilify, Azithromycin, Solu-Medrol\n 125 IV q8, Atrovent, Albuterol, hep sc tid, RISS, nicotine patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.9\nC (96.6\n HR: 75 (70 - 109) bpm\n BP: 139/76(99) {98/63(78) - 157/91(115)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 98 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 98 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): , Movement: Not\n assessed, Tone: Not assessed, lethargic but easily arousable\n Labs / Radiology\n 12.3 g/dL\n 225 K/uL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today clinically but w/ persistent am hypercarbia,\n suboptimal overnight NIPPV\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed, definitely needed overnight\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV another day of q8 Solu-Medrol, decrease tomorrow; insulin\n while on steroids\n -azithro for possible CXR infiltrates/ exacerbation. No clinical signs\n of pna\n Probable OSA/OHV- suboptimal overnight NIPPV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2153-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472942, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Somnolent this morning, however arousable to voice. Tolerating venti\n mask at 6L 31%.\n Action:\n pulm. Care, encouraged use of incentive spirometer, out of bed to chair\n and commode.\n Response:\n stable resp when on venti mask, however desats to 87% when placed on NC\n during meals. No resp complaints offered.\n Plan:\n OOB, Bipap overnight to optimize ventilation given OSA, cont incentive\n spirometry, nebs RTC, cont IV steroids.; wean O2 as tolerated.\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473127, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated vent mask through the day yesterday,\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Colace, Klonopin, Remeron, Paxil, Abilify, Azithromycin, Solu-Medrol\n 125 IV q8, Atrovent, Albuterol, hep sc tid, RISS, nicotine patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.9\nC (96.6\n HR: 75 (70 - 109) bpm\n BP: 139/76(99) {98/63(78) - 157/91(115)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 98 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 98 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): , Movement: Not\n assessed, Tone: Not assessed, lethargic but easily arousable\n Labs / Radiology\n 12.3 g/dL\n 225 K/uL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today clinically but w/ persistent am hypercarbia,\n suboptimal overnight NIPPV\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed, definitely needed overnight\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV another day of q8 Solu-Medrol, decrease tomorrow; insulin\n while on steroids\n -azithro for possible CXR infiltrates/ exacerbation. No clinical signs\n of pna\n Probable OSA/OHV- suboptimal overnight NIPPV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35 minutes\n ------ Protected Section ------\n I was physically present with the resident team on this date for\n discussion of the above history, exam and assessment and plan with\n which I agree. I independently examined the patient and would add the\n following comments: Admitted with acute hypercarbic failure from COPD\n exacerbation. Placed on BiPAP (PS 12/PEEP 5) last night, but still\n hypercarbic this morning, then improved during the afternoon. . Pt\n breathing is subjectively improved. Of note, he does link worsening of\n respiratory sx\ns to a change in his home environment 2 months ago,\n noting increased levels of mold where he now resides for his treatment\n program.\n Physical exam reveals better aeration, though air movement still only\n fair.\n For his hypercarbic failure and COPD exacerbation, pt to continue on\n steroids, azithromycin, NIPPV. His body habitus would not suggest OHV\n though with his snoring and COPD there could be OSA +alveolar\n hypoventilation. Worsening hypercarbia overnight hard to interpret due\n to apparent poor mask fit. Plan to optimize mask fit tonight (nasal\n mask + biPAP machine if needed.) Will first adjust PS based on blood\n gases but if at PS ~15 and still hypercarbic, I would then increase\n PEEP.\n Pt is critically ill. Total time spent: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:56 ------\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473228, "text": "Chief Complaint:\n 24 Hour Events:\n - pCO2 improved during the day\n - BIPAP at night set as:\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: negative\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n Labs / Radiology\n 213 K/uL\n 12.3 g/dL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n OBSTRUCTIVE SLEEP APNEA (OSA)\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 472568, "text": "TITLE:\n Chief Complaint: shortness of breath\n HPI:\n 48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day after stopping his long prednisone taper with about half day\n history of shortness of breath, wheezing and L sided chest \"tingling.\"\n Was not a pain in his chest, did not radiated. He denies hx of fevers,\n cough, body aches. No nausea, vomitting, diaphoresis.\n In the ED, initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on\n NRB. He had audible wheezes and was using his accessory muscles to\n breath. While on the NRB, he was noted to become increasingly\n somnulent and ABG was 7.24/83/262. He was switched to bipap 8/5 and\n 30%, and he improved slightly. His next ABG was 7.30/69/67. He was\n kept on bipap and admitted to the MICU. Patient was given solumedrol\n 125 mg IV x1 and Mag. He has 1 20g PIV.\n .\n On the floor, patient is somnulent but arousable to voice, speaks in\n full sentences but will sometimes fall asleep while talking. Says he\n is feeling better. Is complaining of headache that started last night\n around the time his breathing worsened. No vision changes, no\n dizziness, no fainting. He says his breathing is much improved than\n from when he first presented.\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough. Denied chest pain or tightness, palpitations. Denied nausea,\n vomiting, diarrhea, constipation or abdominal pain. No recent change in\n bowel or bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Asthma/COPD. dx as an adult. Per his report, only has been\n on steroids twice in past, Hospitalized 4 times within the last\n 1.5 years, most recently to .\n Hepatitis C\n IBS\n \"Gastritis and Colitis\"\n h/o polysubstance abuse\n Anxiety and Panick Attacks\n Self Reported Bipolar\n strong FH of asthma/COPD\n Occupation: not working\n Drugs: past of cocaine and heroine, last usage 1+ yrs ago\n Tobacco: past hx, quit 2 weeks ago\n Alcohol: past hx of heavy etoh abuse, now sober, last drink months ago\n Other: recently moved to Bosotn to dual-dx house. brother, mom and\n friend whom helped him get into the program live on \n Review of systems:\n Cardiovascular: No(t) Chest pain, chest \"tingling\"\n Respiratory: Dyspnea, Wheeze\n Neurologic: Headache\n Flowsheet Data as of 01:54 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 84 (83 - 88) bpm\n BP: 127/69(84) {95/59(68) - 127/80(88)} mmHg\n RR: 21 (17 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 454 mL\n PO:\n TF:\n IVF:\n 304 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 454 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (310 - 310) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.31/65/55//3\n Ve: 5.8 L/min\n PaO2 / FiO2: 157\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), very tight with poor\n air movement especially at the bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 191\n 13.4\n 1.1\n 23\n 33\n 104\n 4.4\n 144\n 41.7\n 15.8\n [image002.jpg]\n \n 2:33 A7/22/ 09:45 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 15.5\n Hct\n 41.7\n Plt\n 191\n Cr\n 1.1\n TropT\n <0.09\n TC02\n 34\n Glucose\n 107\n Other labs: PT / PTT / INR:10.8 / 22.1 / 0.9, Lactic Acid:1.8 mmol/L\n Imaging: CXR - hyperinflated lung fields, small opacity in the LLL\n Microbiology: blood cx pending\n ECG: NSR, non specific TW changes\n Assessment and Plan\n Assessment and Plan:\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C - stable, NTD\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens as above\n .\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Comments: NPO until mental status improved\n Glycemic Control: Comments: humalog sliding scale\n Lines:\n 20 Gauge - 08:30 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , MD\n on: 13:57 ------\n" }, { "category": "Physician ", "chartdate": "2153-06-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 472569, "text": "Chief Complaint: shortness of breath\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 48 yo male with COPD, Hep C, substance abuse\n Admitted in late for COPD exacerbation and discharged on a\n prolonged steroid taper completed yesterday.\n Had noticed mild SOB over the past wk with worsening wheezing after\n stopping his steroids.\n no F/C/cough, no overt CP, though reports internal\nitching\n involving\n his thorax\n R30 on arrival, 100% NRB in the ED.\n Became somnolent: 7.24/83/262 on BG\n Started on BiPAP 8/5 30% 7.3/69/67\n Given IV solumedrol and transferred to unit\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n abilify, mirtazapine, clonazpeam, combivent, advair, albuterol\n Past medical history:\n Family history:\n Social History:\n COPD, dx\nd several yrs ago, 3 hospitalizations\n Hep C\n Polysubstance abuse with cocaine and heroin\n Anxiety\n Occupation:\n Drugs: denies recent drug use\n Tobacco: quit 2 wks ago\n Alcohol:\n Other: lives in dual dx sober house\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Flowsheet Data as of 12:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 87 (83 - 88) bpm\n BP: 95/59(68) {95/59(68) - 123/76(84)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 434 mL\n PO:\n TF:\n IVF:\n 284 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 434 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93% on liters\n ABG: 7.31/65/55//3\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: No(t) Wheezes : , Diminished: poor air movement), +accessory\n muscles of respiration\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mild\n distention but soft\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,\n Tone: Normal, Somnolent, arousable to voice\n Labs / Radiology\n 1.1\n 23\n 33\n 104\n 4.4\n 144\n [image002.jpg]\n 09:45 AM\n WBC\n 15.8\n Hct\n 42\n Plt\n 191\n TC02\n 34\n Other labs: Lactic Acid:1.8 mmol/L\n Fluid analysis / Other labs: 7.41/48/120: best ABG from \n hospitalization\n ABG: 7.31/65/55 upon arrival to MICU after neb, on 2 liters n.c.\n Imaging: CXR (viewed): clear CPA, no clear infiltrate\n Assessment and Plan\n 48 yo male with COPD and polysubstance abuse admitted with worsening\n SOB and hypercarbic failure from acute COPD exacerbation. Chest CT from\n his last hospitalization reviewed- more emphysema than would typically\n be expected at this age, even with tobacco abuse. This may be partly\n related to prior cocaine and heroin abuse\n Hypercarbic respiratory failure from acute COPD exacerbation:\n *Mild improvement in blood gases with nebs and NIPPV, but pt moving\n minimal air on physical exam and the lack of expiratory wheezes raises\n concern for worsening respiratory status\n *Solumedrol 125 mg IV Q8hour\n *Alb nebs as needed; atrovent nebs QID\n *Restart NIPPV due to pt's somnolence and tight air movement on PE\n *A-line for frequent ABG\n *Azithromycin for anti inflammatory and infectious coverage\n *check urine and serum tox screen\n *Will review notes from last hospitalization and see if additional w/u\n needed to determine why he developed recurrent hypercarbic failure so\n quickly.\n Tobacco abuse:\n *Nicotine patch\n Anxiety: hold home regimen due to pt's tenuous respiratory status\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:30 AM\n Comments: 2 peripheral's\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473025, "text": "TITLE:\n Chief Complaint: - venti mask during day, doing well\n - bipap overnight, increased PSV over course of night due to increase\n in CO2, having obvious apneic periods, still higher CO2 in AM\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 70 (70 - 109) bpm\n BP: 129/70(91) {98/63(78) - 157/91(115)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 72 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 72 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 225 K/uL\n 12.3 g/dL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare and\n OSA. Treatment of COPD exaccerbation as below. Mental status much\n improved. His high CO2 this morning was likely contributable to his\n OSA more than a worsening COPD exaccerbation. Bipap overnight was used\n but not titrated up aggressively enough.\n - will pursue either more aggressive bipap titration overnight or a\n true sleep study and monitor CO2\n - CO2s in 60s again, likely from OSA last night\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - improved aeration in lungs today\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n has received 2 days of steroids, will try 3 days total for IV steroids\n and then consider transition to PO\n - cont azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n no new CXR, no clinical changes today;\n patient not coughing, WBC stable, no fevers. On azithro for COPD\n flare; if spikes or clinically worsens would broaden to levofloxacin or\n add ceftriaxone.\n .\n # Somnolence\n improving, likely was from hypercarbia, as tox screens\n neg; continues to have morning somnulence that improves as the day\n progresses.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines, anxiety symptoms stable\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals, art line R wrist\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement , ICU overnight for bipap\n titration/?sleep study\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473027, "text": "TITLE:\n Chief Complaint: - venti mask during day, doing well\n - bipap overnight, increased PSV over course of night due to increase\n in CO2, having obvious apneic periods, still higher CO2 in AM\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 70 (70 - 109) bpm\n BP: 129/70(91) {98/63(78) - 157/91(115)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 72 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 72 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 225 K/uL\n 12.3 g/dL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare and\n OSA. Treatment of COPD exaccerbation as below. Mental status much\n improved. His high CO2 this morning was likely contributable to his\n OSA more than a worsening COPD exaccerbation. Bipap overnight was used\n but not titrated up aggressively enough.\n - will pursue either more aggressive bipap titration overnight or a\n true sleep study and monitor CO2\n - CO2s in 60s again, likely from OSA last night\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - improved aeration in lungs today\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n has received 2 days of steroids, will try 3 days total for IV steroids\n and then consider transition to PO\n - cont azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n no new CXR, no clinical changes today;\n patient not coughing, WBC stable, no fevers. On azithro for COPD\n flare; if spikes or clinically worsens would broaden to levofloxacin or\n add ceftriaxone.\n .\n # Somnolence\n improving, likely was from hypercarbia, as tox screens\n neg; continues to have morning somnulence that improves as the day\n progresses.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines, anxiety symptoms stable\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals, art line R wrist\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement , ICU overnight for bipap\n titration/?sleep study\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2153-06-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 473112, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n On presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on venti mask on 6L with 31% O2. LS diminished throughout\n with little movement of air audible. O2 sats 97-100% with RR teens.\n Action:\n Pt switched to 4L NC. Given albuterol/atrovent nebs Q6. Given dose of\n IV azithro this am, now azithro changed to PO. Also receiving 125mg IV\n solumedrol Q8.\n Response:\n Sats remaining >93% throughout day. Pt with no acute resp distress.\n Plan:\n Pt needs sleep study. Will remain in ICU overnoc for monitoring of\n blood gases. Pt to go on autoset CPAP overnoc for OSA.\n" }, { "category": "Nursing", "chartdate": "2153-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 473207, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n On presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Obstructive sleep apnea (OSA)/COPD\n Assessment:\n Pt with OSA, admitted with COPD exacerbation, ABG\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-06-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 473208, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n On presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Obstructive sleep apnea (OSA)/COPD\n Assessment:\n Pt with OSA, admitted with COPD exacerbation, received on 4l NC,\n satting >95, RR regular, denying dyspnea SOB; LS dim to clear\n Action:\n q6h nebs, bipap overnight, serial ABG\ns, weaned NC to 2L while awake\n Response:\n Toelrating wean in O2; hyercarbic on bipap overnight, titrated\n inspiratory pressure up to 16, now PCO2 50\n Plan:\n Continue to follow gases, pt needs sleep study, bipap overnight, goal\n PCO2 40\n" }, { "category": "Physician ", "chartdate": "2153-06-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 472549, "text": "Chief Complaint: shortness of breath\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 48 yo male with COPD, Hep C, substance abuse\n Admitted in late for COPD exacerbation and discharged on a\n prolonged steroid taper completed yesterday.\n Had noticed mild SOB over the past wk with worsening wheezing after\n stopping his steroids.\n no F/C/cough, no overt CP, though reports internal itching\n R30 on arrival, 100% NRB in the ED.\n Became somnolent: 7.24/83/262 on BG\n Started on BiPAP 8/5 30% 7.3/69/67\n Given IV solumedrol and transferred here\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n abilify, mirtazapine, clonazpeam, combivent, advair, albuterol\n Past medical history:\n Family history:\n Social History:\n COPD- 3 hospitalization\n Hep C\n Polysubstance abuse with cocaine and heroin\n Anxiety\n Occupation:\n Drugs: denies recent drug use\n Tobacco: quit 2 wks ago\n Alcohol:\n Other: lives in dual dx sober house\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Flowsheet Data as of 12:07 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 87 (83 - 88) bpm\n BP: 95/59(68) {95/59(68) - 123/76(84)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 434 mL\n PO:\n TF:\n IVF:\n 284 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 434 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93% on liters\n ABG: 7.31/65/55//3\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:\n No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: No(t) Wheezes : , Diminished: poor air movement), +accessory\n muscles of respiration\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, mild\n distention but soft\n Extremities: No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,\n Tone: Normal, Somnolent, arousable to voice\n Labs / Radiology\n 1.1\n 23\n 33\n 104\n 4.4\n 144\n [image002.jpg]\n 09:45 AM\n WBC\n 15.8\n Hct\n 42\n Plt\n 191\n TC02\n 34\n Other labs: Lactic Acid:1.8 mmol/L\n Fluid analysis / Other labs: 7.41/48/120: best ABG from \n hospitalization\n ABG: 7.31/65/55 upon arrival to MICU after neb, on 2 liters n.c.\n Imaging: CXR (viewed): clear CPA, no clear infiltrate\n Assessment and Plan\n 48 yo male with COPD and polysubstance abuse admitted with worsening\n SOB and hypercarbic failure from acute COPD exacerbation\n Hypercarbic respiratory failure:\n *Mild improvement in blood gases with nebs and NIPPV, but pt moving\n minimal air on physical exam\n *Solumedrol 125 mg IV Q8hour\n *Alb nebs as needed; atrovent nebs QID\n *Restart NIPPV due to pt's somnolence and tight air movement on PE\n *Azithromycin for anti inflammatory and infectious coverage\n *check urine and serum tox screen given prior hx of cocaine and heroin\n abuse\n Tobacco abuse:\n *Nicotine patch\n Anxiety: hold home regimen due to pt's tenuous respiratory status\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:30 AM\n Comments: 2 peripheral's\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2153-06-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 473313, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day post completing prednisone taper. Recent adm for LLL PNA\n . On presented by EMS with c/o of increased SOB, wheezing and\n L sided chest \"tingling.\" He denies hx of fevers, cough, body aches.\n In the ED, initial VS were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on\n NRB. He had audible wheezes and was using his accessory muscles to\n breath. While on the NRB, he was noted to become increasingly\n somnulent and ABG was 7.24/83/262. He was switched to bipap 8/5/30%,\n and he improved slightly. His next ABG was 7.30/69/67. Placed on NC\n 2L sats maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm\n to MICU for respiratory support/monitoring. Pt improved with steroids,\n IV abx. Put on BiPAP overnoc for OSA. Pt will need official sleep\n study.\n CODE: FULL\n ACCESS: #22G left hand, #20G right hand\n SOCIAL: Brother is HCP: , mother :\n , friend/ .\n Obstructive sleep apnea (OSA)/COPD\n Assessment:\n Pt with OSA, admitted with COPD exacerbation, received sleeping on\n BiPAP mask with sats 100%, RR teens, no acute resp distress.\n Action:\n Pt on Q6h nebs, PO azithromycin, PO prednisone. Weaned to 2L NC while\n awake.\n Response:\n Pt hypercarbic overnoc OSA, but morning ABG with PCO2 50 and much\n improved.\n Plan:\n Cont prednisone, nebs, abx, BiPAP overnoc. Pt will need official sleep\n study.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ASTHMA;COPD EXACERBATION\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 76 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Asthma, COPD, ETOH, Hepatitis, Smoker\n CV-PMH: Hypertension\n Additional history: Recent LLL PNA \n Hepatitis C\n Gastritis,Colitis, Anxiety\n poly Substance abuse( Cocaine/Heroin)\n ETOH\n Surgery / Procedure and date: NA\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:69\n Temperature:\n 96\n Arterial BP:\n S:160\n D:96\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n CPAP mask\n O2 saturation:\n 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 31% %\n 24h total in:\n 120 mL\n 24h total out:\n 500 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:45 AM\n Potassium:\n 4.5 mEq/L\n 03:45 AM\n Chloride:\n 103 mEq/L\n 03:45 AM\n CO2:\n 28 mEq/L\n 03:45 AM\n BUN:\n 31 mg/dL\n 03:45 AM\n Creatinine:\n 0.9 mg/dL\n 03:45 AM\n Glucose:\n 143 mg/dL\n 03:45 AM\n Hematocrit:\n 39.6 %\n 03:45 AM\n Finger Stick Glucose:\n 141\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 787\n Transferred to: CC718\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472633, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/) Exacerbation Asthma/\n Hypercarbic Respiratory Failure\n Assessment:\n Received Pt from ED @ 0830. lethargic slow to respond to verbal\n stimulation eyes closed. O2 2L/min NC. RR 10-18 audible I/E wheezes,\n sats 90% received Neb alb/atr. Cont somulent behavior arousal to\n verbal stimulation then drifts back to sleep. Oriented x2, Pupils 3mm\n equal react brisk MAE random equal strength. HOB high fowlers. Lungs\n sc wheeze and crackles bases. T-max 97.3 WBC 15.8, received\n Azythromycin . received Solumedrol per routine. ABG on 2L/min\n 7.31-65-55-34, persistent hypercarbia and ^ somulance placed on BIPAP\n PSV 10/5 35% RR 25-35 Sats 95% ABG\n Action:\n Response:\n Plan:\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472636, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/) Exacerbation Asthma/\n Hypercarbic Respiratory Failure\n Assessment:\n Received Pt from ED @ 0830. lethargic slow to respond to verbal\n stimulation eyes closed. O2 2L/min NC. RR 10-18 audible I/E wheezes,\n sats 90% received Neb alb/atr. Cont somulent behavior arousal to\n verbal stimulation then drifts back to sleep. Oriented x2, Pupils 3mm\n equal react brisk MAE random equal strength. HOB high fowlers. Lungs\n sc wheeze and crackles bases. T-max 97.3 WBC 15.8, lactate 1.8,\n received Azythromycin . received Solumedrol per routine. ABG on\n 2L/min 7.31-65-55-34, persistent hypercarbia and ^ somulance placed\n on BIPAP PSV 10/5 35% RR 25-35 Sats 95% ABG 7.312-61-105-33. c/o H/A\n received Tylenol w/effect.\n Action:\n Solumedrol q8hrs, started azythromycin, Nebs q2-4hrs, O2 2l.min NC\n placed on BIPAP PSV R radial aline placed ABG monitoring.\n Response:\n Cont hypercarbia 60\ns baseline 40\ns . Somnolence - likely due to\n hypercarbia, could be secondary to other causes like etoh/drugs.\n Plan:\n Cont BIPAP as tol\n Follow seriel ABG CO2\n Monitor Mental status for sign of hypercarbia\n Cont steroids follow FSBS\n sendiserum and urine tox screens\n Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472639, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/) Exacerbation Asthma/\n Hypercarbic Respiratory Failure\n Assessment:\n Received Pt from ED @ 0830. lethargic slow to respond to verbal\n stimulation eyes closed. O2 2L/min NC. RR 10-18 audible I/E wheezes,\n sats 90% received Neb alb/atr. Cont somulent behavior arousal to\n verbal stimulation then drifts back to sleep. Oriented x2, Pupils 3mm\n equal react brisk MAE random equal strength. HOB high fowlers. Lungs\n sc wheeze and crackles bases. T-max 97.3 WBC 15.8, lactate 1.8,\n received Azythromycin . received Solumedrol per routine. ABG on\n 2L/min 7.31-65-55-34, persistent hypercarbia and ^ somulance placed\n on BIPAP PSV 10/5 35% RR 25-35 Sats 95% ABG 7.312-61-105-33. c/o H/A\n received Tylenol w/effect.\n Action:\n Solumedrol q8hrs, started azythromycin, Nebs q2-4hrs, O2 2l.min NC\n placed on BIPAP PSV R radial aline placed ABG monitoring.\n Response:\n Cont hypercarbia 60\ns baseline 40\ns . Somnolence - likely due to\n hypercarbia, could be secondary to other causes like etoh/drugs.\n Plan:\n Cont BIPAP as tol\n Follow seriel ABG CO2\n Monitor Mental status for sign of hypercarbia\n Cont steroids follow FSBS\n sendiserum and urine tox screens\n Chest pain\n Assessment:\n HR 80-90 NSR no ectopy. BP 110-130/50-70 MAPS>65. no c/oCP , ECG no\n acute changes, neg cardiac enzymes\n Action:\n EKG, seriel CK troponin.\n Response:\n Hemodynamically stable . no episodes of CP. Cardiac enzymes neg x2\n Plan:\n Follow seriel cardiac enzymes.\n EKG am\n" }, { "category": "Respiratory ", "chartdate": "2153-06-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 472716, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Pt was removed from NIV due to Dysynchrony, placed on 31% venti mask,\n blood gases improved and pt is more comfortable.\n Will return to NIV if the need arises.\n" }, { "category": "Respiratory ", "chartdate": "2153-06-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 473180, "text": "Patient placed on BiPAP through the night, tolerated well.\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473288, "text": "Chief Complaint: COPD\n HPI:\n 24 Hour Events:\n Titrated on bipap\n 16/8 with 2L O2\n Slept very well overnight- no AM somnolence this morning\n Continues on IV solumedrol x 3 days\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Atrovent\n Albuterol nebs\n Solumedrol 125 Q8\n Abilify\n Paxil\n Remeron\n Clonipin\n Colace\n Insulin sliding scale\n Heparin subcut\n Nicotine patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n General\n NAD, no accessory muscle use\n HEENT\n EOMI, PERRL, OP clear\n Chest\n right basilar crackles, poor air movement overall\n better at\n apices, no wheezing\n Heart- RRR\n Abd\n benign\n Ext\n wwp, no edema\n Labs / Radiology\n 12.3 g/dL\n 213 K/uL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today clinically but w/ persistent am hypercarbia,\n suboptimal overnight NIPPV\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP at night settings are 16/8 with 2L O2, now satting well on 2L by\n day, could even get off supplemental O2 and tolerate Sats in low 90\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -transition to PO prednisone today; insulin while on steroids\n -azithro for possible CXR infiltrates/ exacerbation. No clinical signs\n of pna\n -pulm consult to continue following on floor\n will need sleep/pulm\n follow up upon discharge\n Probable OSA/OHV- suboptimal overnight NIPPV\n -BiPAP has been titrated, continue settings on floor\n will need sleep\n study as outpatient\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: heparin subcut\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : to floor\n Total time spent: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2153-06-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 473277, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day post completing prednisone taper. Recent adm for LLL PNA\n . On presented by EMS with c/o of increased SOB, wheezing and\n L sided chest \"tingling.\" He denies hx of fevers, cough, body aches.\n In the ED, initial VS were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100\n on NRB. He had audible wheezes and was using his accessory muscles to\n breath. While on the NRB, he was noted to become increasingly\n somnulent and ABG was 7.24/83/262. He was switched to bipap 8/5/30%,\n and he improved slightly. His next ABG was 7.30/69/67. Placed on NC\n 2L sats maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm\n to MICU for respiratory support/monitoring.\n Obstructive sleep apnea (OSA)/COPD\n Assessment:\n Pt with OSA, admitted with COPD exacerbation, received on 4l NC,\n satting >95, RR regular, denying dyspnea SOB; LS dim to clear\n Action:\n q6h nebs, bipap overnight, serial ABG\ns, weaned NC to 2L while awake\n Response:\n Toelrating wean in O2; hyercarbic on bipap overnight, titrated\n inspiratory pressure up to 16, now PCO2 50\n Plan:\n Continue to follow gases, pt needs sleep study, bipap overnight, goal\n PCO2 40\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 473275, "text": "Chief Complaint:\n 24 Hour Events:\n - pCO2 improved during the day\n - BIPAP at night set as: 16/8 on 2L. last gas 7.41/50/100\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: negative\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n General Appearance: Well nourished, A+Ox3 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 213 K/uL\n 12.3 g/dL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n OBSTRUCTIVE SLEEP APNEA (OSA)\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare and\n OSA. Treatment of COPD exaccerbation as below. Mental status much\n improved. His high CO2 this morning was likely contributable to his\n OSA more than a worsening COPD exaccerbation. Bipap overnight was used\n o/n an gas much improved this am.\n - will pursue either more aggressive bipap titration overnight or a\n true sleep study and monitor CO2\n - CO2s in 50 this am with much decreased somnolence\n - conitinue serial ABGs to follow CO2\n - continue tx for COPD with azithro/steroids/nebs\n -transition to PO steroids today.\n -Bipap with settings 16/8 on 2L at night.\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - 3 days of IV steroids, now transition to PO today.\n - cont azithro for COPD flare\n -nebs/bypap as above.\n -will send a1antitrypsin\n .\n #HTN-seen transiently this am. Can consider start of HCTZ on the floor.\n .\n # RML/LLL infiltrate on CXR\n no new CXR, no clinical changes today;\n patient not coughing, WBC stable, no fevers. On azithro for COPD\n flare; if spikes or clinically worsens would broaden to levofloxacin or\n add ceftriaxone.\n .\n # Somnolence\n improving, likely was from hypercarbia, as tox screens\n neg; continues to have morning somnulence that improves as the day\n progresses. Much improve with nightly bipap.\n ..\n # Hep C\n stable\n .\n # Anxiety - continue home medicines, anxiety symptoms stable\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals, art line R wrist\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement , ICU overnight for bipap\n titration/?sleep study\n .\n ICU Care\n Nutrition: PO\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: pneumoboots, hep sc\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: floor\n" }, { "category": "Physician ", "chartdate": "2153-06-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 473271, "text": "Chief Complaint: COPD\n HPI:\n 24 Hour Events:\n Titrated on bipap\n 16/8 with 2L O2\n Slept very well overnight- no AM somnolence this morning\n Continues on IV solumedrol x 3 days\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Lorazepam (Ativan) - 10:15 PM\n Other medications:\n Atrovent\n Albuterol nebs\n Solumedrol 125 Q8\n Abilify\n Paxil\n Remeron\n Clonipin\n Colace\n Insulin sliding scale\n Heparin subcut\n Nicotine patch\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.8\nC (96.4\n HR: 66 (66 - 107) bpm\n BP: 155/94(118) {129/72(94) - 177/111(134)} mmHg\n RR: 15 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 920 mL\n PO:\n 480 mL\n TF:\n IVF:\n 440 mL\n Blood products:\n Total out:\n 2,575 mL\n 0 mL\n Urine:\n 2,575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,655 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 94%\n ABG: 7.41/50/99./28/5\n PaO2 / FiO2: 333\n Physical Examination\n General\n NAD, no accessory muscle use\n HEENT\n EOMI, PERRL, OP clear\n Chest\n right basilar crackles, poor air movement\n better at apices,\n no wheezing\n Heart- RRR\n Abd\n benign\n Ext\n wwp, no edema\n Labs / Radiology\n 12.3 g/dL\n 213 K/uL\n 143 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.5 mEq/L\n 31 mg/dL\n 103 mEq/L\n 140 mEq/L\n 39.6 %\n 15.7 K/uL\n [image002.jpg]\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n 01:54 PM\n 11:13 PM\n 01:44 AM\n 03:45 AM\n 03:55 AM\n 06:55 AM\n WBC\n 16.5\n 15.7\n Hct\n 36.8\n 39.6\n Plt\n 225\n 213\n Cr\n 1.0\n 0.9\n TCO2\n 33\n 33\n 35\n 35\n 35\n 36\n 36\n 33\n Glucose\n 157\n 143\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.6\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today clinically but w/ persistent am hypercarbia,\n suboptimal overnight NIPPV\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP at night settings are 16/8 with 2L O2, now satting well on 2L by\n day, could even get off supplemental O2 and tolerate Sats in low 90\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -transition to PO prednisone today; insulin while on steroids\n -azithro for possible CXR infiltrates/ exacerbation. No clinical signs\n of pna\n Probable OSA/OHV- suboptimal overnight NIPPV\n -BiPAP has been titrated, continue settings on floor\n will need sleep\n study as outpatient\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: heparin subcut\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472975, "text": "TITLE:\n Chief Complaint: - venti mask during day, doing well\n - bipap overnight, increased PSV over course of night due to increase\n in CO2, having obvious apneic periods, still higher CO2 in AM\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 70 (70 - 109) bpm\n BP: 129/70(91) {98/63(78) - 157/91(115)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 72 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 72 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 225 K/uL\n 12.3 g/dL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472976, "text": "TITLE:\n Chief Complaint: - venti mask during day, doing well\n - bipap overnight, increased PSV over course of night due to increase\n in CO2, having obvious apneic periods, still higher CO2 in AM\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 70 (70 - 109) bpm\n BP: 129/70(91) {98/63(78) - 157/91(115)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 72 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 72 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 225 K/uL\n 12.3 g/dL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s. Treatment of COPD exaccerbation as\n below. Mental status much improved.\n - tolerated bipap throughout night yesterday, switched to venti mask\n last evening\n - CO2s in 50s, which is improved over yesterday\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n patient not coughing, WBC stable, no\n fevers. On azithro for COPD flare; if spikes or clinically worsens\n would broaden to levofloxacin or add ceftriaxone.\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs, but tox screens negative and patient\ns mental\n status is improving as respiratory status improving..\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472977, "text": "TITLE:\n Chief Complaint: - venti mask during day, doing well\n - bipap overnight, increased PSV over course of night due to increase\n in CO2, having obvious apneic periods, still higher CO2 in AM\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 11:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.8\nC (96.5\n HR: 70 (70 - 109) bpm\n BP: 129/70(91) {98/63(78) - 157/91(115)} mmHg\n RR: 15 (11 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 780 mL\n 72 mL\n PO:\n 290 mL\n TF:\n IVF:\n 490 mL\n 72 mL\n Blood products:\n Total out:\n 1,400 mL\n 950 mL\n Urine:\n 1,400 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -620 mL\n -878 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 407 (407 - 700) mL\n PS : 12 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 19 cmH2O\n SpO2: 94%\n ABG: 7.36/60/81./31/5\n Ve: 8.2 L/min\n PaO2 / FiO2: 270\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 225 K/uL\n 12.3 g/dL\n 157 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 31 mg/dL\n 101 mEq/L\n 140 mEq/L\n 36.8 %\n 16.5 K/uL\n [image002.jpg]\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n 01:49 PM\n 09:02 PM\n 12:37 AM\n 05:05 AM\n 05:13 AM\n WBC\n 15.1\n 16.5\n Hct\n 39.7\n 36.8\n Plt\n 182\n 225\n Cr\n 1.0\n 1.0\n TCO2\n 33\n 36\n 35\n 33\n 33\n 33\n 33\n 35\n Glucose\n 144\n 157\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, ALT / AST:30/16, Alk Phos / T Bili:65/0.2,\n Differential-Neuts:90.9 %, Lymph:6.8 %, Mono:1.8 %, Eos:0.3 %, Lactic\n Acid:1.8 mmol/L, LDH:184 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.1\n mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s. Treatment of COPD exaccerbation as\n below. Mental status much improved.\n - tolerated bipap throughout night yesterday, switched to venti mask\n last evening\n - CO2s in 50s, which is improved over yesterday\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n patient not coughing, WBC stable, no\n fevers. On azithro for COPD flare; if spikes or clinically worsens\n would broaden to levofloxacin or add ceftriaxone.\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs, but tox screens negative and patient\ns mental\n status is improving as respiratory status improving..\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472594, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU.\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472661, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472601, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU.\n Respiratory failure, acute (not ARDS/) Hypercarbic Respiratory\n Failure\n Assessment:\n Action:\n Response:\n Plan:\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s, so is much higher. His somnolence is\n worrisome. Treatment of COPD exaccerbation as below.\n - restarting bipap\n - serial ABGs to follow CO2, will place a-line\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - wean bipap to face mask today\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472591, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day after stopping his long prednisone taper with about half day\n history of shortness of breath, wheezing and L sided chest \"tingling.\"\n Was not a pain in his chest, did not radiated. He denies hx of fevers,\n cough, body aches. No nausea, vomitting, diaphoresis.\n In the ED, initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on\n NRB. He had audible wheezes and was using his accessory muscles to\n breath. While on the NRB, he was noted to become increasingly\n somnulent and ABG was 7.24/83/262. He was switched to bipap 8/5 and\n 30%, and he improved slightly. His next ABG was 7.30/69/67. He was\n kept on bipap and admitted to the MICU. Patient was given solumedrol\n 125 mg IV x1 and Mag. He has 1 20g PIV.\n" }, { "category": "Nursing", "chartdate": "2153-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472660, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2153-06-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 472617, "text": "Demographics\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well; Comments: Pt to be\n placed on NIV intermittently until respiratory status improves.\n" }, { "category": "Nursing", "chartdate": "2153-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472688, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n somnulent, AO x 3,awakes to voice, falls back to sleep easily, snores,\n on bipap for early evening, off to ventimask in early am with\n satisfactory blood gases, dry cough, no wheeze noted. Sats 92% on 24%\n mask.\n Action:\n pulm. Care, encourage use of incentive spirometer, out of bed as tol.\n wean oxygen as tol.\n Response:\n stable resp. cont. to be somulent, pt does wake with encouragement and\n stimulation and incentive\n Plan:\n oob today, keep sats above 88-90%, incentive spirometry, nebulized\n medicaiton, restart diet if remains stable this day\n Chest pain\n Assessment:\n no c/o chest pain, slight ST elevation seen, no ectopy noted. Labs\n normalizing\n Action:\n stable, follow ekg, reeval ST elevation, pt symptoms, ensure sats\n 88-90%, supplemental oxygen\n Response:\n stable card. status\n Plan:\n follow electrolytes, replete as needed, increase activity as tol. con.t\n oxygen to keep sats 88% or above\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472811, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -on bypap for most of day with slight improvement in resp symptoms\n (wheezing present)\n -steroids, abx, nebs.\n -a-line placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 82 (74 - 88) bpm\n BP: 145/81(103) {87/67(-13) - 147/88(104)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 71 mL\n PO:\n 50 mL\n TF:\n IVF:\n 408 mL\n 71 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 182 K/uL\n 12.6 g/dL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s. Treatment of COPD exaccerbation as\n below. Mental status much improved.\n - tolerated bipap throughout night yesterday, switched to venti mask\n last evening\n - CO2s in 50s, which is improved over yesterday\n - conitinue serial ABGs to follow CO2\n - will try ybipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare. Patient became hypercarbic\n on NRB and stabalized on bipap.\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs.\n - sending serum and urine tox screens\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n first set of cardiac enzymes were negative.\n - cycle enzymes\n - probably is muscloskeletal chest pain\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C - stable, NTD\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens as above\n .\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472820, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -on bypap for most of day with slight improvement in resp symptoms\n (wheezing present)\n -steroids, abx, nebs.\n -a-line placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 82 (74 - 88) bpm\n BP: 145/81(103) {87/67(-13) - 147/88(104)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 71 mL\n PO:\n 50 mL\n TF:\n IVF:\n 408 mL\n 71 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: Well nourished, A+Ox2 this morning\n Eyes / Conjunctiva: PERRL, Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at B bases, Wheezes : throughout, Diminished: ), continues to have very\n poor air movement bilaterally, most notably at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): time and name, had wrong hospital,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 182 K/uL\n 12.6 g/dL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n presents with worsening shortness of breath and COPD flare.\n .\n # Hypercarbic Respiratory Failure - secondary to his COPD flare.\n Likely his CO2 runs in high 40s. Treatment of COPD exaccerbation as\n below. Mental status much improved.\n - tolerated bipap throughout night yesterday, switched to venti mask\n last evening\n - CO2s in 50s, which is improved over yesterday\n - conitinue serial ABGs to follow CO2\n - will try bipap at night with autotitration\n .\n # COPD exaccerbation - patient symptoms and recent end of prednisone\n taper are most consistent with COPD flare.\n - repeat ABG to reassess CO2\n - cont steroids solumedrol 125 mg q8hrs, insulin SC while on steroids\n - add azithro for COPD flare\n .\n # RML/LLL infiltrate on CXR\n patient not coughing, WBC stable, no\n fevers. On azithro for COPD flare; if spikes or clinically worsens\n would broaden to levofloxacin or add ceftriaxone.\n .\n # Somnolence - likely due to hypercarbia, could be secondary to other\n causes like etoh/drugs, but tox screens negative and patient\ns mental\n status is improving as respiratory status improving..\n - continue to correlate mental status with CO2, should improve as his\n respiratory status improves.\n .\n # Chest pain - nonspecific symptoms, unlikely ACS as EKG unchanged and\n Ces neg x2.\n - continue tylenol for musculoskeletal chest pain, could potentially be\n related to PNA.\n .\n # Headache - likely secondary to his respiratory distress, can try\n tylenol for pain control, appears comfortable without any neurolgical\n symptoms or findings on exam.\n - tylenol PRN\n .\n # Hep C\n stable\n .\n # Anxiety - continue home medicines once mental status has improved.\n .\n # Hx of substance abuse - tox screens negative, cont nicotine patch\n .\n FEN: replete electrolytes, regular diet\n Prophylaxis: Subutaneous heparin\n Access: 2 peripherals\n Code: Full (discussed with patient)\n Communication: Patient, brother , \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 472755, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -on bypap for most of day with slight improvement in resp symptoms\n (wheezing present)\n -steroids, abx, nebs.\n -a-line placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 82 (74 - 88) bpm\n BP: 145/81(103) {87/67(-13) - 147/88(104)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 71 mL\n PO:\n 50 mL\n TF:\n IVF:\n 408 mL\n 71 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 31%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 182 K/uL\n 12.6 g/dL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n CHEST PAIN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2153-06-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 472790, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated BiPAP intermittently yest pm.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Azithromycin - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Colace, Klonopin 1 , Mirtazipine 30 qhs, Paxil 20 am, Aripiprazole,\n Azithromycin, Solu-Medrol 125 q8, Atrovent, Albuterol, RISS, Heparin sc\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.6\nC (96\n HR: 86 (74 - 93) bpm\n BP: 140/79(99) {87/67(-13) - 153/88(108)} mmHg\n RR: 20 (14 - 23) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 608 mL\n 400 mL\n PO:\n 50 mL\n 50 mL\n TF:\n IVF:\n 408 mL\n 350 mL\n Blood products:\n Total out:\n 550 mL\n 700 mL\n Urine:\n 550 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 58 mL\n -300 mL\n Respiratory support\n O2 Delivery Device: Venti mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 468 (310 - 983) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 28%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.39/53/68/30/5\n Ve: 4.9 L/min\n PaO2 / FiO2: 243\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Wheezes : , Diminished:\n markedly decreased air mvmt)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 182 K/uL\n 144 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 39.7 %\n 15.1 K/uL\n [image002.jpg]\n 09:45 AM\n 03:26 PM\n 03:37 PM\n 10:08 PM\n 01:09 AM\n 03:59 AM\n 05:59 AM\n WBC\n 15.1\n Hct\n 39.7\n Plt\n 182\n Cr\n 1.0\n TropT\n <0.01\n TCO2\n 34\n 33\n 36\n 35\n 33\n Glucose\n 144\n Other labs: PT / PTT / INR:11.7/23.9/1.0, CK / CKMB /\n Troponin-T:36//<0.01, Differential-Neuts:90.6 %, Lymph:8.5 %, Mono:0.8\n %, Eos:0.0 %, Lactic Acid:1.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Imaging: CXR- RML and LLL infiltrate\n Microbiology: cx pending or neg\n Assessment and Plan\n 48 y/o M with hx of asthma/COPD, Hep C and hx of substance abuse\n admitted w/ acute hypercarbic resp failure related to exacerbation\n of obstructive lung disease.\n Hypercarbic Respiratory Failure- due to obstructive lung disease flare,\n also with likely component of OSA/OHV. baseline PCO2 in high 40s per\n record. improved today but still off baseline\n -obstructive lung disease tx as below\n -sleep disordered breathing mgmt as below\n -cont trending mental status and PCO2\n -BiPAP by day as needed\n COPD exacerbation - multiple recurrent flares, ? if some home or\n environmental exposure related to such poor control\n -steroids IV today; insulin while on steroids\n -azithro to help\n Probable OSA/OHV\n -BiPAP overnight, up-titrate as needed\n -will need eventual sleep study to diagnoise\n Anxiety - continue home medicines\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Comments: advance po diet today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 20 Gauge - 08:30 AM\n 22 Gauge - 10:00 AM\n Arterial Line - 02:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2153-06-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 472746, "text": "48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes to ED\n one day completing prednisone taper. Recent adm for LLL PNA .\n Today presented by EMS with c/o of ^SOB, wheezing and L sided chest\n \"tingling.\" He denies hx of fevers, cough, body aches. In the ED,\n initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat 100 on NRB. He\n had audible wheezes and was using his accessory muscles to breath.\n While on the NRB, he was noted to become increasingly somnulent and ABG\n was 7.24/83/262. He was switched to bipap 8/5 30%, and he improved\n slightly. His next ABG was 7.30/69/67. Placed on NC 2L sats\n maintained low 90\ns. Received solumedrol and Mag Sulfate. Adm to\n MICU for respiratory support/monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n somnulent, AO x 3,awakes to voice, falls back to sleep easily, snores,\n on bipap for early evening, off to ventimask in early am with\n satisfactory blood gases, dry cough, no wheeze noted. Sats 92% on 24%\n mask.\n Action:\n pulm. Care, encourage use of incentive spirometer, out of bed as tol.\n wean oxygen as tol.\n Response:\n stable resp. cont. to be somulent, pt does wake with encouragement and\n stimulation and incentive\n Plan:\n oob today, keep sats above 88-90%, incentive spirometry, nebulized\n medicaiton, restart diet if remains stable this day\n Chest pain\n Assessment:\n no c/o chest pain, slight ST elevation seen, no ectopy noted. Labs\n normalizing\n Action:\n stable, follow ekg, reeval ST elevation, pt symptoms, ensure sats\n 88-90%, supplemental oxygen\n Response:\n stable card. status\n Plan:\n follow electrolytes, replete as needed, increase activity as tol. con.t\n oxygen to keep sats 88% or above\n" }, { "category": "ECG", "chartdate": "2153-06-20 00:00:00.000", "description": "Report", "row_id": 233019, "text": "Sinus tachycardia. Since the previous tracing no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2153-06-20 00:00:00.000", "description": "Report", "row_id": 233020, "text": "Sinus tachycardia. Since the previous tracing probably no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-06-20 00:00:00.000", "description": "Report", "row_id": 233021, "text": "Baseline artifact. Sinus rhythm. Late R wave progression. Since the previous\ntracing of the rate is faster. ST segment elevation in the early\nprecordial leads on the previous tracing is now not apparent.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2153-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1089724, "text": " 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with hx recent pna with asthma attack\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with history of recent pneumonia and asthma\n attack. Rule out pneumonia.\n\n COMPARISON: Chest CT of .\n\n FRONTAL VIEW OF THE CHEST: Lungs are clear bilaterally without areas of focal\n consolidation. There are no pleural effusions or pneumothorax. The\n cardiomediastinal silhouette is within normal limits and unchanged.\n\n IMPRESSION: No acute intrathoracic process.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1089876, "text": " 3:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with COPD, resp failure\n REASON FOR THIS EXAMINATION:\n pls eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: COPD, respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the transparency of the\n lung parenchyma has decreased, notably at the lung bases and in the perihilar\n areas. In the appropriate clinical setting, these changes could be suggestive\n of aspiration or newly developing pneumonia. The size of the cardiac\n silhouette is unchanged. There is no\n evidence of pleural effusion. No pneumothorax or pneumomediastinum.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2153-02-19 00:00:00.000", "description": "Report", "row_id": 233682, "text": "Sinus rhythm with probable sinus arrhythmia, atrial premature beats and\nventricular premature beat. Probable intra-atrial conduction delay.\nRSR' pattern in lead V1 may be a normal variant. Since the previous tracing\nof ventricular ectopy is present but there may be no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2153-02-18 00:00:00.000", "description": "Report", "row_id": 233683, "text": "Sinus rhythm with atrial premature beats. Intra-atrial conduction delay.\nOtherwise, probably normal tracing. Since the previous tracing of \ninferior lead T wave changes appear decreased but there may be no significant\nchange.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341850, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result. ? left peripheral vision\n loss .\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Does not need surgery (neuro) now as per neurosurgery team.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n STROKE;TRANSIENT ISCHEMIC ATTACK\n Code status:\n DNR / DNI\n Height:\n 72 Inch\n Admission weight:\n 72 kg\n Daily weight:\n Allergies/Reactions:\n IV Dye\n Iodine Containing\n Unknown;\n Precautions: Contact\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: prior IPH in (L frontal),dementia (even\n before first IPH), hypercholesterolemia, bleeding ulcers s/p \"stomach\n operation\" s/p appy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:163\n D:64\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 310 mL\n 24h total out:\n 1,185 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:37 AM\n Potassium:\n 3.6 mEq/L\n 02:37 AM\n Chloride:\n 108 mEq/L\n 02:37 AM\n CO2:\n 23 mEq/L\n 02:37 AM\n BUN:\n 19 mg/dL\n 02:37 AM\n Creatinine:\n 1.0 mg/dL\n 02:37 AM\n Glucose:\n 120 mg/dL\n 02:37 AM\n Hematocrit:\n 29.3 %\n 02:37 AM\n Finger Stick Glucose:\n 128\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 18 G left wrist, 20 G rt hand.\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 07\n Transferred to: 1124\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nutrition", "chartdate": "2143-10-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 341819, "text": "Subjective\n Chewing / Swallowing difficulty, per daughter: taking ground solids +\n nectar thick liquids PTA, TF d/c'd 1-2 weeks PTA (Glucerna @ 70ml/hr\n x10hrs)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 72 kg\n 21.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 89\n 75.2 kg ()\n Diagnosis: stroke\n PMH : IPC hemorrhage ', HTN, dementia, IDDM, bleeding ulcers, s/p\n appy, s/p trach/ PEG \n Food allergies and intolerances: NKFA\n Pertinent medications: NS, RISS, Flagyl, Abx, Glucophage, Famotidine\n Labs:\n Value\n Date\n Glucose\n 120 mg/dL\n 02:37 AM\n Glucose Finger Stick\n 128\n 12:00 PM\n BUN\n 19 mg/dL\n 02:37 AM\n Creatinine\n 1.0 mg/dL\n 02:37 AM\n Sodium\n 138 mEq/L\n 02:37 AM\n Potassium\n 3.6 mEq/L\n 02:37 AM\n Chloride\n 108 mEq/L\n 02:37 AM\n TCO2\n 23 mEq/L\n 02:37 AM\n pH (urine)\n 7.0 units\n 09:00 PM\n Calcium non-ionized\n 8.1 mg/dL\n 02:37 AM\n Phosphorus\n 2.5 mg/dL\n 02:37 AM\n Magnesium\n 1.9 mg/dL\n 02:37 AM\n Phenytoin (Dilantin)\n 8.5 ug/mL\n 02:37 AM\n WBC\n 10.6 K/uL\n 02:37 AM\n Hgb\n 9.9 g/dL\n 02:37 AM\n Hematocrit\n 29.3 %\n 02:37 AM\n Current diet order / nutrition support: Diet: pureed, nectar thick\n liquids; 1:1 assist, feed only when awake\n GI: soft, hypo bs\n Assessment of Nutritional Status\n Pt at risk due to: altered consistency diet, low % IBW, AMS, skin\n breakdown (stage 1 on coccyx)\n Estimated Nutritional Needs\n Calories: 1800-2160 (BEE x or / 25-30 cal/kg)\n Protein: 72-86 (1-1.2 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate\n Specifics:\n Pt admitted from NH w/ lethargy, weakness. Head CT = new R occipital\n hemorrhage. Pt TF dependent at baseline until recently TF d/c\nd and pt\n on po diet only. SLP saw pt this AM\n rec downgrade to pureed diet\n (was on ground), nectar thick liquids when pt alert. TF ordered, no\n yet started. Goal TF will provide 1920calories and 119g protein which\n may be feeding excessive protein. Would change to higher calorie per\n cc TF formula.\n Medical Nutrition Therapy Plan - Recommend the Following\n Enc/assist w/ po\ns when pt awake\n Oral supplements: Ensure pudding\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Rec change TF to Fibersource HN w/ goal\n of 65ml/hr = 1872calories and 83g protein\n Check residuals, hold TF if >/= 150ml\n Check chemistry 10 panel daily\n BS mgmt\n Will follow\n page w/ ?s *\n" }, { "category": "Physician ", "chartdate": "2143-10-25 00:00:00.000", "description": "Intensivist Note", "row_id": 341799, "text": "TSICU\n HPI:\n :84year old male with a history of left frontal hemorrhage that\n was not managed surgically. His course in the hospital was complicated\n by respiratory compromise with frequent mucous plugging requiring trach\n and a PEG was placed as well for nutritonal purposes. Over the past\n few days the patients family describes progressive mental decline and\n lethargy that prompted todays presentation the the ER. Head CT in ED\n shows new right occiptal hemorrhage with no midline shift. left frontal\n encephalomalcia\n Chief complaint:\n Intraparenchymal bleed\n PMHx:\n dementia\n hypercholesterolemia\n CAD\n HTN\n NIDDM with diabetic neuropathy\n Peptic Ulcer Disease; bleeding ulcers s/p \"stomach operation\"\n s/p appy\n MRSA aspiration pneumonia\n s/p right UE DVT whle hospitalized at \n AFib with bradycardia\n mild diastolic congestive heart failure;\n Current medications:\n CeftriaXONE 2. Famotidine 3. Insulin 4. Levofloxacin 5. Metoprolol\n Tartrate 6. MetFORMIN (Glucophage)\n 7. MetRONIDAZOLE (FLagyl) 8. NiCARdipine 9. Phenytoin 10. Phenytoin\n 24 Hour Events:\n Allergies:\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.8\nC (98.2\n HR: 74 (73 - 86) bpm\n BP: 166/67(93) {111/49(65) - 206/108(120)} mmHg\n RR: 27 (12 - 30) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 250 mL\n 110 mL\n PO:\n Tube feeding:\n IV Fluid:\n 250 mL\n 30 mL\n Blood products:\n Total out:\n 140 mL\n 605 mL\n Urine:\n 140 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n 110 mL\n -495 mL\n Respiratory support\n SPO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1)\n Labs / Radiology\n 208 K/uL\n 9.9 g/dL\n 120 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 19 mg/dL\n 108 mEq/L\n 138 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 02:37 AM\n WBC\n 10.6\n Hct\n 29.3\n Plt\n 208\n Creatinine\n 1.0\n Glucose\n 120\n Other labs: PT / PTT / INR:14.9/28.4/1.3, Ca:8.1 mg/dL, Mg:1.9 mg/dL,\n PO4:2.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 84 year old male with intrcranial bleeding\n Neurologic: Neuro checks Q: 1 hour\n Loaded with phenytoin 100mg in ED, Phenytoin 100 mg PO TID\n NiCARdipine to be d/c'd\n AM: CT HEAD W/O CONTRAST\n Pain: if needed morphine prn, tylenol prn\n Cardiovascular: History of CAD and HTN, Metoprolol Tartrate 75 mg PO\n BID, on PRN hydral\n Pulmonary: Patient has possible infiltrate recieved flagyland levoquin\n in ER to be continued, started on ceftriaxone in ICU, follow for\n fevers, culture if spikes\n Gastrointestinal / Abdomen: famotidine PPX\n Nutrition: TF with nectar thick liquids and puree solids if energetic\n and awake enough to take PO.\n Renal: following urine output\n Hematology: HCT 33.3 monitor with AM labs\n Endocrine: RISS + MetFORMIN (Glucophage) 500 mg PO BID\n Infectious Disease: UTI, Possible PNA developing on levo, flagyl,\n ceftriaxone\n Lines / Tubes / Drains:\n Wounds:\n Imaging: AM head CT\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:30 PM\n 20 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341723, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Altered mental status (not Delirium)\n Assessment:\n Very confused, combative, very resistant to care and basically he does\n not like to be bothered or exposed.\n Action:\n Kept him comfortable w/ minimal handling\n Response:\n Slept well\n Plan:\n Cont to monitor his mental status changes, reorienting often without\n disturbing him physically\n Hypertension, benign\n Assessment:\n Hypertensive to 200\n Action:\n Nicardepine GTT\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor BP and restart nicardepine if BP increases above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned Q4 to keep off pressure area.\n Response:\n pending\n Plan:\n Cont skin care treatment.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341768, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Altered mental status (not Delirium)\n Assessment:\n Very confused, combative, very resistant to care and basically he does\n not like to be bothered or exposed.\n Action:\n Kept him comfortable w/ minimal handling\n Response:\n Slept well\n Plan:\n Cont to monitor his mental status changes, reorienting often without\n disturbing him physically\n Hypertension, benign\n Assessment:\n Hypertensive to 200\n Action:\n Nicardepine GTT\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor BP and restart nicardepine if BP increases above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned Q4 to keep off pressure area.\n Response:\n pending\n Plan:\n Cont skin care treatment.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341877, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result.\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg & stopped at 1000 hrs. Hydralazine\n 10 mg IV X2 PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341719, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Altered mental status (not Delirium)\n Assessment:\n Very confused, combative, very resistant to care and basically he does\n not like to be bothered or exposed.\n Action:\n Kept him comfortable w/ minimal handling\n Response:\n Slept well\n Plan:\n Cont to monitor his mental status changes, reorienting often without\n disturbing him much\n Hypertension, benign\n Assessment:\n Hypertensive to 200\n Action:\n Nicardepine GTT\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor BP and restart nicardepine as needed.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341712, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341842, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result.\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341843, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result.\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341844, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result. ? left peripheral vision\n loss .\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Does not need surgery (neuro) now as per neurosurgery team.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 341847, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n *** Tranx to floor 1124 today.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result. ? left peripheral vision\n loss .\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Does not need surgery (neuro) now as per neurosurgery team.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341840, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result.\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Nursing", "chartdate": "2143-10-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 341831, "text": "84 yo M with hx of prior intraparenchymal hemorrhage, presents now with\n new right temporo-occipital intraparenchymal hemorrhage. Pt had been\n in NH at baseline health until Mon when the daughter felt that he\n seemed a little \"spaced out\" at times and not focusing. She also felt\n he was weak, in that he was having trouble feeding himself, was\n dragging his feet when walking, and was over stiff. She states in NH CT\n was done at that time, which was supposedly normal, but she was later\n told a bleed was apprecaited and the pt was transferred here for\n further management. Daughter felt that her father was largely at his\n baseline mental status. She states that is at baseline disoriented and\n has an aphasia.\n Significant events : :\n ****CT Scan today AM, results pending.\n **** Nicardipine gtt D/c\n **** Neuro consulted.\n **** tube feeding (Replete with fiber, Full strength) started @ 20\n ml/hr. ( Goal rate : 80 ml/hr).\n **** Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid once he is more awake. need 1:1 to assist in\n feeding.\n Altered mental status (not Delirium)\n Assessment:\n Combative,& very resistant to each & every care and basically he does\n not like to be bothered or exposed. He states\n \n to\n at times. Mostly sleepy all day. Opens his eyes once.\n Action:\n Kept him comfortable w/ minimal exposing. CT scan done today AM.\n Neuro consulted.\n Response:\n Resting well. Awaitng for CT scan result.\n Plan:\n Cont to monitor his mental status changes, F/U with neuro & CT scan.\n Hypertension, benign\n Assessment:\n Hypertensive . SBP ranges from 140-180\n Action:\n Nicardipine gtt restarted @ 1 mcg/kg 7 stopped at 1000 hrs. Hydralazine\n 10 mg IV PRN given for SBP >160\n Response:\n Now SBP ranging from 130-160\n Plan:\n Cont to monitor SBP closely , Hydralazine 10 mg IV if BP increases\n above 160.\n Impaired Skin Integrity\n Assessment:\n Stage 1 pressure sore @ coccyx\n Action:\n Allevyn dressing done, and repositioned to keep off pressure area.\n Response:\n Allevyn dressing in place.\n Plan:\n Cont skin care treatment.\n `\n Altered nutrition.\n Assessment:\n Speech & swallow study done today. Patient may take nectar\n Pre-thickened liquid only if patient\ns mental status is awake, may need\n 1:1 to assist in feeding.\n Action:\n Tube feeding started. Replete with fiber ( full strength) @ 20 ml/hr (\n goal rate : 80 ml/hr) on flow. Po meds given per PEG tube.\n Response:\n Tolerating tube feeding.\n Plan:\n Will cont tube feeding & residual check q 4 hrly till he is more awake.\n" }, { "category": "Radiology", "chartdate": "2143-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1034163, "text": " 2:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for any new hemorrhage\n Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with infarct and right IPH\n REASON FOR THIS EXAMINATION:\n please evaluate for any new hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 9:47 PM\n PFI: Slight decreased density of the large intraparenchymal hematoma,\n consistent with natural evolution of blood products. There is otherwise no\n significant interval change from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with right intraparenchymal hemorrhage.\n\n COMPARISON: CT of the head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: There is slightly decreased density of large right temporo-\n occipital intraparenchymal hematoma, consistent with natural evolution of\n blood products. The occipital of the right lateral ventricle is again\n not visualized. Encephalomalacia in the left frontal lobe with associated ex\n vacuo dilatation of the left lateral ventricle is unchanged. There is no\n evidence for new hemorrhage, mass effect, or infarction. Extensive\n periventricular and subcortical white matter changes, suggestive of chronic\n small vessel ischemic disease, are unchanged, as are multiple small lacunar\n infarcts in the basal ganglia bilaterally.\n\n The paranasal sinuses are normally pneumatized and clear. There is\n opacification of the right mastoid air cells. The left mastoid air cells are\n normally pneumatized and clear.\n\n IMPRESSION:\n 1. Expected evolution of large right temporo-occipital intraparenchymal\n hematoma.\n 2. No significant change in left frontal encephalomalacia, associated\n ventricular dilatation, extensive white matter hypodensities, and multiple\n small lacunar infarcts.\n 3. Opacification of the right mastoid air cells.\n\n" }, { "category": "Radiology", "chartdate": "2143-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1034164, "text": ", J. NSURG FA11 2:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for any new hemorrhage\n Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with infarct and right IPH\n REASON FOR THIS EXAMINATION:\n please evaluate for any new hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Slight decreased density of the large intraparenchymal hematoma,\n consistent with natural evolution of blood products. There is otherwise no\n significant interval change from prior study.\n\n" }, { "category": "Radiology", "chartdate": "2143-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1033546, "text": " 4:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with AMS and fever\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old man with altered mental status and fever, please\n evaluate for pneumonia.\n\n Comparison is made to the prior study of .\n\n FINDINGS: The heart size is moderately enlarged. The aorta is tortuous. The\n hilar contours are normal. Left retrocardiac density is relatively unchanged\n since prior study. Small right pleural effusion. No pneumothorax. No signs\n of heart failure.\n\n IMPRESSION:\n 1. Left retrocardiac density is relatively unchanged since prior studies;\n however, an underlying pneumonia cannot be excluded.\n 2. Small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2143-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033673, "text": " 10:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: stability of hemorrhage?\n Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with IPH\n REASON FOR THIS EXAMINATION:\n stability of hemorrhage?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old male patient, with intraparenchymal hematoma,\n followup.\n\n COMPARISON: CT of the head done on .\n\n TECHNIQUE: Non-contrast CT of the head was performed.\n\n FINDINGS:\n\n There is no significant change in the right temporo-occipital large\n intraparenchymal hematoma with mild indentation on the tentorium cerebelli and\n displacement medially. The right lateral ventricle - the atrium and occipital\n horns are not visualized and are either effaced or filled with blood, not\n clearly separable from the intraparenchymal hematoma. However, this\n appearance is again unchanged. There is no evidence of new mass effect or new\n hemorrhage. Unchanged appearance of the area of encephalomalacia in the left\n frontal lobe, with ex vacuo dilatation of the left frontal is noted.\n\n Three small osteomas are noted, two in the right parietal bones and the other\n one in the left parietal bones in the vertex (series 2, image 27), unchanged,\n the larger one measuring 0.5 cm.\n\n Atherosclerotic calcifications are noted in the vertebral and the cavernous\n carotid arteries. The visualized portions of the paranasal sinuses are\n grossly unremarkable.\n\n IMPRESSION:\n\n Large area of intraparenchymal hematoma in the right temporo-occipital region,\n unchanged measuring approximately 2.9 in the transverse dimension. Extension\n into the atrium and occipital of the right lateral ventricle with\n nonvisualization of these portions of the right lateral ventricle, unchanged.\n No significant change in the surrounding the edema, or mass effect on the\n tentorium cerebelli. No new hemorrhage or no mass effect. Continued close\n followup, is recommended, as clinically indicated.\n\n\n\n\n\n (Over)\n\n 10:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: stability of hemorrhage?\n Admitting Diagnosis: STROKE;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2143-10-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1033541, "text": " 4:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with new right occipital intracerebral hematoma\n REASON FOR THIS EXAMINATION:\n evaluate bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:18 PM\n new right occiptal hemorrhage with no midline shift.\n left frontal encephalomalcia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old man with new right occipital intracerebral hematoma.\n Please evaluate.\n\n Comparison is made to the prior studies of and .\n\n FINDINGS: New right temporo-occipital hemorrhage measures 35 x 30 mm and is\n associated with surrounding edema. There is also a smaller focus of hemorrhage\n along the calcarine sulcus of occiptal lobe measuring 16 x 13 mm. No definite\n extension into the intraventricular system is noted. No shift of midline\n structures is visualized. There is overlying obliteration of the right\n occipital sulci. The patient also demonstrates encephalomalacic changes of the\n left frontal lobe with ex vacuo dilatation of the left lateral ventricle which\n has progressed since prior study. Diffuse periventricular white matter\n hypodensities are compatible with small vessel disease. Old lacunar infarct\n is also noted within the right subinsular cortex. The visualized part of the\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Two hemorrhagic foci are noted within the right temporo-occiptal region\n and are associated with surrounding edema; however, no shift of normal midline\n structures is noted.\n 2. Stable encephalomalacic changes of the left frontal lobe, which have\n progressed since prior study.\n\n\n" }, { "category": "ECG", "chartdate": "2143-10-24 00:00:00.000", "description": "Report", "row_id": 214058, "text": "Atrial fibrillation with controlled ventricular response. Right bundle-branch\nblock. Non-specific inferior ST-T wave flattening. Borderline prolonged\nQTc interval. Compared to the previous tracing of the findings are\nsimilar.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-04-04 00:00:00.000", "description": "CT TRACHEA W/C & W/RECONS", "row_id": 859021, "text": " 4:10 PM\n CT TRACHEA W/C & W/RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Need special ct to evaluate RML and RLL airways and tracheom\n Admitting Diagnosis: TRACHEAL MALASIA;RESPIRATORY FAILURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with known lung collapse\n REASON FOR THIS EXAMINATION:\n Need special ct to evaluate RML and RLL airways and tracheomalacia by Dr.\n \n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT trachea dated .\n\n CLINICAL INDICATION: Known lung collapse. Evaluate right middle lobe and\n right lower lobe airways and also evaluate for tracheomalacia.\n\n CT of the chest was performed using the CT trachea protocol. Images were\n initially obtained at end inspiration following 100 cc of intravenous contrast\n administration. Optiray was administered due to the patient's respiratory\n status. Subsequently, an additional sequence was performed during dynamic\n expiratory phase of respiration to evaluate for airway collapsibility. This\n sequence was performed without contrast and using a low-dose technique. The\n axial data was subsequently used to create a series of multiplanar and 3D\n images, which were reviewed in conjunction with the axial CT images.\n\n A tracheostomy tube is present with the distal tip abutting the posterior wall\n of the trachea at the level of the aortic arch.\n\n Assessment of tracheal caliber is limited due to the patient's inability to\n cooperate with full inspiratory phase of respiration for the inspiratory\n sequence of the examination. During dynamic expiratory breathing, there is\n severe malacia of the lower trachea, main stem bronchi, bronchus intermedius\n and proximal lobar bronchi bilaterally. The lower trachea, carina and main\n stem bronchi demonstrate near complete collapse during expiratory phase of\n respiration.\n\n There is no evidence of lobar collapse. However, due to the patient's\n inability to cooperate with inspiratory phase of respiration, it is not\n possible to evaluate the middle lobe and lower lobe airways for subtle areas\n of abnormality such as nonobstructing endobronchial lesions or stenoses.\n\n Assessment of the lungs demonstrates a focal opacity in the periphery of the\n left upper lobe measuring slightly less than 1 cm in diameter with a somewhat\n nodular configuration. Areas of atelectasis are noted in both lungs,\n predominantly within the dependent portions of the lower lobes, although there\n are scattered foci of subsegmental atelectasis elsewhere as well.\n\n Multiplanar and 3D images confirm the above airway findings.\n\n Soft tissue structures of the thorax demonstrate marked distention of the\n (Over)\n\n 4:10 PM\n CT TRACHEA W/C & W/RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Need special ct to evaluate RML and RLL airways and tracheom\n Admitting Diagnosis: TRACHEAL MALASIA;RESPIRATORY FAILURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n thoracic esophagus in its proximal and mid portions. The lower thoracic\n esophagus is not distended, and there is no distal mass lesion identified. A\n nasogastric tube is in place. Please note that assessment of the soft tissue\n structures is limited due to the patient's inability to position the left arm\n above the head, resulting in extensive streak artifact from the positioning of\n the arm. There are several small mediastinal lymph nodes, which do not meet\n strict size criteria for significant enlargement. The main pulmonary artery\n is enlarged, suggesting pulmonary arterial hypertension. The heart is\n enlarged. There are small dependent pleural effusions bilaterally. Only the\n extreme upper portion of the abdomen was included on the study and the\n extensive streak artifact limits its assessment.\n\n Skeletal structures demonstrate degenerative changes within the spine.\n Postoperative changes are noted in the cervical spine.\n\n Finally, note is made of multifocal air trapping within the lungs on dynamic\n expiratory images, a frequent finding in patients with airway malacia.\n\n IMPRESSION:\n\n 1) Severe tracheobronchomalacia involving the trachea below the level of the\n tracheostomy tube, and extending into the main stem and proximal lobar bronchi\n bilaterally. Please note that the presence of a tracheostomy tube limits\n assessment of the remaining portion of the trachea for the presence of\n malacia.\n\n 2) The patient was unable to cooperate with end inspiratory phase of\n respiration, limiting assessment of the airways for fixed, structural\n abnormalities as well as for subtle endobronchial abnormalities. If warranted\n clinically, correlative bronchoscopy may be considered.\n\n 3) Less than 1 cm diameter nodular opacity in the left upper lobe, for which\n a followup CT scan is suggested in 3 months' duration to exclude interval\n growth. If the patient has strong risk factors for neoplasm, PET CT may be\n considered rather than followup standard CT scan.\n\n 4) Distention of upper and mid portions of the thoracic esophagus. These\n findings suggest the presence of esophageal dysmotility.\n\n 5) Bilateral small pleural effusions and adjacent atelectasis.\n\n 6) Multifocal air trapping, a frequent finding in patients with airway\n malacia.\n (Over)\n\n 4:10 PM\n CT TRACHEA W/C & W/RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Need special ct to evaluate RML and RLL airways and tracheom\n Admitting Diagnosis: TRACHEAL MALASIA;RESPIRATORY FAILURE\n Field of view: 44 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2118-04-02 00:00:00.000", "description": "Report", "row_id": 1345626, "text": "Admission Note 1900-0700\nExtensive PMH including partial quadriplegia following cervical spinal surgery ', obesity, IVC filter, HTN, neurogenic bladder/bowel, GERD, anxiety, a-fib, SSS and cervical spinal stenosis.\n\nPt admitted to for resp distress...started on course of abx. PFTs showing severe obstructive/restrictive disease. Pt has hx recurrent RML/RLL collapse. bronch showed moderae plugging c/o epistaxis. Temporary trach placed and dilation of airway . Permanent trach placed ...CT showing continuation of RML/RLL collaspe with small effusions. Tx to for evaluation by Dr. for placement of stent.\n\nArrived to MICU-A via stretcher accompanied by EMS. Placed on vent with settings AC 10/TV 700/peep 5/psv 20/FIO2 60%. VSS.\n\nAllergies: Intolerance to morphine, zantac.\n\nReview of Systems:\n\n CV: Chronic a-fib, rate controlled 70-80's. Hx IVC filter placement. BP stable 90-120/50's via NIBP cuff. Right basilic dual lumen PICC line (can not use right arm for BP/venipuntures)...insertion site reddened. Capped lumen to have heparin instilled. Pt with generalized 2+ edema.\n\nResp: RR 8-20, sats >98% on CPAP 5/PSV 20 FiO2 50% (decreased from 60% after ABG stick showing 7.43/46/150/32) with TV 800's. Pt having infrequent periods of apnea (hx sleep apnea). BBS rhonorous, snx small-moderate amounts of thick white sputum. Minimal oral secretions.\n\nNeuro: Partial quad, but able to lift bilateral upper extremities and wiggle toes (left side weaker than right). Has decreased sensation in all extremities. Mouthing words and attempting to speak around trach. Alert/oriented, following all commands. Very pleasant and cooperative.\n\nGI/GU: Abdomen obese, BS present. Pt kept NPO in case of procedure in am. Pt priorly on tube feedings. Given ice chips. 3-way foley placed yesterday at outside hospital d/t hematuria which has resolved. Foley draining adequate amounts of clear yellow urine. Pt had large soft/formed BM, heme (-). Refused bowel regimen this evening. Pt states that Q1-2 days he needs disimpacted.\n\nID: Sputum from showing serratia (on zosyn), urine cx had pseudomonas and pt had received vanco for MRSA. On contact precautions. Pt with leukocytosis and hx of spiking temps. Last temp spike yesterday at OSH. Blood cx sent this am.\n\nSkin: Pt on bariair bed. No skin breakdown noted, but buttocks and coccyx reddened...barrier cream applied. Psoriatic lesions in which Clobetasol being applied.\n\nSocial: HCP, called last night shortly after father arrived to unit and given updates on POC. Will be this afternoon. Pt usually resides with daughter whom takes care of him with the help of visiting nursing. Full Code.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2118-04-02 00:00:00.000", "description": "Report", "row_id": 1345627, "text": "Resp Care: pt adm from OSH trached with adjustable flange trach tube # 8, placed on ventilatory support with psv, abg drawn from LRA and fio2 decreased; bs rhonchorous, sxn thick white secretions, positional leak with 5 ml in , maintain support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-02 00:00:00.000", "description": "Report", "row_id": 1345628, "text": "0700-1900 NPN:\n\nNEURO- AWAKE/ALERT AND ORIENTED X 3. FOLLOWS COMMANDS. 2MM/BRISK. QUADRIPLEGIC R/T SPINAL SURGERY. ABLE TO MOVE UPPER EXT, LEFT GREATER THAN RIGHT. MOVING LOWER EXT ON BED. MOUTHING WORDS TO COMMUNICATE. PERCOCET GIVEN FOR C/O BACK PAIN W/ GOOD EFFECTS, SEE .\n\nRESP- TRACH ON CPAP PS 12/5. O2 SAT 92-98%. LS=RHONCHI/DIM. SUCTIONED FOR MODERATE AMTS OF THICK WHITE SPUTUM. DENIES SOB. NO PERIODS OF APNEA NOTED THIS SHIFT, PMH OF SLEEP APNEA.SPUTUM CX W/ SERRATIA, STARTED ON ZOSYN Q 6HRS. CONTACT PRECAUTIONS MAINTAINED. AWAITING IP EVAL FOR STENT PLACEMENT R/T RML/RLL RECURRENT COLLAPSE. CXR DONE THIS AM. CHEST CT ORDERED, NOT DONE AT THIS TIME.\n\nCV- AFIB @ 70-90. STARTED ON HEPARIN GTT @ 1800U/HR, NO BOLUS GIVEN. PTT @ 1700= 51.0, INCREASED GTT TO 2000U/HR @ 1830. GOAL PTT 60-100. EXT WARM, EASILY PALPABLE PEDAL PULSES. TEMP MAX 99.6. WBC=12.8/ LEUKOCYTOSIS. NO B/P IN RIGHT ARM. NBP=100-120/60-80. RELETED W/ K, MG, AND PHOS THIS SHIFT. LYTES DRAWN @ 1700.\n\nGI/GU- ABD SOFT/OBESE. PRESENT BS. NO BM, DECLINED BOWEL REGIMEN TODAY. LAST BM . ULTRACAL STARTED VIA NGT, CURRENTLY @ 20CC/HR W/ GOAL RATE @ 40CC/HR. FOLEY CATH D/S/P DRAINING LARGE AMTS CLEAR YELLOW URINE 50-140CC/HR.\n\nSKIN- COCCYX REDDENED, NO OPEN AREAS. NYSTATIN ORDERED PRN AND APPLIED TO PERINEUM. PT C/O BACK DISCOMFORT WHEN POSITIONED ON LEFT OR RIGHT SIDE. NRSG EXPLAINED FREQ REASONS FOR REPOSITIONING AND ISSUES W/ SKIN BREAKDOWN. PT VERBALIZED UNDERSTANDING. TOLERATING POSITION ON LEFT OR RIGHT SIDE X MAX 1HR AND THEN BACK TO SUPINE. PERCOCET GIVEN PRN AND BARIAIR BED ORDERED, TO BE AVAILABLE SUNDAY .\n\nENDO- FS Q 6 HRS= 131-135, NO SLIDING SCALE.\n\nPLAN- CHEST CT ORDERED TO EVAL RML/RLL COLLAPSE, AWAITING RESPONSE FROM IP TEAM R/T SPECIFIC TYPE OF CT SCAN. PLAN FOR STENT PLACEMENT ON MONDAY. CONTINUE HEPARIN GTT, NEXT PTT DUE @ 2230. ADVANCE ULTRACAL TF TO GOAL RATE PER . MEDICATE W/ PERCOCET PRN FOR BACK DISCOMFORT. FOLLOW UP ON 1700 LYTES AND REPLETE AS NECESSARY.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-04 00:00:00.000", "description": "Report", "row_id": 1345635, "text": "MICU NPN 0700-:\n\n Events: Pt bronched by IP late this afternoon--significant trachael collapse with expiration observed. Pt on list for rigid bronch/stent placement in OR tommorrow. Dr. has numbers for pts dtr and is to contact her to discuss plans. Pt consented for procedure. Pt should be NPO after midnight.\n Pt also travelled to CT scan for dynamic scan of airways--results are pending.\n Pt had + BC from PICC line (GNR) and site appeared infected--2 PIV placed and PICC line d/c'd by IV team. Line tip and surveillance cultures (peripheral and PICC line) sent.\n\n Neuro: Pt alert and oriented. Able to non verbally interact with staff. Percocet X 2 administered for back pain--last at 1500. Pt also c/o anxiety this am--0.25 mg xanax administered with ++ result. Pt c/o nausea from airbed--this was releived with standing dose of prevacid and prn reglan. Pt is very pleasant and cooperative.\n\n CV: Afebrile. Pt in afib with controlled rate in 70's. BP stable on labatelol. Pt producing copious amts of urine (> 600 cc/hr)--am lasix held. Pt currently about -2L today. Plan to start IVF after pt NPO after midnight. AM K+ replaced with 40 meq KCL PO.\n\n Pulm: Pt continues on PSV 12/5. Although RISBE was excellent, no plans for weaning until pt is stented. Lungs CTA with diminished bases. Pt suctioned q 2 hours for large amts thick tan sputum.\n\n GI: Pt NPO until after bronch today. TF restarted when pt returned from CT scan. Ultracal at 40 cc/hr via dopoff tube. Pt refusing bowel regimen. Pt has small formed stool yesterday.\n\n GU: UA and C+ S sent this afternoon. Urine is pale yellow and clear. team aware of copious amts.\n\n Skin: Intact. Bariair bed in continous rotational mode.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-04 00:00:00.000", "description": "Report", "row_id": 1345636, "text": "Respiratory Care\nPt remains on PSV 12/8, Pt bronched today and to cat-scan without incident. Plan to take pt to OR for stent placement tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-05 00:00:00.000", "description": "Report", "row_id": 1345637, "text": "Events: Uneventful night for pt . NPO after midnight for rigid bronchoscopy later today.\n\nNeuro: Pt A+Ox3 able to communicate needs orally in spite of trach. Pt able to move extremities on bed but can only lift RUE well enough to use it. C/O back pain (moderate) Controlled with percocett q4hrs. follows commands consistently. Pleasant/Cooperative.\n\nResp: Lung sounds decreased on R side. Mostly clear on L side. occasionally rhonchorous. Vent on CPAP mode 5 Peep/ 12Psupp 40% O2. Pt has had RML/RLL lung collapse and obstructive airway. To OR today for rigid bronch and stenting of main bronchus. Trach site benign Suctioned x2 for thick yellow sputum.\n\nGI: Abd obese with hypoactive bowel sounds TF ultracal at 40cc/hr off at mn for procedure. No BM this shift. Pt has refused hospital bowel regimen as his daughter provides bowel care. Blood sugars unremarkable.\n\nGU: Voiding large amts of dilute urine via foley 200-400cc/hr. MD's aware. AM lytes pending.\n\nCardiac: Afib with occasional ectopy on monitor. Heparin at 2400u/hr infusing. AM PTT pending. NBP 130's/80's HR wnl\n\nDerm: Grossly intact. PIV sites x2 patent. Trach site benign.\n\nID: IV zosyn continues. Afebrile this shift.\n\nPlan: To OR today for rigid bronch and stent placement. Stop heparin when pt on call. Follow pending cultures (picc tip, bld cx, sputum). ? new picc.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-03 00:00:00.000", "description": "Report", "row_id": 1345631, "text": "0700-1500 NPN:\n\nNEURO- AWAKE/ ALERT AND ORIENTED X3. COMMUNICATES NEEDS BY MOUTHING WORDS. FOLLOWS COMMANDS. PARTIAL QUADRIPLEGIC, ABLE TO MOVE EXT ON BED. RIGHT UPPER EXT ABLE TO LIFT AND HOLD, PT USES TO CONTROL CALLBELL. 2MM/BRISK. PERCOCET GIVEN PRN, LAST DOSE @ 1330 FOR BACK DISCOMFORT. GOOD EFFECTS NOTED. PT RESTING AT THIS TIME.\n\nRESP- ATTEMPTED SBT THIS AM R/T LOW RSBI. PT TOLERATED FOR APPROX 3 HRS, THEN BECAME TACHYPNEIC W/ 02 SAT 88%. RETURNED TO CPAP W/ PS 12/5/50% VIA TRACH. PT AND SUCTIONED, 02 SAT IMPROVED 96-98%. TEAM AWARE OF FAILED SBT, ADVISED HOLDING OFF ON WEAN OF VENT R/T RML/RLL COLLAPSE AND STENT PLACEMENT PLANNED FOR MONDAY. TRACHEAL CHEST CT ORDERED FOR MONDAY AM W/ IP RADIOLOGIST PRESENT.\n\nCV- AFEBRILE. WARM AND DRY. AFIB @ 65-80. CURRENTLY HEPARIN GTT @ 2400U/HR. BOLUS GIVEN AND GTT INCREASED THIS AM FOR PTT 56, GOAL 60- PTT PENDING. NBP- 90-130/40-70. LABETOTOL 200 MG FOR PMH HTN. HYPOTENSION AFTER AM LABETOLOL GIVEN. H/H= 10.3 + 30.7.\n\nGI/GU- ABD SOFT/OBESE. PRESENT BS. NO BM THIS SHIFT. ULTRACAL @ GOAL RATE 40CC/HR VIA LEFT NARE SMALL BORE FEEDING TUBE. FREE H2O BOLUSES 250CC GIVEN Q 6HRS AS ORDERED. FOLEY CATH D/S/P DRAINING LARGE AMTS OF CLEAR YELLOW URINE 80-225CC/HR. PT ON DAILY DOSE OF LASIX SINCE ADMIT.\n\nSKIN- COCCYX INTACT, REDDENED. BARRIER CREAM APPLIED. NYSTATIN APPLIED TO ABDOMINAL FOLDS. BARIAIR BED ARRIVED TODAY AND PT MOVE WELL.\n\nID- CONTACT PRECAUTIONS MAINTAINED. SPUTUM CX POSITIVE FOR SERRATIA, AND URINE CX POSITIVE FOR PSEUDOMONAS. IV ZOSYN CONTINUES. WBC= 9.0\n\n PT'S DAUGHTER IS HCP, PT AWAITING HER VISIT. PT IS FULL CODE.\n\nPLAN- NPO AFTER MN, START IVF @ MN SEE . PLAN FOR TRACHEAL CHEST CT AND STENT PLACEMENT FOR RML/RLL COLLAPSE. IP TEAM TO PT IN AM. CONTINUE ON CPAP/PS, DO NOT ATTEMPT TO WEAN AT THIS TIME. CONTINUE IV ABX. CONTINUE IV HEPARIN, TITRATE FOR 1400 PTT.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2118-04-03 00:00:00.000", "description": "Report", "row_id": 1345632, "text": "Respiratory Care\nPt . 4 hour trial on SBT, and placed back on 40% for increased rr, decreased mv. Pt PSV will. Suctioning copious amts of thick pale yellow secrections. MDI as ordered. Plan to have stent placement tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-07 00:00:00.000", "description": "Report", "row_id": 1345648, "text": "Respiratory Care Note:\n Patient on a 50% trach collar and appears comfortable this afternoon with passy muir valve on extended lenth air trach. Use of PMV reviewed with patient and he demonstrated ability to remove valve with his right hand if need arose. Suctioned for small to med amounts of thick whitish sputum. BS with fair aeration bilat. Plan for possible transfer to rehab today.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-04 00:00:00.000", "description": "Report", "row_id": 1345633, "text": "Shift Note 1900-0700\nCV: HR 60-70's, A-fib with rare PVC's. Periods when patient relaxed/asleep that HR drops into 50's. BP stable via NIBP 118-152/60-80's. Right basilic dual lumen PICC line reddened at insertion site with GNR present in aerobic culture bottle drawn from PICC site. Heparin gtt continues at 2400units/hr, PTT within therapeutic range of 60-100...check APTT Qday.\n\nResp: Vent settings 5peep/12 PSV, FiO2 50%. Snx moderate-copious amounts of tan thick white thick secretions with occasional small of blood tinge noted. RSBI not performed this am since patient going to OR for procedure today.\n\nNeuro: Pt slept well throughout night. Requested that medications be given early so that he could sleep as much as possible...cluster care provided. Pt alert/oriented x3, mouthing words to communicate and following all commands. Very pleasant and cooperative. Given percocet at last evening for back pain with relief.\n\nGI/GU: Abdomen obese, BS present. Tube feedings shut off at MN d/t OR procedure today. Foley cath intact draining large amounts of clear yellow urine 160-500cc/hr. Team aware, and BP stable. NS infusing at 150cc/hr x 2L since TF d/c. First liter completed. No BM this shift and per patient's request, bowel regimen held. To have CT scan today prior to OR procedure (pulmonary stents by Dr.). On acetylcysteine x4 doses---2 doses left to be given.\n\nEndo: BG 122-195, on SSC.\n\nID: Afebrile. WBC 6.6. GNR in aerobic blood culture from PICC site. Pt on zosyn. Contact precautions.\n\nSocial: Daughter in to visit yesterday. No contacts . Full code.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-04 00:00:00.000", "description": "Report", "row_id": 1345634, "text": "Resp Care: Pt continues trached and on ventilatory support with psv, no vent changes maintaining spo2 92-99%; bs rhonchorous, sxn thick white secretions, rx with mdi combivent as ordered, rsbi held d/t impending procedure, will cont slow vent wean after.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-07 00:00:00.000", "description": "Report", "row_id": 1345649, "text": "Shift Note 0700-1600\nPt being transferred from to via EMS services. Pt on 50% trach collar, sats > 96%. Daughter and made aware of transfer by RN. Daughter upset and did not want her father to be transferred to this specific rehab facility, however the patient's wife resides at and the patient agreed/wanted to be transferred to . Pt alert/oriented...passey muir valve in place and patient able to communicate his wishes. Daughter called talked to by case manager.\n\nCV: HR 80's, afib with rare PVC's. BP stable 99-132/60-70's via left radial art line. Art line d/c prior to patient's discharge. PIVx2 intact\n\nResp: Pt on 50% trach collar for >24hrs. Alot less secretions over coarse of day. Snx small amount of thick white. Patient has strong cough present. Speech and swallow evaluated patient at bedside, passey muir placed. BBS coarse occasionally, but currently clear with diminished bases.\n\nNeuro: Pt alert/oriented. Following commands. Very pleasant and cooperative.\n\nGI/GU: Abdomen obese, BS present. Switched from Ultracal to Promote with fiber. Foley cath intact draining adequate yellow clear urine output...on daily PO lasix. No BM this shift....colace given prn.\n\nSocial: Full code. Transferring to rehab facility.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-06 00:00:00.000", "description": "Report", "row_id": 1345644, "text": "Shift Note 0700-1900\nBronch performed yesterday am, no stents placed d/t patient's anatomy secondary to poor neck extension d/t spinal fusion. Pt eventually re-bronched d/t heavy bleeding.\n\nThis am, patient placed on 50% trach collar and tolerating well. No further plans to perform stent placement on patient at this time.\n\nCV: HR 70-80's a-fib with rare PVC's. BP 130-150/70-90's...pt hypertensive at times and labetolol dose increased to 300mg . Extra 100mg dose given at 1300 to equal total 300mg am dose. Left radial art line very positional. PIVx2. Discussed starting coumadin this evening, but decided to hold anticoagulants at this time.\n\nResp: Pt rested on and placed on trach collar this am. Tolerating well, RR 13-17, sats >97% and denies SOB. BBS coarse and suctioning moderate amounts of bloody tinged thick secretions. NIF -60. Speech consulted this afternoon for passy muir valve...spoke with S/S and will perform tomorrow.\n\nNeuro: Alert/oriented, following commands---talking around trach. Occasionally c/o lower back pain, percocet given with good response.\n\nGI/GU: Abdomen obese, BS present. Tube feedings restarted at 1400; ultracal at 20cc. Pt priorly tolerating goal 40cc/hr. D5 1/2NS stopped when tube feedings restarted. Foley cath intact draining 200-500cc/hr light yellow urine; pt on 20mg PO lasix daily. No BM this shift, refuses bowel regimen, so switched to PRN doses.\n\nID: sputum showing serratia and pseudomonas\n blood cx grew serratia and GNR\n urine grew yeast....zosyn d/c and levaquin PO started. Afebrile. Repeat Blood cx sent this afternoon.\n\nSocial: Plan to screen patient for rehab facility. Spoke with daughter on phone this am and given updates. Full code.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-06 00:00:00.000", "description": "Report", "row_id": 1345645, "text": "Respiratory Care\nPt trialed on 50% trachmask without any c/o dyspnea. Suctioning large amts of thick bld tinged. MDI as ordered, NIF of 60.\n\n" }, { "category": "Nursing/other", "chartdate": "2118-04-07 00:00:00.000", "description": "Report", "row_id": 1345646, "text": "pmicu npn 7p-7a\n\n\n the pt had an uneventful noc, remaining on a trach mask t/o the shift without incident. however, he did require frequent suctioning every 1-2hrs for most of the noc.\n\nreview of systems\n\nrespiratory-> pt continues on a 50% trach mask w/rr teens. maintaining sats >94% with a repeat abg this morning: 7.44/43/100/30/4. sputum is thick, tan, and rather tenacious.\n\ncardiac-> hr 70-90's, afib w/rare pvc's. he is not anticoagulated. sbp 100-150's.\n\nneuro-> pleasant, a&o x3, and able to participate w/his care.\n\ngi-> abd is obese w/+bs. tolerating tube feeding @goal rate via a peditube w/o incident. pt had a medium sized, hard, formed stool x1 last evening. he was encouraged to consider taking a stool softner as part of a regular bowel regime.\n\ngu-> uop 60-100cc/hr . he is ~10 liters tfb negative for his los.\n\nendocrine-> fs 100's; he did not require any insulin per the riss parameters.\n\naccess-> left radial a-line is patent and intact; ?d/c of the line today. pt also has 2 peripheral angiocaths in either arm.\n\nsocial-> no contact w/family .\n" }, { "category": "Nursing/other", "chartdate": "2118-04-07 00:00:00.000", "description": "Report", "row_id": 1345647, "text": "resp care\nPt remained off the vent all night and maintained acceptable sats on 50% trach collar. Pt given combivent mdi as ordered. Suct for thick tan occ blood tinged sput. Will con to follow.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-02 00:00:00.000", "description": "Report", "row_id": 1345629, "text": "Respiratory Care:\nPt remains on PSV as per CareVue; He was going to go to CT today but it never happened ?? Combi. given Q vent check No other changes\ntoday.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-03 00:00:00.000", "description": "Report", "row_id": 1345630, "text": "Shift Note 1900-0700\nCV: HR 70-80's, a-fib with no ectopy. BP stable via NIBP 116-140/50's...pt on 200mg labetolol . Pt has right basilic dual lumen PICC line...insertion site reddened (team aware). Pt on heparin gtt, last APTT 53.1...pt bolused with units heparin and rate increased by 200units/hr to total rate 2200units/hr. Next APTT to be drawn 0630.\n\nResp: CPAP/PS 5/12/50% via trach. Snx moderate amounts of thick tan secretions. Minimal oral secretions. BBS coarse, fair cough noted. Trach care provided...small amount of dark serous drainage noted. RR 16-20, TV 700's. Hx of sleep apnea, but no periods of apnea noted .\n\nNeuro: Pt alert/oriented with periods of rest, following commands and mouthing words for communication. Very pleasant and cooperative with care. Requesting prn pain medication for back pain, rates and resolves with administration of one percocet. Patient partial quadraplegic...able to move right arm (using right arm to feed self ice chips). Left arm weaker than right, but able to move on bed. Can wiggle toes, decreased sensation.\n\nGI/GU: Abdomen obese, BS present. Ultracal tube feedings infusing at 40cc/hr via small bore feeding tube in left nare...no residual noted and patient tolerating Q 6hr H2O water flushes. Foley cath intact draining clear yellow urine, 40-200cc/hr. No BM this shift, patient refusing bowel regimen.\n\nID: Pt has leukocytosis...on zosyn and baclofen. Gram negative rods growing in one set of aerobic blood culture bottle.\n\nEndo: BG checks Q6hrs. BG ranging 130-140's. require better glucose control.\n\nSkin: No skin breakdown noted, buttocks reddened and barrier cream applied. Pt has psorasis noted on bilateral hands, clobetasol applied.\n\nSocial: No contacts . Full code.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-05 00:00:00.000", "description": "Report", "row_id": 1345638, "text": "resp care\nPt remained on 12psv/5peep and 40% with volumes of 400-500cc and rr 10-24. BS with upper airway coarseness. Pt given combivent as ordered with some clearing. Suct for thick yellow sput. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-05 00:00:00.000", "description": "Report", "row_id": 1345639, "text": "NURSING PROGRESS NOTES 0700-1900\nEVENTS: PT SCHEDULED FOR OR- RIGID BRONCHOSCOPY W/ STENTS PLACED IN RIGHT MAIN BRONCHUS AT 0800 HEPARIN GTT SHUT OFF ON CALL TO OR.PTT 75.9.\nPT ARRIVED BACK TO MICU A @ 0945. PT PLACED ON 30MCQ/KG/MIN OF DIPRIVAN. PT BLEEDING FROM TRACH SITE, EBL 200CC, PT , OR TEAM CONTINUED TO STAY AT BEDSIDE TO PREFORM BRONCHOSCOPY. LARGE AMOUNTS OF BLOOD AND TISSUE REMOVED. SATS LOW 80S- FIO2 INCREASED TO 80% FROM 50%, SBP 80S 1 LITER OF NS GIVEN LS UPPER LOBES COARSE CRACKLES AND DIMINISHED BASES. PT HAD 2ND BRONCHOSCOPY AT BEDSIDE AT 1030 D/T LOW SATS AND LOW BP. MORE BLOOD AND TISSUE WAS REMOVED, LEFT RADIAL ALINE PLACED ABP 150/80S. PCXR OBTAINED. DIPRIVAN GTT OFF AT 1400 PT ALERT AND ORIENTED ASKING QUESTIONS ABOUT SURGERY, ALL QUESTIONS ANSWERED. VSS STABLE. NEW TRACH SPONGE APPLIED TO TRACH SITE. NO ACUTE BLEEDING NOTED. LABS DRAWN HCT 31, K+ 3.5, MG 1.7 ABG ON 80% AC7.45/40/240/99% FIO2 DECREASED TO 50% ABGS 7.46/42/101/97%. PT TO REMAIN W/ NO FEEDINGS FOR TODAY HEPARIN GTT REMAINS OFF. MICU TEAM ORDERED WEANING TRIAL O/O THEN TRACH MASK.\nPLAN FOR METAL STENT PLACEMENT AT BEDSIDE IN AM, DAUGHTER AND PT FULLY AWARE OF PLAN OF CARE.\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT ALERT AND ORIENTED X 3, MAE ON BED BUT CAN LIFT RUE OFF OF BED. PT C/O BACK PAIN AND REQUESTS PERCOCET, PERCOCET 2 TABS GIVEN AT 1530. PT AFEBRILE. PT ABLE TO COMMUNICATE BY MOUTHING WORDS VERY WELL.\n\nRESP: LS COARSE W/ DIMINISHED BASES. SUCTIONING THICK BLD TINGED SECRETIONS, PT ABLE TO COUGH UP MOST OF THESE SECRETIONS. AT PRESENT PT IS ON VENT SETTINGS OF CPAP5/ PS 12 FIO2 50% OWN TV 800, RR 18. WILL BE PLACED ON CPAP0/PS0, IF HE DOES WELL HE'LL BE PLACED ON TRACH MASK. UNTIL TIRES THEN PLACE BACK ON CPAP5/ PS 12.\n\nCV: PT AFIB W/ OCCASIONAL MULTIFOCAL PVC, HRT RATE 70S, SBP 120-140S EXCEPT FOR EPISODE NOTED ABOVE. PEDAL PULSES +3 POST TIBS +2,\nK+ 3.5 AND REPLACED W/ 4OMEQ KCL PKT VIA NGT, MG 1.7 REPLACED W/ 2GM MAG SULFATE IN 100C NS. PTT 27.4, PT 13.1, INR 1.1, HCT 31.5.\nLEFT ALINE INTACT, #20 POLYCATH RIGHT FA & #20 POLYCATH LEFT WRIST . SINCE PT NPO IVF STARTED: D5 1/2 NS @ 100CC/HR.\n\nGI: PT HAS SMALL PEDI NGT LEFT NARE. PT TO RECEIVE MEDS ONLY D/T TO PROCEDURE IN AM. ABD OBESE BS+ NO STOOL THIS SHIFT.\n\nGU: PT HAS FOLEY CATH DRAINING YELLOW URINE 50-500CC/HR. CRT 1.0/BUN 14. PT RECEIVES 20MG LASIX VIA NGT QD.\n\nSKIN: PT HAS PINK COCCYX, NO OPEN AREAS NOTED ON BUTTOCKS, SMALL OPEN AREA NOTED UNDER LEFT ABD FOLD ? SKIN TEAR ANTIBX OINT APPLIED AND ABD PADS PLACED TO BILATERAL SKIN FOLDS, NYSTATIN POWDER PLACED TO FOLDS AND GROIN AREA, PT IS ON BED THAT ROTATES Q 30MIN. TOLERATES WELL.\n\nSOCIAL: DAUGHTER-HCP- WHO HAS BEEN UPDATED BY MD TWICE.\n\nCODE: FULL\n\nENDO: FINGER STICKS QID AT 1200 118 NO COVERAGE NEEDED\n\nID: PT HAS HX OF MRSA IN SPUTUM, WAS ON VANCO LAST DOSE , BLD + GRAM NEG RODS AWAITING FINAL REPORT TO DETERMINE CONT W/ TX OR NOT. CONT ZOSYN FOR NOW.\n\nPLAN:\n1. CONT TO CLOSELY MONITOR PT RESP STATUS D/T RIGHT MAIN STEM COLAPSE,\n" }, { "category": "Nursing/other", "chartdate": "2118-04-05 00:00:00.000", "description": "Report", "row_id": 1345640, "text": "NURSING PROGRESS NOTES 0700-1900\n(Continued)\nAND PLACE BACK ON CPAP5/PS 12 FIO2 50% IF TIRES. AND NOTIFY IF PT HAS ACUTE BLEEDING.\n\n2. MAINTAIN PT'S COMFORT LEVEL BY USING PERCOCET 2TABS Q 4HR FOR CHRONIC BACK PAIN.\n\n3. KEEP PT NPO EXCEPT FOR MEDS\n\n4, MAINTAIN HEPARIN GTT OFF\n\n5. KEEP PT AND DAUGHTER INFORMED OF ANY CHANGES AND PLAN OF CARE\n\n6. CONT FINGERSTICKS QID W/ COVERAGE\n\n7. LABS IN AM. NEED ABG ORDER\n\n\n" }, { "category": "Nursing/other", "chartdate": "2118-04-05 00:00:00.000", "description": "Report", "row_id": 1345641, "text": "Respiratory Care\nPt did not have stents placed this am, bronched x2 for excessive bleeding. Pt weaned to sbt by end of shift if well will place on trach collar. Plan to place metal stents at bedside tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2118-04-06 00:00:00.000", "description": "Report", "row_id": 1345642, "text": "pmicu npn 7p-7a\n\n\n pt tolerated minimal ventilatory support with plans to transition to a trach mask later this morning. ?whether the pt will go to the or later today for stent placement if he fails a trach mask trial. heparin qtt and enteral feedings on hold for now pending the decision to take the pt to the or.\n\nreview of systems\n\nrespiratory-> pt remains trached and vented on psv5/peep5 and fio2 50%. rr 9-16/min w/tv ~500-600cc. abg this am: 7.41/51/131/33/6. pt suctioned for moderate amts of thick, bloody secretions. as noted above, will place on a trach mask trial later this morning.\n\ncardiac-> hr 70's, afib w/rare pvc's. sbp 130-160's. the heparin qtt continues on hold.\n\nneuro-> alert and oriented. pleasant and cooperative w/his care.\n\ngi-> obese w/+bs. no bm . tube feedings via peditube on hold for now.\n\ngu-> continues to autodiurese w/uop >150cc/hr. the pt is currently ~8 liters tfb negative for his los. he is receiving maintainence fluids @100cc/hr.\n\nendocrine-> receiving insulin per riss parameters.\n\naccess-> 2 #20g angios located in either arm are patent and intact.\n\nsocial-> no contact w/family .\n" }, { "category": "Nursing/other", "chartdate": "2118-04-06 00:00:00.000", "description": "Report", "row_id": 1345643, "text": "resp care\nreceived on spont breathing trial. #'s seemed fine however pt noted to have turbulent expiratory phase but denied sob. placed peep back on for noc with some resolution. only requiring ps 5. will trial on trach mask before end of shift. sxned for bloody sputum.\n" }, { "category": "Radiology", "chartdate": "2118-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 858785, "text": " 8:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: TRACHEAL MALASIA;RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with fever\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Chest single view on .\n\n HISTORY: Fever.\n\n FINDINGS: There are no old films available for comparison. There is a\n tracheostomy tube in good location. There is an NG tube with tip in the\n stomach. The heart is moderately enlarged. The left CP angle is off the\n film. There is no focal infiltrate or effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-04-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 859127, "text": " 11:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: TRACHEAL MALASIA;RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with fever\n\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with fever.\n\n Portable AP view of the chest dated , is compared with the same\n examination dated arch 12, . The patient is status post tracheostomy. An\n NG tube terminates below the diaphragm. There is cardiomegaly and mild\n congestive heart failure as indicated by prominence of the pulmonary\n vasculature. There are small bilateral pleural effusions and atelectasis at\n the lung bases. There is a prominent opacity in the right lower lobe which is\n most likely secondary to atelectasis but could be a consolidation. The aorta\n is tortuous, however this is unchanged.\n\n IMPRESSION:\n 1. Bilateral small pleural effusions and bibasilar atelectasis. Within the\n right lower lobe an opacity is most likely atelectasis but could represent\n consolidation.\n 2. Cardiomegaly with mild congestive heart failure.\n\n\n" }, { "category": "ECG", "chartdate": "2118-04-01 00:00:00.000", "description": "Report", "row_id": 191614, "text": "Poor quality tracing. Probable atrial fibrillation with variable ventricular\nresponse. Borderline low limb lead voltage. Persistent S waves to lead V6. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "L FEMUR (AP & LAT) LEFT", "row_id": 878041, "text": " 1:47 PM\n FEMUR (AP & LAT) LEFT; -77 BY DIFFERENT PHYSICIAN # \n LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT\n Reason: S/P FEMUR RODDING\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post femur rodding.\n\n Sixteen fluoroscopic images are provided from the operating room during\n interval placement of a right intramedullary femoral rod with proximal\n and distal interlocking screws transfixing comminuted fracture of the mid\n femoral shaft. Oblique fracture of the fibula is also re-identified.\n Radiologist was not present.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "L ANKLE 1 VIEW LEFT", "row_id": 878042, "text": " 1:50 PM\n ANKLE 1 VIEW LEFT Clip # \n Reason: S/P MVC POSSIBLE FX WITH CASTING IN OR\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post MVC. Casting in O.R.\n\n Three images of the ankle provided from the operating room, side not\n specified. There is an oblique fracture through the fibula and a medial\n malleolar fracture. A radiologist was not present.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 878004, "text": " 5:00 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: MVA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Motor vehicle accident.\n\n There are no prior studies available for comparison.\n\n SUPINE AP OF THE CHEST: The heart, mediastinal and hilar contours are within\n normal limits. The lungs are clear without effusion, consolidation or\n pneumothorax. There is no evidence of fracture in the chest.\n\n Portable AP of the pelvis was also obtained. There is diastasis of the pubic\n symphysis, measuring approximately 2.4 cm across. There is also evidence of a\n left inferior pubic rami fracture and fracture line along the ileum involving\n the acetabulum.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 878006, "text": " 5:30 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: trauma eval pelvic fracture\n Field of view: 37 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28M s/p motorcycle accident, PLEASE DO RETROGRADE CYSTOURETHROGRAM\n REASON FOR THIS EXAMINATION:\n trauma eval pelvic fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JHjc SAT 6:42 AM\n active extravasation in deep pelvis/base penis. large hematoma, rightward\n displacement of bladder. extraperitenal blood. left acetabular, inferior\n pubic rami, right L3 transverse process fracture. widened pubic symphsis.\n small left renal laceration.\n\n WET READ VERSION #1 JHjc SAT 6:08 AM\n WET READ VERSION #2 JHjc SAT 6:37 AM\n active extravasation in deep pelvis/base penis. large hematoma, rightward\n displacement of bladder. hemoperiteneum. left acetabular, inferior pubic\n rami, right L3 transverse process fracture. widened pubic symphsis. small\n left renal laceration.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle accident.\n\n There are no prior studies available for comparison.\n\n TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed\n following intravenous administration of 150 cc of Optiray contrast. Coronal\n and sagittal reformations were also obtained as well as delayed imaging\n through the pelvis.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The visualized lung bases are\n clear. The liver, gallbladder, spleen, right kidney, adrenals and unopacified\n loops of large and small bowel are within normal limits. Note is made of\n surgical clips and a suture line in the right upper quadrant with evidence of\n right colectomy. There is a small laceration demonstrated in the anterior\n aspect of the upper pole of the left kidney with a small adjacent subcapsular\n collection. The left renal pelvis is remarkable for a small amount of\n extravasation of urine, which is best appreciated on the sagittal\n reconstructins anteriorly. The spleen is also notable for several small\n scattered areas of hypodensity, which could potentiallly represent contusions.\n There is no adjacent collection or extravasation from the spleen. There is a\n large amount of extraperitoneal high- density fluid consistent with hemorrhage\n seen along the right flank as well as a lesser degree along the left.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is evidence of active\n extravasation of contrast material in the deep pelvis at the base of the\n (Over)\n\n 5:30 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: trauma eval pelvic fracture\n Field of view: 37 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n penis. There is an associated contrast material extending superiorly into a\n large hematoma which displaces the bladder to the right. On delayed images,\n contrast is seen contrained within the bladder. High-density fluid is also\n demonstrated anterior to the bladder most consistent with extraperitoneal\n blood. The rectum and sigmoid are within normal limits. The distal ureters\n are unremarkable. There is no adenopathy.\n\n BONE WINDOWS: There is a vertically oriented fracture line which extends from\n the left inferior pubic rami in to the acetabulum extending through the joint\n space. There is widening of the pubic symphysis. Note is also made of a\n subtle fracture involving the right transverse process of the L3 vertebral\n body. Multiple non-displaced left inferior rib fractures are also noted.\n\n Degenerative osteophytes are also demonstrated at the sacroiliac joints, which\n possible subtle widening of the right SI joint but without fracture\n idenitifed.\n\n CT RECONSTRUCTIONS: The above findings were confirmed with coronal and\n sagittal reformations.\n\n IMPRESSION:\n 1. Active extravasation of arterial contrast in the deep pelvis superior to\n the widening pubic symphysis with a large amount of associated hematoma\n extending into the pelvis as well as extraperitoneal locations, most\n pronounced along the right flank\n .\n 2. Small left anterior upper pole renal laceration with associated urine\n extravasation from the left renal pelvis, consistent with renal pelvis injury.\n\n 3. Left acetabular and inferior pubic rami fractures.\n\n 4. Possible small contusions in the spleen without associated\n collection/extravasation.\n\n 5. Degenerative changes at the sacroiliac joints with questionable widening\n of the right SI joint.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 878008, "text": " 5:36 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MVC, head trauma\n REASON FOR THIS EXAMINATION:\n please eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JHjc SAT 6:33 AM\n no c-spine fracture\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE\n\n INDICATION: Status post MVC, head trauma.\n\n There are no prior studies available for comparison.\n\n TECHNIQUE: Multidetector CT scanning of the cervical spine was performed\n without administration of intravenous contrast. Coronal and sagittal\n reformations were also obtained.\n\n FINDINGS: There are no fractures identified. The vertebral body heights and\n disc spaces are preserved. There is normal alignment. The paravertebral soft\n tissues are within normal limits. The visualized outline of the spinal canal\n is within normal limits.\n\n CT RECONSTRUCTIONS: The above findings were confirmed with coronal and\n sagittal reformations.\n\n IMPRESSION: No evidence of cervical spine fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "R HAND (AP, LAT & OBLIQUE) RIGHT", "row_id": 878009, "text": " 6:04 AM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MCC with LLE pain and R hand pain\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right hand pain.\n\n There are no prior studies available for comparison.\n\n FINDINGS: Three views of the right hand were obtained. No fracture is\n identified. The joint spaces are preserved. There is normal alignment.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "L FEMUR (AP & LAT) LEFT", "row_id": 878056, "text": " 4:50 PM\n FEMUR (AP & LAT) LEFT; -76 BY SAME PHYSICIAN # \n Reason: Please shoot only AP view, whole left femur on ONE picture\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man S/p MVC, now s/p L femur repair\n REASON FOR THIS EXAMINATION:\n Please shoot only AP view, whole left femur on ONE picture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR\n\n INDICATION: Fracture with rod insertion.\n\n Only AP views were obtained demonstrating a long intramedullary rod in place.\n The position of the main fracture fragment is much improved compared to the\n previous preop x-ray at 6 a.m. on . A few small fragments are noted\n displaced medially and laterally. The rod is anchored by two screws distally.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-20 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 878223, "text": " 10:06 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: evaluation/comparison of soft tissue injuries\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p motorcycle accident, pelvic fracture, L femur fx, L\n tib/fib fx, L renal fx, L rib fx\n REASON FOR THIS EXAMINATION:\n evaluation/comparison of soft tissue injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PAOb MON 12:26 PM\n Significant interval reduction in the size of the extraperitoneal pelvic\n hematoma.\n Interval resolution in the small perirenal collection around the upper pole\n left renal laceration.\n\n Minor splenic contusions unchanged.\n\n Pelvic bone injuries previously described.\n\n Minor left basal atelectasis and effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND IV CONTRAST.\n\n CLINICAL DETAILS: Post-motorcycle trauma. Prior embolization of bleeding\n right internal pudendal artery.\n\n Comparison is made to previous CT of .\n\n FINDINGS: Right lung base is clear. There is a minimal left basilar pleural\n effusion and minor atelectasis at the posterior aspect of the left lower lobe.\n\n Within the abdomen, the liver, pancreas, gallbladder are normal.\n\n There are several small linear hypodensities in the splenic parenchyma in\n keeping with areas of splenic injury but no perisplenic hematoma or interval\n change demonstrated.\n\n There is a linear hypodensity in the anterior aspect of the upper pole cortex\n of the left kidney in keeping with renal laceration at that point. There has\n been interval regression of the small left perirenal fluid collection which\n now measures less than a half centimeter in diameter. The collecting systems\n are normally opacified with no evidence of any extraluminal contrast from the\n collecting tracts.\n\n There has also been significant interval regression of the extraperitoneal\n pelvic hematoma which now measures less than 11 mm in depth in the right lower\n quadrant anteriorly.\n (Over)\n\n 10:06 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: evaluation/comparison of soft tissue injuries\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Coils are noted in the inferior right pelvic region at the site of previous\n coil embolization. Just medially there is a smaller area of slightly\n increased density likely to represent contrast medium following previous\n procedures.\n\n There is a urinary catheter within the bladder which is empty at the time of\n scanning. There are a small number of tiny air air locules noted anterior to\n the coils in the anterior midline pelvis. The remainder of the intra-\n abdominal and pelvic organs are unremarkable\n\n On bone windows settings, there is a nondisplaced fracture of at least the\n left eleventh rib laterally,a fracture of the right L3 transverse process.\n There is a linear nondisplaced fracture through the left acetabulum extending\n from its antero-superior portion inferiorly through the mid portion of the\n acetabular fossa to reach the inferior aspect of the left pubic ramus.There\n is widening of the symphysis pubis to 17 mm.\n There is degenerative change at the superior aspect of the right sacroiliac\n joint but no definite acute bone injury or bone displacement demonstrated.\n\n CONCLUSION:\n 1. Significant interval reduction in size of the extraperitoneal pelvic\n hematoma. There has been also interval regression in size of the small left\n perirenal fluid collection.\n 2. Linear laceration of the anterior pole cortex of left kidney and the small\n parenchymal hypodensities in the spleen,likely posttraumatic, are stable in\n the interval.\n 3. Diastasis of the symphysis pubis. Nondisplaced fracture of the left\n acetabulum extending into the left pubic rami, L3 right transverse process\n fracture, and at least one lower left rib fracture (left 10th laterally).\n\n 4. Minor effusion at the left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 878007, "text": " 5:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MVC, head trauma\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JHjc SAT 6:25 AM\n No intracranial hemorrhage or mass effect. Multiple incidnental hypodensities\n in left cerebral hemisphere, chronic in nature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC, head trauma.\n\n There are no prior studies available for comparison.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intraparenchymal or extraaxial hemorrhage. There is no\n shift of normally midline structures, mass effect or hydrocephalus. The\n ventricles, sulci and cisterns are within normal limits. Multiple hypodense\n foci are demonstrated through the left cerebral hemisphere in the subcorital\n white matter with a watershed distribution. The visualized paranasal sinuses\n demonstrate minor mucosal thickening in the ethmoids and right maxillary\n sinus. No fractures are identified.\n\n IMPRESSION:\n 1. No intracranial hemorrhage or mass effect.\n\n 2. Multiple hypodense foci in the subcortical white matter through the left\n cerebral hemisphere, probably relating to chronic infarcts in a watershed\n distribution. MR is suggested to rule out acute component relating to the\n other injuries, particularly in the absence of prior history relating to this\n abnormality or prior studies.\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "L FEMUR (AP & LAT) LEFT", "row_id": 878010, "text": " 6:04 AM\n FEMUR (AP & LAT) LEFT; TIB/FIB (AP & LAT) LEFT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with MCC with LLE pain and R hand pain\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left lower extremity pain, motor vehicle accident.\n\n FINDINGS: There is a transverse comminuted fracture through the distal\n diaphysis of the left femur with lateral and posterior displacement of the\n distal fracture fragment and overriding of the fracture fragments by\n approximately 2.2 cm. There are multiple associated smaller fragments and a\n large amount of soft tissue prominence consistent with hematoma. The knee is\n grossly intact with note of a large amount of suprapatellar swelling.\n Underlying ligamentous injury cannot be evaluated. There is also an obliquely\n oriented fracture through the left distal fibula as well as an obliquely\n oriented fracture through the inferior articular surface of the distal left\n tibia, consistent with a bimalleolar fracture. There is also a tiny likely\n avulsion fragment which could orginate from the talus or navicular.\n\n IMPRESSION: Comminuted transverse fracture of the left femur and bimalleolar\n fracture, as discussed above.\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "EMBO NON NEURO", "row_id": 878011, "text": " 7:12 AM\n MESENTERIC Clip # \n Reason: eval for bleeding vessel & embolize if possible\n Contrast: OPTIRAY Amt: 200\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY INITAL 3RD ORDER ABD/PEL/LOWER *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER ABD/PEL/LO *\n * ADD'L 2ND/3RD ORDER ABD/PEL/LO CYSTOGRAM *\n * -51 MULTI-PROCEDURE SAME DAY TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO AORTO-ILIAC A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE PELVIS SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE PELVIS SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE RENAL UNILAT SEL INCL'ING FLUS *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE EA ADD'L VESSEL AFTER BASIC A- *\n * -59 DISTINCT PROCEDURAL SERVICE CYSTOGRAPHY *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28M s/p motorcycle accident, with pelvic fracture & contrast extrav in pelvis\n on CT\n REASON FOR THIS EXAMINATION:\n eval for bleeding vessel & embolize if possible\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient had a motorcycle accident and has an active\n extravasation of blood into his left pelvis. There is also concern for a left\n renal injury on the CT scan. He had a drop in hematocrit and required\n transfusion.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. , with Dr.\n being present throughout. The right groin was prepared in a sterile\n fashion. After local anesthesia with 5 mL 1% lidocaine, the right femoral\n artery was entered with a 19-gauge needle. Over a Bentson guidewire a 5-\n French sheath was placed. An Omniflush catheter was placed at the level of L3\n and an aortogram with iliofemoral runoff was performed. It demonstrated a\n small distal aorta. The anterior division branches of the right internal\n iliac artery were attenuated. Active extravasation was identified at the base\n of the penis. Of note was marked mass effect on the left side of the pelvis\n pushing the bladder towards the right and elongating it. The external iliac\n arteries were not affected and there was symmetric flow from the pelvis into\n the lower extremities.\n\n The Omniflush catheter was deflected over a Bentson guidewire into the left\n external iliac artery and exchange was made for a catheter. It was\n used to selectively engage the right internal iliac artery. A selective\n arteriogram of the obturator artery was performed. This demonstrated no\n (Over)\n\n 7:12 AM\n MESENTERIC Clip # \n Reason: eval for bleeding vessel & embolize if possible\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n contribution to the bleeding site at the lower pelvis. The catheter was then\n brought into the internal pudendal artery and an arteriogram was performed. It\n clearly identified a site of extravasation arising from a small branch distal\n to the takeoff of the external pudendal branch. A Tracker catheter was\n advanced under road map conditions peripherally into this branch. Injection\n demonstrated active extravasation. Based on the diagnostic findings, it was\n decided to perform embolization. A 2 mm/2 cm coil was deployed. The catheter\n was then brought more proximally in the trunk of the internal pudendal artery\n and close to the takeoff of the artery to the base of the corpus spongiosum\n and another arteriogram was performed. It demonstrated marked slowing of the\n extravasation but still contribution through an additional more inferiorly and\n more peripherally located side branch. This branch was subsequently engaged\n super- selectively. Appropriate positioning was demonstrated under\n fluoroscopic injection of contrast. With the Tracker catheter, another 2 mm/2\n cm coil was deployed. A followup arteriogram demonstrated an ideal situation\n with the bleeding controlled, and with the dorsal penile artery still being\n patent as well as the tributory to the cavernosal artery.\n\n The Tracker catheter was removed. The catheter was now advanced into\n the left anterior division of the internal iliac artery and an arteriogram was\n performed. From this site, no extravasation was identified. The \n catheter was then advanced into the external iliac artery to undo its \n shape and was removed. An Omniflush catheter was then advanced to the level of\n L2 and an aortogram of the abdominal aorta was performed. It demonstrated on\n the right side a single renal artery with an intact renal collecting system\n and absence of extravasation. The left kidney is supplied by two renal\n arteries which are of about equal diameter. The upper one arises at the usual\n level of the L1-L2 interspace. The more inferior one arises at the level of\n L3. Of note is that there is marked extravasation of contrast from the\n disrupted left renal collecting system. A selective arteriogram was then\n first performed of the upper renal artery into which a Sos catheter had been\n advanced super- selectively. Then the left lower renal artery was engaged and\n another arteriogram was performed. There was no injury to the arteries\n visible and no extravasation from the arterial tree could be observed. However\n there was considerable transit of contrast from the renal collecting system\n into the retroperitoneum.\n\n Then the request for a retrograde urethrogram and placement of a Foley\n catheter was made by teh trauma team. A Foley catheter was advanced into the\n penis. It showed some marked compression at the junction to the pelvis due to\n the hematoma. It was possible to advance the Foley catheter under fluoroscopy\n and placement in the bladder.\n\n IMPRESSION: Massive extravasation from the branches of the right internal\n pudendal artery with tracking into the left pelvis and displacement of the\n bladder. Successful embolization of two small side branches of the right\n (Over)\n\n 7:12 AM\n MESENTERIC Clip # \n Reason: eval for bleeding vessel & embolize if possible\n Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n internal pudendal artery with preservation of the dorsalis penis artery and\n the cavernosal artery. Two renal arteries on the left without vascular injury,\n however leakage from the disrupted renal collecting system.\n\n Compression of the urethra due to hematoma, but patent.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-20 00:00:00.000", "description": "PELVIS WITH JUDET VIEWS", "row_id": 878227, "text": " 10:27 AM\n PELVIS WITH JUDET VIEWS Clip # \n Reason: eval acetab fx\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with\n REASON FOR THIS EXAMINATION:\n eval acetab fx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient with pelvic fractures status post embolization.\n Evaluate pelvic fractures.\n\n STUDY: AP pelvis, inlet and outlet views of the pelvis, and bilateral Judet\n views of the pelvis.\n\n COMPARISONS: Plain films and CT from .\n\n FINDINGS:\n\n As before, there is pubic symphysis diastasis and widening of the right\n sacroiliac joint. There is a minimally displaced inferior pubic ramus\n fracture and acetabular fracture involving the anterior column, unchanged.\n Left pelvic hematoma displacing the urinary bladder rightward is again noted,\n as are right pelvic embolization coils. Left femoral rod is noted in an\n altered position. Foley catheter is in place.\n\n IMPRESSION:\n\n Unchanged appearance of left acetabular and inferior pubic ramus fractures,\n pubic symphysis diastasis, and right sacroiliac widening with pelvic\n embolization coils and left femoral intramedullary rod.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2122-07-18 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 878059, "text": " 5:06 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: Please use ONLY RECTAL contrast! R/o rectal laceration.\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with s/p motorcycle accident, pelvic fracture, L femur fx, L\n tib/fib fx, L renal fx, L rib fx\n REASON FOR THIS EXAMINATION:\n Please use ONLY RECTAL contrast! R/o rectal laceration.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motorcycle accident with pelvic and left femoral\n fractures, left renal laceration, status post coiling of the right pudendal\n artery.\n\n COMPARISON: CT of the abdomen from , at 5:36.\n\n TECHNIQUE: MDCT-acquired contiguous axial images from the pelvic brim to the\n femoral necks were obtained before and after the administration of 200 cc of\n 5% gastrograffin rectal contrast administered via a Foley catheter. No IV\n contrast was administered. Coronal and sagittal reconstructions were\n obtained.\n\n CT OF THE PELVIS WITHOUT AND WITH RECTAL CONTRAST: The rectum and distal\n aspect of the sigmoid colon appear normal without evidence of wall thickening,\n pericolonic fat stranding, or dilatation. After the instillation of rectal\n contrast, there was no evidence of contrast extravasation to suggest a\n perforation through the rectum. A large left extraperitoneal pelvic hematoma\n containing contrast is again demonstrated displacing the bladder towards the\n right, similar in size since the prior examination. Small amount of\n extraperitoneal contrast is also demonstrated in a hematoma at the base of the\n penis adjacent to new embolization coils within the right pudendal arterial\n branches. A Foley catheter is identified with a small amount of contrast\n demonstrated within a collapsed bladder. A tiny amount of air is also seen\n within the bladder lumen. The bladder wall appears slightly thickened, but\n this may be secondary to lack of distension. There has been no significant\n interval change in the extraperitoneal hematoma along the right flank. The\n distal right ureter is opacified and appears unremarkable. The left ureter is\n not visualized on this examination.\n\n There has been interval placement of a left intramedullary femoral rod\n transfixed by several screws. Again noted are multiple left pubic fractures.\n Widening of the pubic symphysis is unchanged. Small amount of air is also\n seen within the muscles of the left thigh and anterior to the right pubic\n ramus.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in\n confirming the absence of contrast extravasation from the rectum.\n\n IMPRESSION:\n 1. No evidence of contrast extravasation from the rectum or distal sigmoid\n (Over)\n\n 5:06 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: Please use ONLY RECTAL contrast! R/o rectal laceration.\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n colon.\n\n 2. Stable appearance of multiple extraperitoneal hematomas within the pelvis\n status post coiling of the right pudendal artery. No new areas of hematoma\n identified.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2122-07-22 00:00:00.000", "description": "O PELVIS (AP ONLY) IN O.R.", "row_id": 878506, "text": " 12:41 PM\n PELVIS (AP ONLY) IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: PELVIC FX\n Admitting Diagnosis: IM ROD PLACEEMENT TO LEFT FEMUR\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP PELVIS INTRAOPERATIVE IMAGES. PERFORMED ON .\n\n HISTORY: Acetabular and pubic symphysis fracture.\n\n FINDINGS AND IMPRESSION: The dictating radiologist was not present during the\n procedure. Multiple spot fluoroscopic images from the operating room\n demonstrates interval placement of a reconstruction plate with multiple screws\n fixating a diastased pubic symphysis fracture. There is also a long\n cannulated screw seen placed to the anterior column of the left pelvis\n fixating a fracture in this region. The proximal aspect of a intramedullary\n rod and interlocking screws are seen in the proximal femur. Would refer to\n the surgical report for further details.\n\n\n DR. \n" }, { "category": "Nursing/other", "chartdate": "2122-07-19 00:00:00.000", "description": "Report", "row_id": 1269044, "text": "TSICU NPN 7p-7a\nS/O\n\nNeuro- alert and oriented times 3, pt appropriate=ly concerned about plan of care and status of injuries, cooperative w/ care. PCA Morphine for pain control, pt using well, reports that w/ activity pain is about an , at rest pain is a 3. He also reports that he is more sore this AM in abdominal region and pelvis area yet no gaurding. Pt slept on and off for periods during the night in which he did not use PCA as much. Cervical collar remains intact, pt denies neck pain.\n\n pt in sinus, HR in the 70-80's at rest yet w/ exertion he readily becomes tachycardic w/ HR as high as 140 transiently, HR resolves after rest period yet when follow up hct checked it was down from 24.7 to 20.9. Tm notified and pt transfused w/ 2 units of PC's over night and repeat hct 1 1/2 hours after blood infused up to 25.4. pt's BP stable from 140-160/40-65, extremities slightly cool to touch yet pt prefers the room temp to be quite cool, pulses easily palpable in distal pulses however. Lytes repleted as ordered.\n\n pt on 2 liters NC over night secondary to desating to 89-90% . Bresth sounds clear bilaterally, nonproductive cough.\n\nGI- abd soft nondistended, hypoative bowel sounds. Pt denies nausea at rest. Remains NPO w/ IVF of LR at 100cc's hr.\n\nGU- u/o adequate overnight however urine w/ increased hematuriaa the night progressed.\n\n pt w/ small abrasion on left perineum w/ slight serosang oozing.\n\nEndo blood sugar 206 when pt still on D5W down to 127 this AM.\n\nID- afebrile, no abx's.\n\nA/P- borderline hct, recheck q 6hrs per team, otherwise remains hemodynamically stable, assess next hcitto see if pt may start on PO clear liq's. con't to monitor lights and replete as needed.\n" }, { "category": "Nursing/other", "chartdate": "2122-07-18 00:00:00.000", "description": "Report", "row_id": 1269043, "text": "TSICU ADM NOTED\nPt 28 yo male s/p motorcycle crash. No LOC. +Helmet, found approx 15ft from pt. Pt to OSH, then to for trauma eval. Injuries: splenic lac, left kidney lac, lg RP bleed/hematoma, L3 right sided transverse process fx, left distal tib/fib fx (splinted), left acetab/inferiror pubic rami fx, foley placed in IR with cystogram d/t lg amt of bleeding, left rib fx, left femur fx (s/p IM rod), to angio for +DPL; embolization of internal pudentals. Extubated in OR. Arrived to TSICU on simple face mask, awake and following commands. Pt to xray for postop femur imaging and CT scan with rectal contrast for ?of rectal tear. (Pt appearantly had lg pool of unexplained blood on sheets in EW, team concerned about rectal injury. CT preliminary results neg).\n\nNEURO: A+Ox3. Pt very short tempered. Frequently expressed frustration regarding hospitalization d/t no insurance and need to stay home from work. Pain well controlled with MSO4 PCA 1/6/8. +CSM to BLE.\n\n\nRESP: Weaned to RA. LS clear. Sats 94-98%.\n\nCV: HR 100s ST no ectopy noted. BP 130s/80s.\n\nHEME: Hct 24 from 26. Sq heparin/pboot to RLE.\n\nGI: Abd soft, nontender/nondistended. NPO.\n\nGU: U/o amber. Adequate amt. Creat 1.3. IVF D5W + 150meqNaHCO3 at 150x1L for renal protection s/p angio. Mucomyst given x 2 doses for contrast from CT. Lytes repleted.\n\nID: Afebrile. No abx.\n\nENDO: Ordered for RISS.\n\nSKIN: Abrasions to bilat knuckles. Otherwise grossly intact.\n\nSOCIAL: Lives with fiance. Has 9month old and 7yr old children. Pt is a pipefitter. Frequently expressed frustration and concern that he \"won't be able to support his kids.\" Discussed pt plan to contact SW and case mgmt regarding no insurance.\n\nASMT: Pt s/p motorcycle crash with above stated injuries. Post-op hemodynamically stable.\n\nPLAN: Cont to monitor vs, serial hcts, pain mgmt, f/u with imaging resultss, encourage mobility, sw/case mgmt consult, ? trans to floor or stepdown in AM if stable.\n" } ]

[ { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 387542, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 6+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 this am.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 387543, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 6+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 this am.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 387513, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 6+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 this am.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n" }, { "category": "Physician ", "chartdate": "2113-08-10 00:00:00.000", "description": "ICU Note - CVI", "row_id": 387515, "text": "CVICU\n HPI:\n HD3 POD 127-CABG/MVrepair\n POD 83-sternal wound debridement\n POD 79-sternal debridement//omental flap\n Ejection Fraction:55\n Hemoglobin A1c:6.9\n Pre-Op Weight:169.97 lbs 77.1 kgs\n Baseline Creatinine:0.7\n 65F\n s/p sternal debridement6/26; sternal debridement/omental flap \n s/p CABG/MVrepair . frontal meningioma. Admitted with infected\n incision\n Antibx: none until deeper cx obtained-wound surface w/pseudomonas and\n serratia\n PMH:s/p MV repair/CABG, frontal meningioma, NIDDM, HTN,\n anxiety/depression, GERD\n :dexamethasone 2mg ,Metoprolol XL 10mg/D,captopril 12.5mg\n TID,Metfromin 500mg/D,Pantoprazole 40mg/D,ASA 81mg/D,Vits,Lamotrigine\n 25mg/AM,50mg/HS,Simvastatin 40mg/D,Citalopram 20mg/D,Percocet,Plavix\n 75mg/D,Dilaudid,Albuterol IH,Fluticasone110 2p ,Nicoderm14mg/24hr\n Assessment:s/p CABG/MV repair w/ sternal wound debrdiement and omental\n flap \n Current medications:\n Acyclovir, Acetaminophen, Albuterol 0.083% Neb Soln, Aripiprazole,\n Aspirin EC, Citalopram Hydrobromide, Dexamethasone, Famotidine, Ferrous\n Sulfate, Floranex, Fluticasone Propionate, HYDROmorphone, Heparin,\n Ipratropium Bromide Neb, LaMOTrigine, Lisinopril, Lorazepam, Metoprolol\n Tartrate, Meropenem, Meropenem, Morphine Sulfate, Ondansetron,\n Vancomycin\n 24 Hour Events:\n Received from OR extubated and VAC in place\n Heparin started for known PE\n ARTERIAL LINE - START 06:49 PM\n PICC LINE - START 06:50 PM\n Allergies:\n Influenza Virus Vaccine\n Shortness of br\n Shellfish Derived\n Unknown;\n Egg\n Unknown;\n Adhesive Bandage (Topical)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Meropenem - 04:37 AM\n Infusions:\n Heparin Sodium - 600 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.2\n T current: 36.2\nC (97.2\n HR: 99 (69 - 106) bpm\n BP: 141/87(101) {141/87(101) - 141/87(101)} mmHg\n RR: 24 (19 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,403 mL\n 1,216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,403 mL\n 1,216 mL\n Blood products:\n Total out:\n 177 mL\n 240 mL\n Urine:\n 177 mL\n 215 mL\n NG:\n Stool:\n Drains:\n 25 mL\n Balance:\n 1,226 mL\n 976 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.41/35/174/22/-1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear\n bilaterally),\n Abdominal: Soft, Non-tender, Bowel sounds hypoactive\n Left Extremities: (Edema: +2), (Temperature: Warm), (Pulse\n DP/PT:\n diminished)\n Right Extremities: (Edema: +2), (Temperature: Warm), (Pulse\n DP/PT:\n diminished)\n Skin: (Incision: Clean / Dry / Intact) VAC dressing intact on sternal\n wound mild erythema on edges\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 226 K/uL\n 8.7 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 114 mEq/L\n 143 mEq/L\n 29.7 %\n 9.3 K/uL\n [image002.jpg]\n 11:00 PM\n 02:09 AM\n 02:24 AM\n WBC\n 9.3\n Hct\n 29.7\n Plt\n 226\n Creatinine\n 0.5\n TCO2\n 23\n Glucose\n 144\n 147\n Other labs: PT / PTT / INR:20.1/148.2/1.9, Differential-Neuts:92.7 %,\n Lymph:5.3 %, Mono:1.8 %, Eos:0.1 %, Ca:8.3 mg/dL, Mg:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n .H/O WOUND INFECTION\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, ativan for anxiety and dialudid prn\n pain\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, cough and deep breath, oob to chair, nebs q6h\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clears advance as tolerated\n Renal: Foley, Adequate UO, dc foley\n Hematology: stable anemia\n Endocrine: sliding scale insulin with goal BG < 150\n Infectious Disease: WBC 9 on meropenum and vancomycin started postop\n follow up with ID for plan\n Wounds: Dry dressings\n Consults: P.T., plastic surgery, ID\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:49 PM\n PICC Line - 06:50 PM\n 22 Gauge - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip, Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2113-08-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 387417, "text": "1840-1900\n Pt admitted from OR on 12L non-rebreather. Pt lethargic, oriented to\n slef only, following commands, denies pain on assessment.\n Pt put on 5L NC, foley inserted upon arrival\n Pt asking to get out of bed, calling out continuously\n 19:01\n" }, { "category": "Physician ", "chartdate": "2113-08-10 00:00:00.000", "description": "ICU Note - CVI", "row_id": 387505, "text": "CVICU\n HPI:\n HD3 POD 127-CABG/MVrepair\n POD 83-sternal wound debridement\n POD 79-sternal debridement//omental flap\n Ejection Fraction:55\n Hemoglobin A1c:6.9\n Pre-Op Weight:169.97 lbs 77.1 kgs\n Baseline Creatinine:0.7\n 65F\n s/p sternal debridement6/26; sternal debridement/omental flap \n s/p CABG/MVrepair . frontal meningioma. Admitted with infected\n incision\n Antibx: none until deeper cx obtained-wound surface w/pseudomonas and\n serratia\n PMH:s/p MV repair/CABG, frontal meningioma, NIDDM, HTN,\n anxiety/depression, GERD\n :dexamethasone 2mg ,Metoprolol XL 10mg/D,captopril 12.5mg\n TID,Metfromin 500mg/D,Pantoprazole 40mg/D,ASA 81mg/D,Vits,Lamotrigine\n 25mg/AM,50mg/HS,Simvastatin 40mg/D,Citalopram 20mg/D,Percocet,Plavix\n 75mg/D,Dilaudid,Albuterol IH,Fluticasone110 2p ,Nicoderm14mg/24hr\n Assessment:s/p CABG/MV repair w/ sternal wound debrdiement and omental\n flap \n Chief complaint:\n PMHx:\n Current medications:\n 2. 3. 1000 mL NS 4. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 5.\n Acyclovir 6. Acetaminophen\n 7. Albuterol 0.083% Neb Soln 8. Aripiprazole 9. Aspirin EC 10.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. Citalopram Hydrobromide 12. Dexamethasone 13. Famotidine 14.\n Ferrous Sulfate 15. Floranex 16. Fluticasone Propionate 110mcg\n 17. HYDROmorphone (Dilaudid) 18. Heparin 19. Ipratropium Bromide Neb\n 20. LaMOTrigine 21. Lisinopril\n 22. Lidocaine 5% Patch 23. Lorazepam 24. Metoprolol Tartrate 25.\n Meropenem 26. Meropenem 27. Morphine Sulfate\n 28. Ondansetron 29. Pneumococcal Vac Polyvalent 30. Sodium Chloride\n 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 06:49 PM\n PICC LINE - START 06:50 PM\n Allergies:\n Influenza Virus Vaccine\n Shortness of br\n Shellfish Derived\n Unknown;\n Egg\n Unknown;\n Adhesive Bandage (Topical)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Meropenem - 04:37 AM\n Infusions:\n Heparin Sodium - 600 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.2\n T current: 36.2\nC (97.2\n HR: 99 (69 - 106) bpm\n BP: 141/87(101) {141/87(101) - 141/87(101)} mmHg\n RR: 24 (19 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,403 mL\n 1,216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,403 mL\n 1,216 mL\n Blood products:\n Total out:\n 177 mL\n 240 mL\n Urine:\n 177 mL\n 215 mL\n NG:\n Stool:\n Drains:\n 25 mL\n Balance:\n 1,226 mL\n 976 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.41/35/174/22/-1\n Physical Examination\n Labs / Radiology\n 226 K/uL\n 8.7 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 114 mEq/L\n 143 mEq/L\n 29.7 %\n 9.3 K/uL\n [image002.jpg]\n 11:00 PM\n 02:09 AM\n 02:24 AM\n WBC\n 9.3\n Hct\n 29.7\n Plt\n 226\n Creatinine\n 0.5\n TCO2\n 23\n Glucose\n 144\n 147\n Other labs: PT / PTT / INR:20.1/148.2/1.9, Differential-Neuts:92.7 %,\n Lymph:5.3 %, Mono:1.8 %, Eos:0.1 %, Ca:8.3 mg/dL, Mg:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n .H/O WOUND INFECTION\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:49 PM\n PICC Line - 06:50 PM\n 22 Gauge - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip, Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2113-08-10 00:00:00.000", "description": "ICU Note - CVI", "row_id": 387511, "text": "CVICU\n HPI:\n HD3 POD 127-CABG/MVrepair\n POD 83-sternal wound debridement\n POD 79-sternal debridement//omental flap\n Ejection Fraction:55\n Hemoglobin A1c:6.9\n Pre-Op Weight:169.97 lbs 77.1 kgs\n Baseline Creatinine:0.7\n 65F\n s/p sternal debridement6/26; sternal debridement/omental flap \n s/p CABG/MVrepair . frontal meningioma. Admitted with infected\n incision\n Antibx: none until deeper cx obtained-wound surface w/pseudomonas and\n serratia\n PMH:s/p MV repair/CABG, frontal meningioma, NIDDM, HTN,\n anxiety/depression, GERD\n :dexamethasone 2mg ,Metoprolol XL 10mg/D,captopril 12.5mg\n TID,Metfromin 500mg/D,Pantoprazole 40mg/D,ASA 81mg/D,Vits,Lamotrigine\n 25mg/AM,50mg/HS,Simvastatin 40mg/D,Citalopram 20mg/D,Percocet,Plavix\n 75mg/D,Dilaudid,Albuterol IH,Fluticasone110 2p ,Nicoderm14mg/24hr\n Assessment:s/p CABG/MV repair w/ sternal wound debrdiement and omental\n flap \n Chief complaint:\n PMHx:\n Current medications:\n 2. 3. 1000 mL NS 4. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 5.\n Acyclovir 6. Acetaminophen\n 7. Albuterol 0.083% Neb Soln 8. Aripiprazole 9. Aspirin EC 10.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. Citalopram Hydrobromide 12. Dexamethasone 13. Famotidine 14.\n Ferrous Sulfate 15. Floranex 16. Fluticasone Propionate 110mcg\n 17. HYDROmorphone (Dilaudid) 18. Heparin 19. Ipratropium Bromide Neb\n 20. LaMOTrigine 21. Lisinopril\n 22. Lidocaine 5% Patch 23. Lorazepam 24. Metoprolol Tartrate 25.\n Meropenem 26. Meropenem 27. Morphine Sulfate\n 28. Ondansetron 29. Pneumococcal Vac Polyvalent 30. Sodium Chloride\n 0.9% Flush 31. Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 06:49 PM\n PICC LINE - START 06:50 PM\n Allergies:\n Influenza Virus Vaccine\n Shortness of br\n Shellfish Derived\n Unknown;\n Egg\n Unknown;\n Adhesive Bandage (Topical)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 07:30 PM\n Meropenem - 04:37 AM\n Infusions:\n Heparin Sodium - 600 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.2\n T current: 36.2\nC (97.2\n HR: 99 (69 - 106) bpm\n BP: 141/87(101) {141/87(101) - 141/87(101)} mmHg\n RR: 24 (19 - 32) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,403 mL\n 1,216 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,403 mL\n 1,216 mL\n Blood products:\n Total out:\n 177 mL\n 240 mL\n Urine:\n 177 mL\n 215 mL\n NG:\n Stool:\n Drains:\n 25 mL\n Balance:\n 1,226 mL\n 976 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.41/35/174/22/-1\n Physical Examination\n Labs / Radiology\n 226 K/uL\n 8.7 g/dL\n 147 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 114 mEq/L\n 143 mEq/L\n 29.7 %\n 9.3 K/uL\n [image002.jpg]\n 11:00 PM\n 02:09 AM\n 02:24 AM\n WBC\n 9.3\n Hct\n 29.7\n Plt\n 226\n Creatinine\n 0.5\n TCO2\n 23\n Glucose\n 144\n 147\n Other labs: PT / PTT / INR:20.1/148.2/1.9, Differential-Neuts:92.7 %,\n Lymph:5.3 %, Mono:1.8 %, Eos:0.1 %, Ca:8.3 mg/dL, Mg:2.3 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n .H/O WOUND INFECTION\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 06:49 PM\n PICC Line - 06:50 PM\n 22 Gauge - 08:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip, Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear\n bilaterally), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds hypoactive\n Left Extremities: (Edema: none), (Temperature: Warm), (Pulse\n DP/PT:\n present)\n Right Extremities: (Edema: none), (Temperature: Warm), (Pulse\n DP/PT:\n present)\n Skin: (Incision: Clean / Dry / Intact) Left EVH with ACE wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 143 K/uL\n 9.9 g/dL\n 100\n 0.7 mg/dL\n 22 mEq/L\n 4.1\n 12 mg/dL\n 111 mEq/L\n 140 mEq/L\n 29.4 %\n 11.3 K/uL\n 11:46 AM\n 11:48 AM\n 12:47 PM\n 01:19 PM\n 06:20 PM\n 06:38 PM\n 09:45 PM\n 02:28 AM\n 02:44 AM\n 07:00 AM\n WBC\n 7.3\n 14.1\n 11.3\n Hct\n 26.6\n 27\n 29.1\n 29.2\n 27.6\n 29.4\n Plt\n 124\n 130\n 143\n Creatinine\n 0.7\n 0.7\n TCO2\n 24\n 24\n 25\n 25\n Glucose\n 107\n 99\n 128\n 100\n Other labs: PT / PTT / INR:13.7/36.3/1.2, Fibrinogen:154 mg/dL, Lactic\n Acid:3.3 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, adjust pain medications for control\n toradol and dilaudid prn\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS, cough and deep breath, oob to chair, nebs q6h and\n transition back to home inhalers\n Gastrointestinal / Abdomen: bowel regimen, zofran prn nausea which may\n be related to pain medications\n morphine discontinued\n Nutrition: Clears advance as tolerated\n Renal: Foley, Adequate UO, Lasix for diuresis with goal 1000 ml\n negative for 24 hours\n Hematology: stable anemia\n Endocrine: insulin drip with goal BG < 150\n Infectious Disease: WBC 11, cefazolin for perioperative antibiotics no\n evidence of infection\n Wounds: Dry dressings\n Consults: P.T.\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 387485, "text": ": 66 y/o admitted from NH with purulent drainage of sternal\n wound. Surgical finding showed fat necrosis of SQ fat. Pectoral flaps\n intact, wound debrided to bleeding tissue base, wound edges debrided,\n irrigated with 3L. Tissue specimen sent, VAC placed.\n .H/O wound infection/sternal dehiscence\n Assessment:\n VAC dressing intact to low suction, 25cc serous fluid drained.\n Sinus rhythm-tach, 75-105, with occasional to frequent pac\ns, rare pvc.\n SBP 140\ns-170.\n Expiratory wheezing with exertion otherwise clear. PO2 170\ns on 5l.\n 8++ edema of feet bilaterally.\n Foley to CD, oliguric at 15-30cc/hr.\n Calling out occasionally, oriented to self, inconsistently to place.\n Action:\n VAC to suction.\n BP monitored via L radial arterial line.\n D51/2NS with 20 kcl @ 75cc/hr via R PICC.\n # 22 insyte started R hand, Heparin gtt started at 800 units/hr at\n , no bolus.\n Lopressor and Lisinopril given po at .\n Ipratropium and Albuterol Nebs given q6h. o2 weaned to 3l.\n Two 500cc boluses of NS given for low UO. Foley irrigated with NS x 2,\n same amounts irrigation returned.\n Limit setting, bed low, locked, alarm on.\n Response:\n Minimal VAC drainage, dressing intact.\n PTT 148.9 at 0200. Heparin off at 0315 x 2 hours. Resumed at 600\n units/hr at 0515 MD \n HR and BP down some after meds and fluid boluses.\n Sats > 96%, wheezing with exertion.\n slept\n Plan:\n Continue po meds.\n Limit setting.\n ? Lasix.\n PTT at 1115.\n Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 387588, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x2/3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 4+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 -125.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n Assist to void.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n OPEN WOUND, CHEST/SDA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 78 kg\n Daily weight:\n Allergies/Reactions:\n Influenza Virus Vaccine\n Shortness of br\n Shellfish Derived\n Unknown;\n Egg\n Unknown;\n Adhesive Bandage (Topical)\n Unknown;\n Precautions: Contact (Hx CDiff)\n PMH: COPD, Diabetes - Insulin\n CV-PMH: Arrhythmias, CAD, Hypertension, MI\n Additional history: severe MR, CAD s/p RCA stenting c/b by ISR x 2 with\n cypher stenting done , NSTEMI, frontal lobe meningioma,\n dyslipidemia, post cath retroperitoneal hematoma from R groin\n superiorly to level of lower pole of R kidney, required 7 units PRBCs\n in , non-sustained polymorphic VT s/p ICD , depression, panic\n attacks/anxiety, prior psych admission within past several years, GERD,\n osteopenia, pulmonary nodules followed by serial imaging, diabetes, hx\n of H. pylori. smoker.\n CABG x2 <MV Repair\n Surgery / Procedure and date: - sternal debridement. to cvicu\n at 1600. out on propofol. paralyzed on cisatracurim gtt.\n Debridement, sternum, Omental Flap Reconstruction.\n pt to OR for debredement and VAC placement. to ICU due to\n respiratory issues\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:66\n Temperature:\n 95.8\n Arterial BP:\n S:154\n D:84\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula 3 lN/C\n O2 saturation:\n 100%\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2074 mL\n 24h total out:\n 390 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:09 AM\n Potassium:\n 4.0 mEq/L\n 02:09 AM\n Chloride:\n 114 mEq/L\n 02:09 AM\n CO2:\n 22 mEq/L\n 02:09 AM\n BUN:\n 16 mg/dL\n 02:09 AM\n Creatinine:\n 0.5 mg/dL\n 02:09 AM\n Glucose:\n 190\n 09:00 AM\n Hematocrit:\n 29.7 %\n 02:09 AM\n Finger Stick Glucose:\n 149\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: \n Transferred to: \n Date & time of Transfer: @ 20:00\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 387570, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 4+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 -125.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n OPEN WOUND, CHEST/SDA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 78 kg\n Daily weight:\n Allergies/Reactions:\n Influenza Virus Vaccine\n Shortness of br\n Shellfish Derived\n Unknown;\n Egg\n Unknown;\n Adhesive Bandage (Topical)\n Unknown;\n Precautions: Contact\n PMH: COPD, Diabetes - Insulin\n CV-PMH: Arrhythmias, CAD, Hypertension, MI\n Additional history: severe MR, CAD s/p RCA stenting c/b by ISR x 2 with\n cypher stenting done , NSTEMI, frontal lobe meningioma,\n dyslipidemia, post cath retroperitoneal hematoma from R groin\n superiorly to level of lower pole of R kidney, required 7 units PRBCs\n in , non-sustained polymorphic VT s/p ICD , depression, panic\n attacks/anxiety, prior psych admission within past several years, GERD,\n osteopenia, pulmonary nodules followed by serial imaging, diabetes, hx\n of H. pylori. smoker.\n CABG x2 <MV Repair\n Surgery / Procedure and date: - sternal debridement. to cvicu\n at 1600. out on propofol. paralyzed on cisatracurim gtt.\n Debridement, sternum, Omental Flap Reconstruction.\n pt to OR for debredement and VAC placement. to ICU due to\n respiratory issues\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:66\n Temperature:\n 95.8\n Arterial BP:\n S:154\n D:84\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100%\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 1,874 mL\n 24h total out:\n 390 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:09 AM\n Potassium:\n 4.0 mEq/L\n 02:09 AM\n Chloride:\n 114 mEq/L\n 02:09 AM\n CO2:\n 22 mEq/L\n 02:09 AM\n BUN:\n 16 mg/dL\n 02:09 AM\n Creatinine:\n 0.5 mg/dL\n 02:09 AM\n Glucose:\n 190\n 09:00 AM\n Hematocrit:\n 29.7 %\n 02:09 AM\n Finger Stick Glucose:\n 149\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 387571, "text": ".H/O wound infection\n Assessment:\n Alert and oriented x3, inappropriate, yelling out and pressing call\n lights continually.\n Lungs clear, diminished at bases. O2 sats > 95% on 3l nc.\n Remains in SR 90-ST 100, no ectopy. SBP stable. 6+ bilateral lower\n extremity edema. Dopplerable pedal pulses bilaterally.\n Abdomen soft, nd. BS positive. Tolerating po.\n Foley discontinued at 0800. DTV 1400-1600.\n Blood sugar 190 this am.\n Action:\n Limit setting done. Psych meds continue. Ativan ATC.\n Treated with lopressor per orders.\n OOB to chair.\n Tolerating breakfast, blood glucose treated per orders.\n VAC to sternal wound.\n Response:\n Continues to yell out at RN staff.\n HR 90\ns, SBP 120\n Needs assistance with OOB, difficult transfer.\n Plan:\n Monitor mental status, maintain safe environment.\n Monitor blood glucose.\n Monitor sternal wound.\n ------ Protected Section ------\n Blood glucose 125-190, treated per regular insulin sc. 4+ bilateral\n lower extremity edema. Voided 150 cc yellow urine on bedpan.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:02 ------\n" }, { "category": "Nursing", "chartdate": "2113-08-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 387453, "text": ": 66 y/o admitted from NH with purulent drainage of sternal\n wound. Surgical finding showed fat necrosis of SQ fat. Pectoral flaps\n intact, wound debrided to bleeding tissue base, wound edges debrided,\n irrigated with 3L. Tissue specimen sent, VAC placed.\n .H/O wound infection/sternal dehiscence\n Assessment:\n VAC dressing intact to low suction, 25cc serous fluid drained.\n Sinus rhythm-tach, 75-105, with occasional to frequent pac\ns, rare pvc.\n SBP 140\ns-170.\n Expiratory wheezing with exertion otherwise clear. PO2 170\ns on 5l.\n 8++ edema of feet bilaterally.\n Foley to CD, oliguric at 15-30cc/hr.\n Calling out occasionally, oriented to self, inconsistently to place.\n Action:\n VAC to suction.\n BP monitored via L radial arterial line.\n D51/2NS with 20 kcl @ 75cc/hr via R PICC.\n # 22 insyte started R hand, Heparin gtt started at 800 units/hr at\n , no bolus.\n Lopressor and Lisinopril given po at .\n Ipratropium and Albuterol Nebs given q6h. o2 weaned to 3l.\n Two 500cc boluses of NS given for low UO. Foley irrigated with NS x 2,\n same amounts irrigation returned.\n Limit setting, bed low, locked, alarm on.\n Response:\n Minimal VAC drainage, dressing intact.\n PTT 148.9 at 0200. Heparin off at 0315 x 2 hours. Resumed at 600\n units/hr at 0515 MD \n HR and BP down some after meds and fluid boluses.\n Sats > 96%, wheezing with exertion.\n slept\n Plan:\n Continue po meds.\n Limit setting.\n ? Lasix.\n PTT at 1115.\n Transfer to VICU.\n" }, { "category": "ECG", "chartdate": "2113-08-08 00:00:00.000", "description": "Report", "row_id": 308915, "text": "Sinus rhythm with ventricular and supraventricular premature depolarizations.\nDiffuse non-diagnostic repolarization abnormalities. Compared to the previous\ntracing of atrial and ventricular ectopy are now noted.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2175-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989886, "text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumo s/p chest tube removal\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p AVR/CABG, now readmit with sternal wound infection\n REASON FOR THIS EXAMINATION:\n eval for pneumo s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:37 A.M., .\n\n HISTORY: Status post CABG. Sternal wound infection. Chest tube removed.\n\n IMPRESSION: AP chest compared to :\n\n Moderate right pleural effusion has changed in distribution but not in overall\n volume since following removal of right pleural drains. Aside from\n the obscured portion of the right lower lobe where there is probably mild\n atelectasis, lungs are grossly clear. Heart size top normal. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 989104, "text": " 1:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tube placement\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with sternal wound s/p I&D\n REASON FOR THIS EXAMINATION:\n chest tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:05 P.M., \n\n HISTORY: Sternal wound infection.\n\n IMPRESSION: AP chest compared to and 29:\n\n Following removal of sternal wires, mild pulmonary edema has developed\n accompanied by persistent small right pleural effusion. Cardiomediastinal\n silhouette is grossly unchanged and unremarkable aside from vascular\n engorgement due in part to supine positioning. Gastric tube ends in the\n stomach, ET tube in standard position, new midline and subcutaneous drains in\n place. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2175-01-12 00:00:00.000", "description": "CT CHEST W&W/O C", "row_id": 988792, "text": " 8:54 PM\n CT CHEST W&W/O C Clip # \n Reason: S/P CABG, AVR\n Admitting Diagnosis: WOUND INFECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p AVR and CABG now with wound infection\n REASON FOR THIS EXAMINATION:\n eval for fluid collection behind sternum\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj FRI 6:36 AM\n No organized retrosternal fluid collection. Foci of retrosternal air noted,\n less in amount compared to . Anterior mediastinal stranding largely\n unchanged. Focus of air within the pulmonary artery likely related to\n injection. No pericardial effusion. Bilateral pleural effusions, right greater\n than left. Moderate hiatal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 76-year-old woman status post AVR and CABG, now with\n wound infection, evaluate for fluid collection behind the sternum.\n\n COMPARISON: CT chest performed .\n\n TECHNIQUE: MDCT acquired images were obtained through the chest after the\n administration of IV Optiray contrast.\n\n FINDINGS: A slightly enlarged lymph node in the right paratracheal station\n measuring 17 x 11 mm is unchanged from . There is no hilar or\n axillary lymphadenopathy. Extensive coronary artery calcifications, most\n severe in the left main artery and its branches is unchanged since .\n The patient is post-prosthetic aortic valve replacement and CABG.\n\n Edematous retrosternal fat is noted without evidence of drainable fluid\n collection. Interval debridement has produced a large defect in the presternal\n soft tissues extending to the xiphoid from the mid sternum, with packing\n material in place. There is no evidence of osteomyelitis. Sternal wires are\n intact and apposition of bones is satisfactory.\n\n Heart size is normal. There is no pericardial effusion. A moderate right\n pleural effusion has increased in size from . The pleural effusion\n causes increased atelectasis especially within the lateral and posterior basal\n segments of the right lung. A small left pleural effusion is stable since\n .\n\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n\n Although this exam was not optimized for subdiaphragmatic diagnosis, a hiatal\n hernia is noted, moderate.\n\n IMPRESSION:\n\n (Over)\n\n 8:54 PM\n CT CHEST W&W/O C Clip # \n Reason: S/P CABG, AVR\n Admitting Diagnosis: WOUND INFECTION\n Field of view: 36 Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No evidence of osteomyelitis or sternal instability. Upper peristernal\n phlegmon has cleared; no drainable fluid collection.\n\n 2. Enlarged right lower paratracheal mediastinal lymph node, unchanged since\n .\n\n 3. Increased moderate right, stable small, left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2175-01-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 988788, "text": " 8:23 PM\n CHEST (PA & LAT) Clip # \n Reason: eval sternum; picc placement\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval sternum; picc placement\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST.\n\n HISTORY: Status post AVR and CABG. Evaluate the sternum and PICC placement.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Small right pleural effusion has increased since and is probably\n responsible for mild right lower lobe atelectasis. Lungs are otherwise\n essentially clear. Minimal left pleural effusion has decreased.\n Cardiomediastinal silhouette has a normal postoperative appearance. The\n alignment of sternal wires has not changed over three weeks, but assessment of\n any wound complications will be discussed in the chest CT separate report.\n\n Tip of the left PIC catheter can be traced best on the lateral view to the\n superior cavoatrial junction.\n\n\n" }, { "category": "Echo", "chartdate": "2175-01-15 00:00:00.000", "description": "Report", "row_id": 85874, "text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Aortic valve disease. Coronary artery disease. H/O cardiac surgery. Pericardial effusion.\nStatus: Inpatient\nDate/Time: at 09:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of\nthe LA. No spontaneous echo contrast or thrombus in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast\nin the body of the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Simple atheroma in aortic arch. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Minimally increased\ngradient c/w minimal AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The patient received antibiotic\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\nstaff using a laryngoscope. No TEE related complications. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\n1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in\nthe body of the left atrium. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium or left atrial appendage.\n2. No spontaneous echo contrast is seen in the body of the right atrium. No\natrial septal defect is seen by 2D or color Doppler.\n3. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is mildly\ndepressed (LVEF= 45%).\n4. Right ventricular chamber size and free wall motion are normal.\n5. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n6. A bioprosthetic aortic valve prosthesis is present and well-seated. . There\nis a minimally increased gradient consistent with minimal aortic valve\nstenosis. Trace aortic regurgitation is seen. There is no paravalvular leak.\n7. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n8. There is a trivial/physiologic pericardial effusion.\n9. There is a moderate sized pleural effusion on both sides.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-01-16 00:00:00.000", "description": "Report", "row_id": 1671798, "text": " update\nneuro/pain: pt sleeping in naps. oriented. follows commands. morphine 2 mg iv prn for pain w/ effect. see flowsheet.\n\ncv: vs as per flowsheet. remains on neosynephrine to keep SBP ~120 or greater.(renal perf). lopressor/hydralazine held. NSR. no ect. extrems warm/dry. 2 unit prbc for hct 26.\n\nresp: on n/c. lungs clear, dim bases. using IS only to ~400cc. good cough.\n\ngi/gu: low uop. foley irrigation w/out diff. transfused as noted followed by lasix 40 mg ivp. uop improving last hour. bladder pressure check=13. abd large, soft. taking clears. denies nausea so far. rare bsp.\n\nid: wbc to 30. diff done. vanco trough 26. dosing decrease to q 24hr. reamins on cefepime q 24hr also. low grade temp.\n\nassess: low uop now improving s/p 2 unit prbc and lasix.\n\nplan: cont to monitor vs/uop/labs. keep sbp at least 120mmhg. analgesia.pulm hygiene. increase activity/diet as able. swan if uop not maintained.\n" }, { "category": "Nursing/other", "chartdate": "2175-01-17 00:00:00.000", "description": "Report", "row_id": 1671799, "text": "Neuro: pleasant. mentation & neuro intact. no deficit\n\nid: afebrile. though wbc rising. blood cx x2 sent. vanco trought 13.6\npt receiving cefepime. will have vanco later today?\n\ncv; sr, no vea. con't low dose NEO to keep sbp >120 for renal perfusion. post hct stable >30. peripheral skin w/d. sl gen edema\n\nwound: sternal-abdom wound with transparent dsd cdi. 2 JPs to bulb sxn with serosang drg. L pleural Ct to sxn- no leak/crepitus. pt wears surgical bra. abdoment fold, perinum area rash, red- applied nystatin cream.\n\nrsp: ls cta, diminish bases. pt on 4lnc with sat >96%. breathing even. pt recieving albuteral puffs. no distress\n\ngen: tol sip cl liquid. ivf continue at 75cc/hr.\npt huo marginal. bun/creatinine rising\ntreat bs with riss protocol\nleft picc and art line intact\n\ncomfort: gave morphine x1 dose in am with bathing for sternal wound pain with relief. no familiy call overnoc. provide support to pt\n\na/p pulm toilet. wean off neo. f/u uo. advance diet. ^activity to chair. support\n" }, { "category": "Nursing/other", "chartdate": "2175-01-16 00:00:00.000", "description": "Report", "row_id": 1671797, "text": "Neuro: pt alert oriented following commands moving all extremities.\nResp: pt weaned to Cpap last eveningand extubated around midnight without difficulty. Placed on 100% face tent 2nd to O2 sats initially dropped this was weaned down to 50% and then to 4l NP this am with O2 sats 96%. Pt coughing and raising small amounts..\nC/V: vss pt requiring Nitro and HYdralazine plus lopressor added last evening for BP of 160-170. post extubation SBP dipped down to 120's and nitro weaned off. Heart rate 100-115 ST but down to 90's after lopressor. pt required Neo early this am for low BP 80's /30's with MAP of 52-55. Neo on at present at 0.5mcg. with SBP of 118/47. Hct 26.4. ? Transfusion this am.\nGI: pt remained NPO for night will advance diet this am\nEndo: Insulin gtt on for several hours but presently off for BS in the 70's\nGU: Urine outputs poor all night 5-15cc/hr pt given a total of 1 l of Lr and Lasix 20mg then 40mg with no response . Foley irrigated x 2 without difficulty. Pt does not feel like her bladder is full. Neo started this am to improve BP to see if this helps urines. At present last urine output was 30 on Neo. Cr up to 1.2 from 0.8 post op yesterday\nSkin: Dsg intact no drainage.\nID WBC up to 30 pt receiving Vanco and Cefipime.\nPain: pt complains of pain in chest with coughing and deep breathing good effect from Morphine 2mg sc\nPlan: Monitor urines wean neo as tolerated. Restart preop meds.\n\n" }, { "category": "Nursing/other", "chartdate": "2175-01-15 00:00:00.000", "description": "Report", "row_id": 1671795, "text": " ADM\nPT ADM S/P STERNAL WOUND I+D, OMENTAL AND PECTORALIS FLAP.\n\nNEURO/PAIN: REMAINS ON PROPOFOL (VERY HYPERTENSIVE W/ WAKING). DOES AROUSE. FOLLOWS COMMANDS, MAE TO COMMAND. PERL. DENIES PAIN, MORPHINE GIVEN POST-OP FOR ELEVATED BP AND PRESUMED PAIN.\n\nCV: VS AS NOTED. HYPERTENSION. NTG DRIP ADDED, HYDRALAZINE GIVEN. SLOW WEAN OF PROPOFOL AS BP ALLOWS. NSR, NO ECT. K+ REPLETED. 1L NS GIVEN FOR UOP.\n\nRESP: LUNGS CLEAR BILAT. INITIALLY \"TIGHT\". ALBUTEROL ADDED W/ EFFECT. KNOWN BILAT PLEURAL EFFUSIONS. FIO2 WEAN SO FAR.\n\nWOUND: STAPLES INTACT. JP X2 W/ MIN SANG DNG. MEDIASTINAL W/ SCANT DNG, +AIRLEAK. VANCO TO CONT.\n\nGI/GU: NPO. OGT W/ BILOUS DNG. UOP MARG. FLUIDS GIVEN AS NOTED. DRIFTING AGAIN. TEAM AWARE. NO NEW ORDERS AT THIS TIME.\n\nSOCIAL: DAUGHTER IN. UPDATED.\n\nASSESS: HYPERTENSION W/ WAKE UP. MARG UOP.\n\nPLAN: CONT TO MONITOR. ANTIHYPERTENSIVES, WEAN PROPOFOL, VENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2175-01-15 00:00:00.000", "description": "Report", "row_id": 1671796, "text": "76yr female s/p MVR/CABG approximately one month PTA, returns now s/p sternal debridement. 7.0 ET, 21 @ lip. Small air leak through R chest tube. BS coarse crackles and expiratory wheezing clearing with MDI. Continue to wean per protocol.\n" }, { "category": "ECG", "chartdate": "2175-01-20 00:00:00.000", "description": "Report", "row_id": 217819, "text": "Baseline artifact. Probable sinus rhythm with low amplitude P waves and mild\nP-R interval prolonagation. Low limb lead voltage. ST-T wave abnormalities.\nSince previous tracing of inferior T waves are improved.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2189-08-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469950, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Family discussion with Neuro medicine team resulted in\n decision to make patient CMO\n waiting for family arrival at beginning of shift\n Action:\n family arrived\n propofol stopped\n morphine drip started\n patient extubated\n Response:\n pt appeared very comfortable, breathing easily\n family decided to go home, would like a call if patient\n passed away\n patient did pass away ~ 0500 after repositioning\n Plan:\n Family was contact\n Discussion about a necklace that patient always wore with\n family. Through speaking with ED and documentation, patient did not\n come to with the necklace on. I spoke with \n hospital where she was transferred from, and they will\nleave a note\n for the day staff to ask them about it.\n Only belongings that are present are her home medications\n which the patient\ns son asked me to dispose of.\n Family support.\n" }, { "category": "Nursing", "chartdate": "2189-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469873, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - Pt found down this morning on her porch by her neighbor; R ICH\n hemorrhage with 1.5 cm midline shift. Pt\ns r pupil glaucoma; L pupil\n 5mm/non-reactive; extension/posturing in upper extremities; localizing\n in lower extremities. Not opening eyes; negative gag/cough/corneals;\n not following commands.\n Action:\n - Neuro exam, Propofol for general comfort; keppra; sent periph blood\n culture X1, urine cx, mrsa swab.\n Response:\n - Neuro exam remains unchanged.\n Plan:\n - SBP <160; keppra; neuro exam Q2; possible repeat head CT tomorrow.\n ------ Protected Section ------\n Patient\ns son and granddaughter met with this writer, team\n including attending Dr , and SICU resident to discuss poor\n prognosis. Dr related to family that patient will not make\n appreciable recovery from this injury. Family understands prognosis and\n stated that patient would not want to prolong life on artificial life\n support with no chance of appreciable recovery. Family decided to make\n patient DNR/CMO.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:11 ------\n" }, { "category": "Physician ", "chartdate": "2189-08-05 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 469854, "text": "Chief Complaint: Right ICH\n HPI:\n 89F with hx HTN, prior stroke, HLD, seizures, CRF, presents now with\n large Right ICH. She was found down at her home on the back porch this\n AM after son had left for work, and taken to Hosp.\n GSC there was felt to be 6 and she was intubated. Coags were normal.\n NCHCT showed large R ICH with intraventricular extension and 1.5 cm\n midline shift.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, HLD, prior stroke to R eye leaving her blind, prior brain bleed\n 1-2 years ago, (son not clear what type), CRF, ?DM (not by hx, but\n elevated serum glucose and glucose in urine)\n PSH: CCY, VHR, L hip fx fixation\n FH: daughter w/ CA\n SH: Lives at home with son. reports some mild dementia, but MS\n largely intact.\n PCP = , MD: \n Son : \n Flowsheet Data as of 05:47 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 102 (100 - 102) bpm\n BP: 158/87(101) {158/87(101) - 158/87(101)} mmHg\n RR: 32 (29 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -149 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 291 (291 - 291) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 15 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: Pupils dilated, fixed\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases)\n Abdominal: Soft, Non-tender, Obese, midline scar, umbillical hernia\n Extremities: Right: 2+, Left: 2+, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment And Plan: 89 F with hx HTN, prior stroke, HLD, seizures,\n CRF, found\n down at her home on the front stairs this AM with NCHCT revealing\n large Right ICH. Though she has known HTN, bleed appears lobar\n and most likey amyloid angiopathy. Poor prognosis\n Neurologic: keppra 500''. Head elevated. Consider repeat CT. Propofol.\n Not surgical candidate per NS.\n Cardiovascular: SBP < 160, lopressor and hydral prn; trop 1.14\n Pulmonary: intubated\n Gastrointestinal: NPO/meds\n Renal: CRF +lasix dependent, watch fluid status (keep neg); Cr 3.7\n Hematology: Hct 31.2, boots\n Infectious Disease: WBC 23>18, FU cx\n Endocrine: RISS\n Fluids: NS 75\n Electrolytes: Replete lytes\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:19 PM\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family to discuss code\n status again\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2189-08-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 469907, "text": "Patient extubated without any complication. Nurse present at the time\n of extubation.\n" }, { "category": "Physician ", "chartdate": "2189-08-05 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 469860, "text": "Chief Complaint: Right ICH\n HPI:\n 89F with hx HTN, prior stroke, HLD, seizures, CRF, presents now with\n large Right ICH. She was found down at her home on the back porch this\n AM after son had left for work, and taken to Hosp.\n GSC there was felt to be 6 and she was intubated. Coags were normal.\n NCHCT showed large R ICH with intraventricular extension and 1.5 cm\n midline shift.\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family / Social history:\n HTN, HLD, prior stroke to R eye leaving her blind, prior brain bleed\n 1-2 years ago, (son not clear what type), CRF, ?DM (not by hx, but\n elevated serum glucose and glucose in urine)\n PSH: CCY, VHR, L hip fx fixation\n FH: daughter w/ CA\n SH: Lives at home with son. reports some mild dementia, but MS\n largely intact.\n PCP = , MD: \n Son : \n Flowsheet Data as of 05:47 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 102 (100 - 102) bpm\n BP: 158/87(101) {158/87(101) - 158/87(101)} mmHg\n RR: 32 (29 - 32) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1 mL\n PO:\n TF:\n IVF:\n 1 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -149 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 291 (291 - 291) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 94%\n ABG: ////\n Ve: 15 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: Pupils dilated, fixed\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: bases)\n Abdominal: Soft, Non-tender, Obese, midline scar, umbillical hernia\n Extremities: Right: 2+, Left: 2+, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment And Plan: 89 F with hx HTN, prior stroke, HLD, seizures,\n CRF, found\n down at her home on the front stairs this AM with NCHCT revealing\n large Right ICH. Though she has known HTN, bleed appears lobar\n and most likey amyloid angiopathy. Poor prognosis\n Neurologic: keppra 500''. Head elevated. Consider repeat CT. Propofol.\n Not surgical candidate per NS.\n Cardiovascular: SBP < 160, lopressor and hydral prn; trop 1.14\n Pulmonary: intubated\n Gastrointestinal: NPO/meds\n Renal: CRF +lasix dependent, watch fluid status (keep neg); Cr 3.7\n Hematology: Hct 31.2, boots\n Infectious Disease: WBC 23>18, FU cx\n Endocrine: RISS\n Fluids: NS 75\n Electrolytes: Replete lytes\n Nutrition: NPO\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:19 PM\n 20 Gauge - 05:20 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family to discuss code\n status again\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n ------ Protected Section ------\n Addendum\n Patient\ns family wishes to change code status to DNR. Discussed with\n son and grand daughter, confirmed on at 1800.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:59 ------\n" }, { "category": "Respiratory ", "chartdate": "2189-08-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 469863, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt transfered to icu then placed on psv 5/5 where she now\n remains\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: plan to continue on current settings as tolerated\n" }, { "category": "Nursing", "chartdate": "2189-08-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 469866, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - Pt found down this morning on her porch by her neighbor; R ICH\n hemorrhage with 1.5 cm midline shift. Pt\ns r pupil glaucoma; L pupil\n 5mm/non-reactive; extension/posturing in upper extremities; localizing\n in lower extremities. Not opening eyes; negative gag/cough/corneals;\n not following commands.\n Action:\n - Neuro exam, Propofol for general comfort; keppra; sent periph blood\n culture X1, urine cx, mrsa swab.\n Response:\n - Neuro exam remains unchanged.\n Plan:\n - SBP <160; keppra; neuro exam Q2; possible repeat head CT tomorrow.\n" }, { "category": "ECG", "chartdate": "2189-08-05 00:00:00.000", "description": "Report", "row_id": 234903, "text": "Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available\nfor comparison.\n\n" }, { "category": "Radiology", "chartdate": "2189-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087411, "text": " 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tub placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with cva, intubated\n REASON FOR THIS EXAMINATION:\n tub placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj WED 2:47 PM\n PFI: ETT and NG tubes in standard position. Mild pulmonary edema. Large\n left retrocardiac opacity which may represent a combination of effusion and\n atelectasis. However, a post-obstructive lesion cannot be excluded and close\n interval followup is advised.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89-year-old female with CVA status post intubation.\n\n COMPARISONS: None.\n\n AP PORTABLE CHEST: An endotracheal tube terminates 4.9 cm above the carina. A\n nasogastric tube terminates well within the stomach, in good position. A\n large retrocardiac opacity may represent a combination of effusion and\n atelectasis. However, the presence of a post-obstructive lesion cannot be\n completely excluded in the absence of prior radiographs. The left upper lobe\n demonstrates a hazy appearance. There is fullness of the central pulmonary\n vascularities and mild increase in interstitial markings compatible with mild\n pulmonary edema. There is no definite right pleural effusion. Incidental\n note is made of surgical clips in the right upper quadrant of the abdomen and\n calcifications of the carotid arteries bilaterally.\n\n IMPRESSION:\n\n 1. Mild pulmonary edema.\n\n 2. ETT and NG tubes in standard positions.\n\n 3. Left retrocardiac opacity most likely representing a combination of\n effusion and lobar atelectasis. However, in the absence of prior examinations\n for comparison, a post-obstructive process cannot be excluded. Close interval\n radiographic followup is advised. Consider CT if persistent.\n\n" }, { "category": "Radiology", "chartdate": "2189-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1087412, "text": ", EU 12:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tub placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with cva, intubated\n REASON FOR THIS EXAMINATION:\n tub placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: ETT and NG tubes in standard position. Mild pulmonary edema. Large\n left retrocardiac opacity which may represent a combination of effusion and\n atelectasis. However, a post-obstructive lesion cannot be excluded and close\n interval followup is advised.\n\n" }, { "category": "Radiology", "chartdate": "2189-08-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087475, "text": " 4:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed CNS evaluate extension\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with LOC\n REASON FOR THIS EXAMINATION:\n bleed CNS evaluate extension\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 7:12 PM\n Large frontal lobar hemorrhage with blood-fluid levels. Subarachnoid\n hemorrhage. 2.2 cm of leftward subfalcine herniation. Suprasellar cisterns\n effaced with uncal herniation. There is downward transtentorial herniation,\n no tonsillar herniation. No intraventricular blood.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 89-year-old woman with sudden loss of consciousness. Evaluate known\n CNS bleed.\n\n HEAD CT: Axial MDCT imaging was performed through the brain without IV\n contrast administration.\n\n COMPARISON: At the time of dictation, no outside study was available on PACS\n for comparsion. However, a head CT was known to have been performed at an\n outside institution prior to transfer to .\n\n FINDINGS: There is a large lobar hemorrhage involving the right frontal,\n temporal and parietal lobes. There is a prominent blood-fluid level (2:16) in\n this parenchymal hemorrhage, usually seen in setting of therapeutic\n anticoagulation or native coagulopathy. There is prominent but\n focal subarachnoid hemorrhage with blood in the immediately-overlying\n right frontal sulci (2:27). This lobar hemorrhage with surrounding\n hypodensity, likely vasogenic edema, causes severe leftward subfalcine\n herniation with 2.2 cm of leftward shift of normally-midline structures. There\n is complete effacement of the frontal of the right lateral ventricle. The\n suprasellar cistern is entirely effaced with right uncal herniation. At the\n level of the ambient cisterns (2:12), there is downward transtentorial\n herniation with widening of the right and effacement of the left ambient\n cistern, while the quadrigeminal plate cistern is relatively preserved. The\n left lateral ventricle and temporal appear enlarged and may be \"trapped\"\n at the level of the foramen of . There is no tonsillar herniation. There\n is no blood in the ventricular system. There are no signs of hypodensity in\n the distribution of the PCA to suggest acute infarction secondary to\n herniation.\n\n There are periventricular white matter hypodensities better visualized around\n the left lateral ventricle (2:19), likely sequela of chronic microvascular\n infarction. Osseous structures appear intact without evidence for fracture.\n Carotid siphons are densely calcified. There is minimal mucosal thickening of\n the ethmoidal air cells; the remaining paranasal sinuses and mastoid air cells\n are clear.\n (Over)\n\n 4:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed CNS evaluate extension\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Large right frontotemporoparietal lobar hemorrhage with blood-fluid level.\n Of note, there is overlying right frontal subarachnoid, but no\n intraventricular hemorrhage. The differential diagnosis favors\n underlying amyloid angiopathy with associated involvement of pial vessels;\n however, the prominent blood-fluid level, at time of presentation, suggests\n that anticoagulation or intrinsic coagulopathy may have contributed to the\n hemorrhage.\n\n 2. Significant edema surrounding the right lobar hemorrhage and as a result,\n there is 2.2 cm of leftward shift of midline structures and subfalcine\n herniation. The suprasellar cistern is effaced with uncal herniation. There\n is downward transtentorial herniation with narrowing of the ambient cistern.\n There is no tonsillar herniation.\n\n 3. No intraventricular hemorrhage.\n\n 4. Effacement of the right lateral ventricle with enlargement and possible\n \"trapping\" of the left lateral ventricle. There is no sign of territorial\n infarction involving the PCA or other arterial distribution.\n\n COMMENT: Comparison to THE outside study would allow for evaluation of the\n tempo of interval change, which may provide prognostic information.\n\n These findings were communicated via telephone by Dr. to Dr.\n (Neurology service) at approximately 5:30 PM, on .\n\n" }, { "category": "Radiology", "chartdate": "2189-08-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1087476, "text": ", C. NMED SICU-A 4:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed CNS evaluate extension\n Admitting Diagnosis: INTRAPARENCHYMAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old woman with LOC\n REASON FOR THIS EXAMINATION:\n bleed CNS evaluate extension\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large frontal lobar hemorrhage with blood-fluid levels. Subarachnoid\n hemorrhage. 2.2 cm of leftward subfalcine herniation. Suprasellar cisterns\n effaced with uncal herniation. There is downward transtentorial herniation,\n no tonsillar herniation. No intraventricular blood.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580896, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n Ca: 7.6 Mg: 2.0 P: 1.7\n ALT: 57\n AP: 92\n Tbili: 2.3\n Alb:\n AST: 34\n LDH: 537\n Dbili:\n TProt:\n : 430\n Lip: 763\n UricA:1.6\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n Assessment and Plan\n PANCYTOPENIA\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n onging hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. Differential includes underlying\n malignancy, infectious etiology, alcohol, autoimmune process, or drug\n induced. Infectious etiologies include parvo, malaria(but no travel\n history), encapsulated organisms (salmonella, staph), mycoplasma, EBv,\n CMV. Did recently complete course of bactrim/keflex but no evidence of\n drug-rxn. Must also consider Bartonella given Cats at home, but no skin\n lesions present.\n - clarify w/ PCP any new drugs\n - send off serology for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - given joint effusion, send off lyme, check smear for erlichia,\n babesia\n - neutropenic precautions, start vancomycin/cefepime/azithro\n - hold HIV meds, consult ID as to what can be continued/should be in\n this setting\n - consult heme/onc\n .\n # pancreatitis - gallstone pancreatitis vs. ETOH-induced pancreatitis.\n Cocurrent elevated LFTs in a cholestatic pattern make gallstone\n pancreatitis more likely (see below). Currently without pain\n - NPO, IVF prn\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider alcoholic\n hepatitis given patient's history.\n - trend LFTs\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend HCT Q6H, check post-tx HCT at 2Pm\n - transfuse to goal HCT >21 once has HCt has stabilized\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - repeat VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: IVFs / replete lytes prn / NPO\n .\n # PPX: hold on SQ heparin given thrombocytopenia, bowel regimen prn, H2\n blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "ECG", "chartdate": "2187-08-01 00:00:00.000", "description": "Report", "row_id": 150058, "text": "Sinus tachycardia. Compared to the previous tracing of the rate has\nincreased.\n\n" }, { "category": "ECG", "chartdate": "2187-07-19 00:00:00.000", "description": "Report", "row_id": 150059, "text": "Sinus rhythm. Normal tracing with slowing of the rate as compared with\nprevious tracing of . Otherwise, no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2187-07-18 00:00:00.000", "description": "Report", "row_id": 150060, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2187-07-20 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1084707, "text": " 8:57 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for mass or signs of viral infections\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and Progressive multifocal leukoencephalopathy now\n with mental status change\n REASON FOR THIS EXAMINATION:\n assess for mass or signs of viral infections\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:37 PM\n Ex-vacuo dilatation of both lateral ventricles with encephalomalacia changes\n in the left cerebral hemisphere and right periatrial region are again noted.\n The ventricular size is increased which could be secondary to progressive\n atrophy. No enhancing brain lesions, new signal abnormalities or acute\n infarcts seen.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with HIV and progressive multifocal\n leukoencephalopathy, now with mental status changes, for further evaluation to\n exclude viral infection or other signs of infection.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following gadolinium. Comparison was made with the previous\n MRI of .\n\n FINDINGS: Again ex vacuo dilatation of the left lateral ventricle identified\n with changes of encephalomalacia in the left parieto-occipital region. The\n left temporal is also dilated. There are hyperintensities in the right\n periatrial region with dilatation of atrium of the right lateral ventricle.\n There appears to be a progressive dilatation of the left lateral ventricle\n with decrease in cortical width in the region which could be due to\n progression in encephalomalacia and atrophy. There is no acute infarcts seen.\n There is no hydrocephalus identified. There is evidence of wallerian\n degeneration with atrophy of the left side of the midbrain. Following\n gadolinium no evidence of abnormal parenchymal, vascular or meningeal\n enhancement seen. Soft tissue changes with retention cysts are seen in the\n right maxillary sinus.\n\n IMPRESSION:\n 1. Left-sided frontoparietal and occipital encephalomalacia with ex vacuo\n dilatation of the left lateral ventricle which has slightly increased since\n the previous study due to progression in encephalomalacia changes.\n\n 2. Signal changes in the right periatrial region with dilatation of the atrium\n of the right lateral ventricle as before.\n\n (Over)\n\n 8:57 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for mass or signs of viral infections\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. The overall size of the lateral and third ventricles has slightly\n increased which appears to be secondary to progressive atrophy.\n 4.. Wallerian degeneration is seen in left side of the midbrain with atrophy.\n 5. No evidence of acute infarct or new signal abnormalities or enhancing\n brain lesions.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-20 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1084708, "text": ", S. MED FA9A 8:57 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for mass or signs of viral infections\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and Progressive multifocal leukoencephalopathy now\n with mental status change\n REASON FOR THIS EXAMINATION:\n assess for mass or signs of viral infections\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Ex-vacuo dilatation of both lateral ventricles with encephalomalacia changes\n in the left cerebral hemisphere and right periatrial region are again noted.\n The ventricular size is increased which could be secondary to progressive\n atrophy. No enhancing brain lesions, new signal abnormalities or acute\n infarcts seen.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085642, "text": " 5:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pna\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with febrile neutropenia\n REASON FOR THIS EXAMINATION:\n Please assess for pna\n ______________________________________________________________________________\n WET READ: 9:46 PM\n No evidence of pneumonia. - 9:30 pm .\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Febrile neutropenia.\n\n Portable AP chest radiograph was compared to .\n\n Cardiomediastinal silhouette is stable. There is increase in the lung volumes\n consistent with better aeration of the lung bases and resolution of previously\n seen bibasilar areas of atelectasis. The stomach continues to be distended.\n There is no pleural effusion or pneumothorax. There are no lung\n consolidations worrisome for infectious process within the limitations of the\n chest radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1085400, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with PE's now with febrile neutropenia\n REASON FOR THIS EXAMINATION:\n assess for PNA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Febrile neutropenia.\n\n Portable AP chest radiograph was compared to .\n\n The lung volumes are lower than on the prior study which contributes to larger\n looking cardiomediastinal silhouette. The stomach is distended. The bibasal\n opacities are most likely consistent with areas of atelectasis but no overt\n consolidation to suggest pneumonia is demonstrated. Note is made that the\n septal findings might be occult on the chest radiograph thus if clinically\n warranted evaluation with chest CT might be considered.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-19 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1084526, "text": " 10:26 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please evaluate for evidence of infection or other explanati\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man w/ HIV p/w AMS, pancytopenia, hypoxia\n REASON FOR THIS EXAMINATION:\n please evaluate for evidence of infection or other explanation sx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc FRI 8:42 AM\n bilateral central (lobar) PE, without CT evidence for right heart strain.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: HIV, pancytopenia, hypoxia.\n\n TECHNIQUE: Multidetector CT through the chest was acquired after\n administration of IV contrast. 5- and 1.25-mm collimation images, sagittal\n and coronal reformations were provided and reviewed.\n\n FINDINGS: The evaluation of this study is limited by respiratory motion.\n There is extensive bilateral central PE which extends to the segmental left\n lower lobe pulmonary arteries. There is no evidence of right heart strain.\n The aorta is normal in caliber. Cardiac size is normal. There is no\n pericardial or pleural effusion. Minimal calcification is in the LAD. There\n are no enlarged mediastinal, hilar, or axillary lymph nodes. Emphysema in the\n upper lobes is very mild. Linear atelectases are present in the lower lobes\n bilaterally and in the left upper lobe. Calcified granuloma is in the right\n apex (4, 47). Subpleural non-calcified lung nodule in the right upper lobe (4,\n 98) could be atelectasis.\n\n This examination is not tailored for subdiaphragmatic evaluation. There is\n splenomegaly. Portacaval lymph node measures 10 mm.\n\n There are no bone findings of malignancy. Old healed fractures are in the\n posterior 5th, 6th, 8th, 9th, amd 10th right ribs.\n\n IMPRESSION: Bilateral extensive pulmonary embolism without CT evidence of\n right heart strain. Findings were discussed with Dr. by Dr. \n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-29 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1086012, "text": " 10:48 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: RUQ PAIN ,TRANSAMINITIS,EVAL FOR GB/LIVER PATHOLOGY\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV now with RUQ pain, n/v, and transaminitis and elevated\n bilis.\n REASON FOR THIS EXAMINATION:\n Please assess for gallbladder/liver pathology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SUN 11:48 AM\n Persistent ecjhogenic liver (C/w diffuse fatty infiltration) &\n cholelithisiasis\n No intra hepatic biliary dilatation\n Extrahepatic dilation to 9mm - refer to CT from today and consider MRCP\n Focal GB wall thickening may related to liver disease non specific for\n cholecystitis (if high clinical suspiscion consider nuclear medicine\n hepatobilairy study)\\\n No ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, now with right upper quadrant pain, nausea and vomiting,\n transaminitis and elevated bilirubin; please assess for gallbladder/liver\n pathology.\n\n COMPARISON: CT , ultrasound .\n\n LIVER/GALLBLADDER ULTRASOUND: -scale and color Doppler son images\n demonstrate the liver to be echogenic, but without focal hepatic lesions.\n There is no intrahepatic bile duct dilatation. There is no ascites. The\n common bile duct measures from 5-8 mm. The gallbladder is not distended.\n There is focal gallbladder wall thickening to 6 mm.\n\n Again seen are mobile hyperechogenic foci with posterior acoustic shadowing\n consistent with gallbladder stones. There is no gallbladder wall thickening\n or pericholecystic fluid. Main portal venous flow is hepatopetal.\n\n IMPRESSION:\n 1. Persistent echogenic liver consistent with diffuse fatty infiltration.\n Other forms of more advanced liver disease such as fibrosis/cirrhosis cannot\n be excluded.\n 2. Persistent cholelithiasis. No intrahepatic biliary dilatation.\n 3. Extrahepatic ducts more prominant on this study. Refer to CT for more\n details and/or consider MRCP for further characterization.\n 4. Focal gallbladder wall thickening to 6 mm most likely due to hepatic\n disease or pancreatitis.\n\n (Over)\n\n 10:48 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: RUQ PAIN ,TRANSAMINITIS,EVAL FOR GB/LIVER PATHOLOGY\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2187-07-29 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1086013, "text": ", V. MED FA2 10:48 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: RUQ PAIN ,TRANSAMINITIS,EVAL FOR GB/LIVER PATHOLOGY\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV now with RUQ pain, n/v, and transaminitis and elevated\n bilis.\n REASON FOR THIS EXAMINATION:\n Please assess for gallbladder/liver pathology\n ______________________________________________________________________________\n PFI REPORT\n Persistent ecjhogenic liver (C/w diffuse fatty infiltration) &\n cholelithisiasis\n No intra hepatic biliary dilatation\n Extrahepatic dilation to 9mm - refer to CT from today and consider MRCP\n Focal GB wall thickening may related to liver disease non specific for\n cholecystitis (if high clinical suspiscion consider nuclear medicine\n hepatobilairy study)\\\n No ascites\n\n" }, { "category": "Radiology", "chartdate": "2187-08-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1086790, "text": " 5:38 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for pna\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV, PE with IVC, RP bleed now stable, c diff on po vanc\n presents with fever\n REASON FOR THIS EXAMINATION:\n please eval for pna\n ______________________________________________________________________________\n WET READ: RSRc FRI 9:24 PM\n No change or evidence of PNA. 8p .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old male with HIV, history of pulmonary embolism and\n retroperitoneal hemorrhage as well as C. difficile colitis, now with fever.\n Concern for pneumonia.\n\n COMPARISON: .\n\n CHEST, TWO VIEWS: Heart size and mediastinal contours are normal. There is\n no pleural effusion or parenchymal consolidation. Skeletal structures are\n unremarkable.\n\n IMPRESSION: No pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-31 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1086305, "text": " 1:09 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PT ON LARGE HEMATOMA EVALUATE FOR FILTER ?DVT\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with pe and who was on heparin but developed rp hematoma now\n eval for IVC filter\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old man with PE, evaluate for DVT.\n\n COMPARISON: Left leg ultrasound .\n\n FINDINGS: Grayscale, color and Doppler son of bilateral common femoral,\n superficial femoral, popliteal and tibial veins were performed. The right\n popliteal vein does not completely compress on compression views. Some venous\n flow is identified within the right popliteal vein, but the flow is not\n wall-to-wall. These findings are consistent with nonocclusive thrombus in the\n right popliteal vein. There is normal flow, compression and augmentation seen\n in the remainder of the vessels of both legs.\n\n IMPRESSION: Nonocclusive deep vein thrombus in the right popliteal vein. No\n additional DVT is seen in the remainder of the veins of both legs.\n\n These findings were conveyed to Dr. at 3:30 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1086173, "text": " 3:48 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for retroperitoneal hematoma\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and illiopsoas inflammation concerning for abscess on\n zosyn, CT evidence of billiary stones awaiting ERCP, as well as multiple PEs\n who was on heparin pw acute anemia.\n REASON FOR THIS EXAMINATION:\n please eval for retroperitoneal hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf MON 7:51 PM\n PFI: Fluid collection at the right iliopsoas muscle concerning for hematoma.\n Hyperdense fluid in the right posterior pararenal space. Two small fluid\n collections tracking along the right iliacus muscle in the pelvis concerning\n for smaller hematoma. Asymmetry at the right high with loss of fat planes at\n the adductor compartment, and fat stranding in the soft tissue, concerning for\n possible hematoma, if clinically correlated. Findings were discussed with\n at 5:10 p.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old man with HIV and iliopsoas inflammation concerning for\n abscess on Zosyn, CT evidence of biliary stones awaiting ERCP as well as\n multiple PEs who was on heparin and now presents with acute anemia. Evaluate\n for retroperitoneal hematoma.\n\n TECHNIQUE: CT abdomen and pelvis without IV or oral contrast. Coronal and\n sagittal reformatted images provided.\n\n COMPARISON: Compared to CT abdomen and pelvis .\n\n FINDINGS: There is minor atelectasis at the lung bases with interval decrease\n in bilateral small pleural effusions.\n\n Study is limited for evaluation of solid organs due to lack of IV contrast\n administration. There are several small calcified stones within the\n gallbladder. The pancreas, spleen, adrenal glands, kidneys, and small and\n bowel appear within normal limits. There are no pathologically enlarged lymph\n nodes in the retroperitoneum or mesentery according to CT size criteria.\n Spleen is mildly enlarged. Scattered diverticula in the colon; however, there\n is no evidence of acute diverticulitis. Fluid is seen within the cecum, with\n mild fat stranding at the wall of the colon and terminal ileum, with similar\n appearance compared to prior study and could be related to C. difficile.\n\n In the right iliopsoas muscle there is a fluid collection with hematocrit\n level, best seen on series 2 image 58, which is concerning for hematoma.\n Please note that no IV contrast was administrated and therefore we are not\n able to comment on active extravasation. Additionally there is high- density\n fluid in the right posterior pararenal space, concerning for retroperitoneal\n hematoma, extending in to pelvis, 2:83. There are two fluid collections in the\n pelvis tracking along the iliac muscle on the right, measuring 29 x 33 mm\n (Over)\n\n 3:48 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for retroperitoneal hematoma\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n (2:84), and 20 x 20 mm, 2:80 concerning for small hematoma.\n\n There is asymmetry at the right thigh, with loss of fat planes at the adductor\n compartment, 2:115, limited in evaluation due to streak artifact from a hip\n prosthesis, and concerning for possible hematoma. Additionally there is fat\n stranding in the subcutaneous fat, 2:103 at the right thigh.\n\n CT PELVIS: There is remaining contrast in the urinary bladder likely from a\n prior CT scan. There is remaining contrast in the rectum and sigmoid, likely\n from a prior CT scan. There are no pathologically enlarged lymph nodes in the\n pelvis or inguinal area. Prostate and seminal vesicles appear within normal\n size.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n\n 1. Fluid collection in the right iliopsoas muscle consistent with hematoma.\n Retroperitoneal hemorrhage in the right posterior pararenal space. Two fluid\n collections in the pelvis tracking along the right iliacus muscle, concerning\n for hematoma. Asymmetry at the right thigh consistent with possible hematoma.\n Please note that no IV contrast was administered limiting the evaluation for\n active extravasation.\n\n 2. Cholelithiasis with no CT evidence for acute cholecystitis.\n\n 3. Minimal fat stranding at the cecum and terminal ileum, which could be due\n to patient history of C. difficile.\n\n Findings were discussed with Dr. at 5:10 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-30 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1086174, "text": ", C. MED FA2 3:48 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for retroperitoneal hematoma\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and illiopsoas inflammation concerning for abscess on\n zosyn, CT evidence of billiary stones awaiting ERCP, as well as multiple PEs\n who was on heparin pw acute anemia.\n REASON FOR THIS EXAMINATION:\n please eval for retroperitoneal hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Fluid collection at the right iliopsoas muscle concerning for hematoma.\n Hyperdense fluid in the right posterior pararenal space. Two small fluid\n collections tracking along the right iliacus muscle in the pelvis concerning\n for smaller hematoma. Asymmetry at the right high with loss of fat planes at\n the adductor compartment, and fat stranding in the soft tissue, concerning for\n possible hematoma, if clinically correlated. Findings were discussed with\n at 5:10 p.m. on .\n\n" }, { "category": "Physician ", "chartdate": "2187-07-19 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 580774, "text": "Chief Complaint: lethargy, weakness\n HPI:\n 40 y/o hx HIV (CD4 300 w/ undetectable viral load), PML since ',\n found incontient of urine/stool yesterday, found on floor by staff at\n supportive living. He refused house doctor evaluation at that time. He\n was lightheaded, dizzy, with question of fever, tachycardic and notibly\n jaundice. The patient himself without focal complaints but per HCP was\n just not himself as he was listless and overall not looking good.\n .\n Per HCP/primary care giver, 3-4 days ago he noted him to be\n increasingly lethargic and progressively more weak. He hasn't been\n drinking the last few days and last ETOH purchase was on . He was\n no longer able to do his normal transferring from wheelchair to bed and\n had fallen.\n .\n In the emergency department, initial vitals: T 97.3 HR 110 BP 113/66 RR\n 20 POx 92. Tm 101. Had epigastric pain and scleral icterus, guiac\n positive. He received vancomycin, zosyn, calcium gluconate,\n acetaminophen, 4L IVF, 40meq po and IV K. He was type and cross matched\n and 2 unit of PRBCs were infused. Surgery was consulted who felt no\n active surgical issues at this time. At time of transfer, BP 108/70 HR\n 86 RR 20 POx98% on 2L NC.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n dapasone 100mg daily\n trazadone 100mg qhs\n combivir 1 tab \n viramune 1 tab \n zoloft 150mg daily\n seroquel 50mg \n MVI\n kcl 10meq daily\n neurontin 900mg tid\n hctz 25mg daily\n klonipin 2mg TID, 1 mg qhs\n Past medical history:\n Family history:\n Social History:\n HIV (per report undetectable Viral load, CD4 >300)\n history of progressive multifocal leukoencephalopathy \n ->expressive aphasia, R hemiparesis at baseline, able to transfer\n independently and get around on power wheelchair himself\n h/o EtOH abuse\n chronic R foot 5th digit infection s/p course of TMP-SMX/cephalexin\n legally blind\n Alcoholism.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in group home but has a home nursing aide. His HCP who is\n very involved in his care. He quit smoking 8 years ago, no IVDU, but\n known to be a heavy drinker. Has two cats at home. Does not travel\n outside .\n Review of systems:\n (+) Per HPI - Suprapubic pain and dysuria, swelling of his left ankle,\n dry cough.\n (-) No hematemesis, BRBPR. Denies fever. Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied shortness of breath.\n Denied chest pain or tightness, palpitations. Denied nausea, vomiting,\n diarrhea, constipation or abdominal pain. Denied arthralgias or\n myalgias.\n Flowsheet Data as of 12:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 91 (87 - 91) bpm\n BP: 110/70(76) {105/65(75) - 110/70(76)} mmHg\n RR: 22 (21 - 28) insp/min\n SpO2: 98%\n Height: 72 Inch\n Total In:\n 308 mL\n PO:\n TF:\n IVF:\n 181 mL\n Blood products:\n 127 mL\n Total out:\n 0 mL\n 280 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 28 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Neck: supple w/ FROM w/o pain, JVP not elevated, no LAD, no\n meningismus\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Neuro: Cn II-XII intact, strength on left side , Right side \n Labs / Radiology\n 104\n 0.5\n 100 mEq/L\n 3.1 mEq/L\n 128\n 21\n 0.5\n [image002.jpg]\n \n 2:33 A6/18/ 08:56 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 21\n Other labs: Lactic Acid:0.6 mmol/L\n Fluid analysis / Other labs: 12:30 am JOINT FLUID\n RIGHT/KNEE FLUID.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n Ca: 6.4 Mg: 2.7 P: 2.4\n ALT: 62\n AP: 94\n Tbili: 2.6\n Alb:\n AST: 55\n LDH: 689\n Dbili: 1.8\n TProt:\n :\n Lip: 747\n Other Blood Chemistry:\n Hapto: <20\n Imaging: RUQ US -Cholelithiasis and gallbladder sludge. No\n intrahepatic or extraheaptic biliary dilation. Distal common bile duct\n and pancreas not well-visualized.\n .\n Head CT w/o- lt ventriculomegaly is chronic, but since prior MR\n of , there is interval increase in size of lateral ventricles and\n 3rd ventricle, without cause identified. periventricular white matter\n hypodensities again noted, non-specific, possible due to chronic\n microangiopathic ischemic disease vs transependymal migration of csf.\n right parafalcine hypodensity incompletely evaluated. recommend MR \ngad for further eval.\n .\n CT abd w/wo - cholelithiasis w/o CT evidence of cholecystitis,\n or pancreatitis (although this does not exclude pancreatitis). no\n biliary dilatation. splenomegaly. no free fluid, free air or hematoma\n seen.\n .\n CXR - No acute cardiacpulmonary process.\n .\n Knee Right Film - small effusion, no fracture or dislocation\n Microbiology: Blood Cx/Urine Cx pending.\n Right Knee fluid - Cx pending, negative gram stain\n UA - neg LE, nitrate, + bacteria, few WBCs\n Assessment and Plan\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n onging hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. Differential includes underlying\n malignancy, infectious etiology, alcohol, autoimmune process, or drug\n induced. Infectious etiologies include parvo, malaria(but no travel\n history), encapsulated organisms (salmonella, staph), mycoplasma, EBv,\n CMV. Did recently complete course of bactrim/keflex but no evidence of\n drug-rxn. Must also consider Bartonella given Cats at home, but no skin\n lesions present.\n - clarify w/ PCP any new drugs\n - send off serology for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - given joint effusion, send off lyme, check smear for erlichia,\n babesia\n - neutropenic precautions, start vancomycin/cefepime/azithro\n - hold HIV meds, consult ID as to what can be continued/should be in\n this setting\n - consult heme/onc\n .\n # pancreatitis - gallstone pancreatitis vs. ETOH-induced pancreatitis.\n Cocurrent elevated LFTs in a cholestatic pattern make gallstone\n pancreatitis more likely (see below). Currently without pain\n - NPO, IVF prn\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider alcoholic\n hepatitis given patient's history.\n - trend LFTs\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend HCT Q6H, check post-tx HCT at 2Pm\n - transfuse to goal HCT >21 once has HCt has stabilized\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - repeat VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: IVFs / replete lytes prn / NPO\n .\n # PPX: hold on SQ heparin given thrombocytopenia, bowel regimen prn, H2\n blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n .\n # DISPOSITION: c/o to floor later this afternoon if remains\n hemodynamically stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 40M HIV (CD4 >300, VL UD), PML c/b R\n hemiparesis p/w recent fall, fevers, jaundice and lethargy over 3d.\n +EtOH use, but not for a few days. HD stable in ED, treated with\n volume, abx, xfusion but HCT decreased from 21 to 17.\n Exam notable for Tm 101 BP 110/70 HR 86 RR 18 with sat 97 on 2LNC. WD\n man, L hemiplegia, aphasia. Coarse BS B. RRR s1s2, Soft obese, +BS, non\n tender. Trace edema. Small erosion L foot. Labs notable for WBC 0.7K,\n HCT 17, K+ 2.9, Cr 1.0, lactate 1.2. CXR with clear lungs.\n 40M HIV, PML, pancytopenia and LFT abnormalities. For pancytopenia,\n appears to have elements of low production and hemolysis as well as an\n elevated MCV. Will check parvo serologies, EBV, CMV, lyme, thick/thin\n smear for possible infectious causes, as well as DAT and Coombs. This\n may all be due to recent bactrim - will check with PCP and consult\n heme/onc for BMBX to exclude infiltrative process. Will place pt on\n neutropenic precautions and will cover with cefepime, vanco and azithro\n while awaiting culture results given ongoing fever. need more\n transfusions over the course of the day, maintain BBS and recheck CBC\n now s/p 2 units PRBC. Continue to monitor stool guiacs, but does not\n appear to have a brisk GIB; will alos trend coags. For LFT\n abnormalities, suspect he passed a stone - will monitor with hydration\n and abx. Will provide thiamine, folate MVI, B12 and monitor with CIWA\n given EtOH abuse. Will place PNBTS, H2B, PIV. Full code, will d/w HCP\n and PCP. of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:06 PM ------\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580840, "text": "Pancytopenia\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580841, "text": "40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n Pancytopenia\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 580933, "text": "Pt is an 40yo male resident of facility who was found\n by down by HHA, confused & incontenent of urine/ stool. Is wheel chair\n bound. Per HHA pt has been lethargic, dizzy & weak for 3-4 days & has\n not been able to tnsf himself bed-chair. Refused to see the house\n doctor. Hx of ETOH, last drink reported . EMS tnsf to EW. Tmax\n 101, c/o epigastric pain, scleral icterus. Given Vanco, Zosyn. K+ 2.6,\n given 40 kcl iv x2, 40 kcl po x1. Repeat 3.2, Hct 16.9, type/crossed &\n infused 2 units prbc. Repeat Hct 21.5, Pt received total of 4L ivf.\n Head CT unchanged from baseline, Abd CT showed cholelithiasis w/o\n evidence of cholecystitis & pancreatitis ? related to gallstones vs\n ETOH. R knee swollen, ? trauma vs underlying infectious process. Tapped\n w/ samples sent. Has R foot abrasion ? cellulitis, tx'd w/ bactrum, now\n scabbed over. Dx w/ Pancytopenia of unclear etiology, ? Bactrum related\n vs new onset Leukemia vs viral related. ID & Hematology consulted. CT\n of chest showed PEs, probably chronic, 02 sats remain >94% on 2L n/c.\n Pancytopenia\n Assessment:\n Etiology unclear, causes include underlying malignancy, infectious\n etiology, ETOH, autoimmune process or drug induced. Infectious\n etiologies include parvo virus, malaria, encapsulated organism\n (salmonella, staph) mycoplasma, EBv, CMV.\n Action:\n Started on Heparin gtt at 1800 units/hr. Diet advanced to regular.\n Remains on droplet precautions til Flu r/o. Hct 24.0, after 1unit prbc.\n Remains on Vanco, Cefepime & Acyclovir, remains afeb, all BCs,\n cytologies/ serologies pending. Bone marrow bx done by Hematology.\n Response:\n Stable, remains incontinent of sm amts loose stool. Voiding qs via\n foley. Needs 1pm CBC & PTT (6hrs p heparin gtt)\n Plan:\n ? Resume HIV meds, monitor serial Hcts.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PANCYTOPENIA;PANCREATITIS\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 101.2 kg\n Daily weight:\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Precautions: Droplet, Neutropenic\n PMH: ETOH\n CV-PMH:\n Additional history: HIV, PML w/ R sided hemiparisis & expressive\n aphasia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:70\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,527 mL\n 24h total out:\n 1,630 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 05:14 AM\n Potassium:\n 3.8 mEq/L\n 05:14 AM\n Chloride:\n 99 mEq/L\n 05:14 AM\n CO2:\n 28 mEq/L\n 05:14 AM\n BUN:\n 8 mg/dL\n 05:14 AM\n Creatinine:\n 0.5 mg/dL\n 05:14 AM\n Glucose:\n 104 mg/dL\n 05:14 AM\n Hematocrit:\n 23.9 %\n 05:14 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 9\n Date & time of Transfer: 1200\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580915, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n PT: 13.5\n PTT: 21.6\n INR: 1.2\n Fibrinogen: 287\n Ca: 7.6 Mg: 2.0 P: 1.7\n ALT: 57\n AP: 92\n Tbili: 2.3\n Alb:\n AST: 34\n LDH: 537\n Dbili:\n TProt:\n : 430\n Lip: 763\n UricA:1.6\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n CMV Viral Load-PENDING\n CRYPTOCOCCAL ANTIGEN-PENDING\n MRSA SCREEN-PENDING\n Blood Culture, Routine-PENDING\n HIV-1 Viral Load/Ultrasensitive-PENDING\n Blood Culture, Routine-PENDING\n - VIRUS VCA-IgG AB-PENDING; - VIRUS EBNA IgG\n AB-PENDING; - VIRUS VCA-IgM AB-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n LYME SEROLOGY-PENDING\n CT Chest : bilateral PE\ns that appear chronic. FR pending.\n Assessment and Plan\n PANCYTOPENIA\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # Pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n ongoing hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. ID and heme/onc feel this is to\n infectious cause. Infectious etiologies include parvo, malaria(but no\n travel history), encapsulated organisms (salmonella, staph),\n mycoplasma, EBv, CMV. Did recently complete course of bactrim/keflex\n but no evidence of drug-rxn. Must also consider Bartonella given Cats\n at home, but no skin lesions present.\n - Check collateral info re: his baseline MS as appears to be at\n baseline. Will hold w/u of meningitis for now as low likelihood\n - f/u serologies for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - f/u lyme, smear for erlichia, babesia\n - neutropenic precautions, cte vancomycin/cefepime/azithro/acv\n - hold HIV meds and consider re-starting today pending ID recs\n - f/u ID and heme recs\n - When HSV VL returns if negative consider d/c acv\n # PE: Look chronic on CT\n - Will start hep gtt today and bridge to coumadin once sure will not\n have procedures and will need to check interactions between HAART meds\n and coumadin\n - monitor platelets prior to beginning coumadin/lovenox as heparin\n short-acting if platelets fall\n # pancreatitis\n gallstone pancreatitis. Concurrent elevated LFTs in a\n cholestatic pattern make gallstone pancreatitis more likely (see\n below). Currently without pain\n - advance diet today low fat\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime/azithro/acv\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider CMV/EBV\n and alcoholic hepatitis given patient's history.\n - trend LFTs daily\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - f/u fluid cx and continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend hct daily\n - transfuse to goal HCT >21\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale X 1 more day and if no need for meds will d/c tomorrow\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - f/u VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: ADAT\n .\n # PPX: Pneumoboots, hold on SQ heparin given thrombocytopenia, bowel\n regimen prn, H2 blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n ICU Care\n Nutrition: low fat/HH\n Glycemic Control: None needed\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: hep gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU->call out to floor today\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580876, "text": "40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n Pancytopenia\n Assessment:\n Evening labs showing no change in WC. Severe neurtropenia with\n absolute neutrophil cnt 125.\n Repeat HCT 24(21). K+ 3.9 after repletion.\n Action:\n Placed on neutropenic precautions in addition to droplet precautions.\n Antibiotics vanco, cefepim, azithromycin and acyclovir continue.\n Multiple labs sent in eve.\n CT of chest at 2200.\n Response:\n Results of CT pnd. Afeb. VSS. Voiding 100-200cc/hr via foley.\n Taking sips of water. Denies pain.\n Plan:\n Follow up on lab results and CT. monitor temp. IVAB.\n r/o for pancreatites, cholelithiasis, hepatitis. Follow pertinent\n labs. NPO.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Pt. incontinent of stool x4. brown, loose, Guiac pos. no BRB. Denies\n abd pain, nausea, cramps. States he has no warning of diahrea.\n Action:\n NPO except water with meds.\n Stool sent for culture.\n Response:\n At risk for further skin breakdown d/t incontinence. Stool not loose\n enough for flexiseal .\n Plan:\n Place flexiseal if needed. Send for C.diff.\n history of progressive multifocal leukoencephalopathy \n ->expressive aphasia, R hemiparesis at baseline,\n Overnight: pt. awake and alert. Responds approp. With yes/no answers\n to questions. Also uses some gesturing to make needs known. Denies\n pain. psych meds ordered during the night and will restart in AM.\n Explained to pt.\n Hx of ETOH and last drink . CIWA 0.\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580888, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n Assessment and Plan\n ALTERATION IN ELIMINATION RELATED TO DIARRHEA\n PANCYTOPENIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580891, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n Assessment and Plan\n ALTERATION IN ELIMINATION RELATED TO DIARRHEA\n PANCYTOPENIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580898, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n PT: 13.5\n PTT: 21.6\n INR: 1.2\n Fibrinogen: 287\n Ca: 7.6 Mg: 2.0 P: 1.7\n ALT: 57\n AP: 92\n Tbili: 2.3\n Alb:\n AST: 34\n LDH: 537\n Dbili:\n TProt:\n : 430\n Lip: 763\n UricA:1.6\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n Assessment and Plan\n PANCYTOPENIA\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n onging hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. Differential includes underlying\n malignancy, infectious etiology, alcohol, autoimmune process, or drug\n induced. Infectious etiologies include parvo, malaria(but no travel\n history), encapsulated organisms (salmonella, staph), mycoplasma, EBv,\n CMV. Did recently complete course of bactrim/keflex but no evidence of\n drug-rxn. Must also consider Bartonella given Cats at home, but no skin\n lesions present.\n - clarify w/ PCP any new drugs\n - send off serology for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - given joint effusion, send off lyme, check smear for erlichia,\n babesia\n - neutropenic precautions, start vancomycin/cefepime/azithro\n - hold HIV meds, consult ID as to what can be continued/should be in\n this setting\n - consult heme/onc\n .\n # pancreatitis - gallstone pancreatitis vs. ETOH-induced pancreatitis.\n Cocurrent elevated LFTs in a cholestatic pattern make gallstone\n pancreatitis more likely (see below). Currently without pain\n - NPO, IVF prn\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider alcoholic\n hepatitis given patient's history.\n - trend LFTs\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend HCT Q6H, check post-tx HCT at 2Pm\n - transfuse to goal HCT >21 once has HCt has stabilized\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - repeat VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: IVFs / replete lytes prn / NPO\n .\n # PPX: hold on SQ heparin given thrombocytopenia, bowel regimen prn, H2\n blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 580907, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n PT: 13.5\n PTT: 21.6\n INR: 1.2\n Fibrinogen: 287\n Ca: 7.6 Mg: 2.0 P: 1.7\n ALT: 57\n AP: 92\n Tbili: 2.3\n Alb:\n AST: 34\n LDH: 537\n Dbili:\n TProt:\n : 430\n Lip: 763\n UricA:1.6\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n CMV Viral Load-PENDING\n CRYPTOCOCCAL ANTIGEN-PENDING\n MRSA SCREEN-PENDING\n Blood Culture, Routine-PENDING\n HIV-1 Viral Load/Ultrasensitive-PENDING\n Blood Culture, Routine-PENDING\n - VIRUS VCA-IgG AB-PENDING; - VIRUS EBNA IgG\n AB-PENDING; - VIRUS VCA-IgM AB-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n LYME SEROLOGY-PENDING\n Assessment and Plan\n PANCYTOPENIA\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # Pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n ongoing hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. ID and heme/onc feel this is to\n infectious cause. Infectious etiologies include parvo, malaria(but no\n travel history), encapsulated organisms (salmonella, staph),\n mycoplasma, EBv, CMV. Did recently complete course of bactrim/keflex\n but no evidence of drug-rxn. Must also consider Bartonella given Cats\n at home, but no skin lesions present.\n - f/u serologies for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - given joint effusion, send off lyme, check smear for erlichia,\n babesia\n - neutropenic precautions, start vancomycin/cefepime/azithro\n - hold HIV meds\n - f/u ID and heme recs\n .\n # pancreatitis - gallstone pancreatitis vs. ETOH-induced pancreatitis.\n Cocurrent elevated LFTs in a cholestatic pattern make gallstone\n pancreatitis more likely (see below). Currently without pain\n - NPO, IVF prn\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider CMV/EBV\n and alcoholic hepatitis given patient's history.\n - trend LFTs\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - f/u fluid cx and continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend HCT Q6H, check post-tx HCT at 2Pm\n - transfuse to goal HCT >21 once has HCt has stabilized\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - repeat VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: ADAT\n .\n # PPX: Pneumoboots, hold on SQ heparin given thrombocytopenia, bowel\n regimen prn, H2 blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580866, "text": "40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n Pancytopenia\n Assessment:\n Evening labs showing no change in WC. Severe neurtropenia with\n absolute neutrophil cnt 125.\n Repeat HCT 24(21). K+ 3.9 after repletion.\n Action:\n Placed on neutropenic precautions in addition to droplet precautions.\n Antibiotics vanco, cefepim, azithromycin and acyclovir continue.\n Multiple labs sent in eve.\n CT of chest at 2200.\n Response:\n Results of CT pnd. Afeb. VSS. Voiding 100-200cc/hr via foley.\n Taking sips of water. Denies pain.\n Plan:\n Follow up on lab results and CT. monitor temp. IVAB.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Pt. incontinent of stool x4. brown, loose, Guiac pos. no BRB. Denies\n abd pain, nausea, cramps. States he has no warning of diahrea.\n Action:\n NPO except water with meds.\n Stool sent for culture.\n Response:\n At risk for further skin breakdown d/t incontinence. Stool not loose\n enough for flexiseal .\n Plan:\n Place flexiseal if needed. Send for C.diff.\n" }, { "category": "Nursing", "chartdate": "2187-07-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580872, "text": "40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n Pancytopenia\n Assessment:\n Evening labs showing no change in WC. Severe neurtropenia with\n absolute neutrophil cnt 125.\n Repeat HCT 24(21). K+ 3.9 after repletion.\n Action:\n Placed on neutropenic precautions in addition to droplet precautions.\n Antibiotics vanco, cefepim, azithromycin and acyclovir continue.\n Multiple labs sent in eve.\n CT of chest at 2200.\n Response:\n Results of CT pnd. Afeb. VSS. Voiding 100-200cc/hr via foley.\n Taking sips of water. Denies pain.\n Plan:\n Follow up on lab results and CT. monitor temp. IVAB.\n Alteration in Elimination Related to Diarrhea\n Assessment:\n Pt. incontinent of stool x4. brown, loose, Guiac pos. no BRB. Denies\n abd pain, nausea, cramps. States he has no warning of diahrea.\n Action:\n NPO except water with meds.\n Stool sent for culture.\n Response:\n At risk for further skin breakdown d/t incontinence. Stool not loose\n enough for flexiseal .\n Plan:\n Place flexiseal if needed. Send for C.diff.\n" }, { "category": "Physician ", "chartdate": "2187-07-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 580739, "text": "Chief Complaint: lethargy, weakness\n HPI:\n 40 y/o hx HIV (CD4 300 w/ undetectable viral load), PML since ',\n found incontient of urine/stool yesterday, found on floor by staff at\n supportive living. He refused house doctor evaluation at that time. He\n was lightheaded, dizzy, with question of fever, tachycardic and notibly\n jaundice. The patient himself without focal complaints but per HCP was\n just not himself as he was listless and overall not looking good.\n .\n Per HCP/primary care giver, 3-4 days ago he noted him to be\n increasingly lethargic and progressively more weak. He hasn't been\n drinking the last few days and last ETOH purchase was on . He was\n no longer able to do his normal transferring from wheelchair to bed and\n had fallen.\n .\n In the emergency department, initial vitals: T 97.3 HR 110 BP 113/66 RR\n 20 POx 92. Tm 101. Had epigastric pain and scleral icterus, guiac\n positive. He received vancomycin, zosyn, calcium gluconate,\n acetaminophen, 4L IVF, 40meq po and IV K. He was type and cross matched\n and 2 unit of PRBCs were infused. Surgery was consulted who felt no\n active surgical issues at this time. At time of transfer, BP 108/70 HR\n 86 RR 20 POx98% on 2L NC.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n dapasone 100mg daily\n trazadone 100mg qhs\n combivir 1 tab \n viramune 1 tab \n zoloft 150mg daily\n seroquel 50mg \n MVI\n kcl 10meq daily\n neurontin 900mg tid\n hctz 25mg daily\n klonipin 2mg TID, 1 mg qhs\n Past medical history:\n Family history:\n Social History:\n HIV (per report undetectable Viral load, CD4 >300)\n history of progressive multifocal leukoencephalopathy \n ->expressive aphasia, R hemiparesis at baseline, able to transfer\n independently and get around on power wheelchair himself\n h/o EtOH abuse\n chronic R foot 5th digit infection s/p course of TMP-SMX/cephalexin\n legally blind\n Alcoholism.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in group home but has a home nursing aide. His HCP who is\n very involved in his care. He quit smoking 8 years ago, no IVDU, but\n known to be a heavy drinker. Has two cats at home. Does not travel\n outside .\n Review of systems:\n (+) Per HPI - Suprapubic pain and dysuria, swelling of his left ankle,\n dry cough.\n (-) No hematemesis, BRBPR. Denies fever. Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied shortness of breath.\n Denied chest pain or tightness, palpitations. Denied nausea, vomiting,\n diarrhea, constipation or abdominal pain. Denied arthralgias or\n myalgias.\n Flowsheet Data as of 12:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 91 (87 - 91) bpm\n BP: 110/70(76) {105/65(75) - 110/70(76)} mmHg\n RR: 22 (21 - 28) insp/min\n SpO2: 98%\n Height: 72 Inch\n Total In:\n 308 mL\n PO:\n TF:\n IVF:\n 181 mL\n Blood products:\n 127 mL\n Total out:\n 0 mL\n 280 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 28 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Neck: supple w/ FROM w/o pain, JVP not elevated, no LAD, no\n meningismus\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Neuro: Cn II-XII intact, strength on left side , Right side \n Labs / Radiology\n 104\n 0.5\n 100 mEq/L\n 3.1 mEq/L\n 128\n 21\n 0.5\n [image002.jpg]\n \n 2:33 A6/18/ 08:56 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 21\n Other labs: Lactic Acid:0.6 mmol/L\n Fluid analysis / Other labs: 12:30 am JOINT FLUID\n RIGHT/KNEE FLUID.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n Ca: 6.4 Mg: 2.7 P: 2.4\n ALT: 62\n AP: 94\n Tbili: 2.6\n Alb:\n AST: 55\n LDH: 689\n Dbili: 1.8\n TProt:\n :\n Lip: 747\n Other Blood Chemistry:\n Hapto: <20\n Imaging: RUQ US -Cholelithiasis and gallbladder sludge. No\n intrahepatic or extraheaptic biliary dilation. Distal common bile duct\n and pancreas not well-visualized.\n .\n Head CT w/o- lt ventriculomegaly is chronic, but since prior MR\n of , there is interval increase in size of lateral ventricles and\n 3rd ventricle, without cause identified. periventricular white matter\n hypodensities again noted, non-specific, possible due to chronic\n microangiopathic ischemic disease vs transependymal migration of csf.\n right parafalcine hypodensity incompletely evaluated. recommend MR \ngad for further eval.\n .\n CT abd w/wo - cholelithiasis w/o CT evidence of cholecystitis,\n or pancreatitis (although this does not exclude pancreatitis). no\n biliary dilatation. splenomegaly. no free fluid, free air or hematoma\n seen.\n .\n CXR - No acute cardiacpulmonary process.\n .\n Knee Right Film - small effusion, no fracture or dislocation\n Microbiology: Blood Cx/Urine Cx pending.\n Right Knee fluid - Cx pending, negative gram stain\n UA - neg LE, nitrate, + bacteria, few WBCs\n Assessment and Plan\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n onging hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. Differential includes underlying\n malignancy, infectious etiology, alcohol, autoimmune process, or drug\n induced. Infectious etiologies include parvo, malaria(but no travel\n history), encapsulated organisms (salmonella, staph), mycoplasma, EBv,\n CMV. Did recently complete course of bactrim/keflex but no evidence of\n drug-rxn. Must also consider Bartonella given Cats at home, but no skin\n lesions present.\n - clarify w/ PCP any new drugs\n - send off serology for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - given joint effusion, send off lyme, check smear for erlichia,\n babesia\n - neutropenic precautions, start vancomycin/cefepime/azithro\n - hold HIV meds, consult ID as to what can be continued/should be in\n this setting\n - consult heme/onc\n .\n # pancreatitis - gallstone pancreatitis vs. ETOH-induced pancreatitis.\n Cocurrent elevated LFTs in a cholestatic pattern make gallstone\n pancreatitis more likely (see below). Currently without pain\n - NPO, IVF prn\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider alcoholic\n hepatitis given patient's history.\n - trend LFTs\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend HCT Q6H, check post-tx HCT at 2Pm\n - transfuse to goal HCT >21 once has HCt has stabilized\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - repeat VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: IVFs / replete lytes prn / NPO\n .\n # PPX: hold on SQ heparin given thrombocytopenia, bowel regimen prn, H2\n blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n .\n # DISPOSITION: c/o to floor later this afternoon if remains\n hemodynamically stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2187-07-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 580812, "text": "Pt is an 40yo male resident of facility who was found\n by down by HHA, confused & incontenent of urine/ stool. Is wheel chair\n bound. Per HHA pt has been lethargic, dizzy & weak for 3-4 days & has\n not been able to tnsf himself bed-chair. Refused to see the house\n doctor. Hx of ETOH, last drink reported . EMS tnsf to EW. Tmax\n 101, c/o epigastric pain, scleral icterus. Given Vanco, Zosyn. K+ 2.6,\n given 40 kcl iv x2, 40 kcl po x1. Repeat 3.2, Hct 16.9, type/crossed &\n infused 2 units prbc. Repeat Hct 21.5, Pt received total of 4L ivf.\n Head CT unchanged from baseline, Abd CT showed cholelithiasis w/o\n evidence of cholecystitis & pancreatitis ? related to gallstones vs\n ETOH. R knee swollen, ? trauma vs underlying infectious process. Tapped\n w/ samples sent. Has R foot abrasion ? cellulitis, tx'd w/ bactrum, now\n scabbed over. Reported hx of foot traumas by ramming wheel chair. Dx w/\n Pancytopenia of unclear etiology, ? Bactrum related vs new onset\n Leukemia. ID & Hematology consulted.\n Pancytopenia\n Assessment:\n Etiology unclear, causes include underlying malignancy, infectious\n etiology, ETOH, autoimmune process or drug induced. Infectious\n etiologies include parvo virus, malaria, encapsulated organism\n (salmonella, staph) mycoplasma, EBv, CMV.\n Action:\n NPO. Placed on droplet precautions. Hct 21.5, Transfused 1unit prbc.\n Started on Cefepime, ordered for Acyclovir, sent BC x2. Bone marrow bx\n done by Hematology.\n Response:\n Repeat Hct pending. Needs serology for Parvo, EBV, CMV, lyme.\n Plan:\n Chest CT, monitor serial Hcts.\n" }, { "category": "Physician ", "chartdate": "2187-07-20 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 580950, "text": "Chief Complaint:\n 24 Hour Events:\n \n - LFTs continuing to trend down\n - Hct bumped 16.9 -> 20.3 w/ 2 units. Received another 2 units with Hct\n 21.2. Transfused 1 more unit...\n - Tbili decreased 2.7 -> 2.4. Hapto...\n - Fibrinogen 2.1 and coags stable.\n - Repeat CBC still w/ pancytopenia. ANC 120.\n - Heme-Onc did BM tap. Likely infectious rather than lymphoma. No\n blasts on smear. Would check DIC labs (coags, fibrinogen), tumor lysis\n labs (Chem 10, uric acid, LDH), also LFTs qid-tid.\n - ID thought most likely viral (parvo, influenza, CMV, EBV, HSV; also\n mycoplasma). Added ACV. Given hypoxia, recommended CT chest; resp cx.\n Also concerned about CNS process and recommended LP and MRI head -\n holding on ordering for now.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Neutropenia; Pa\n Last dose of Antibiotics:\n Azithromycin - 10:30 PM\n Cefipime - 12:00 AM\n Acyclovir - 01:02 AM\n Vancomycin - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 95 (85 - 99) bpm\n BP: 107/69(77) {97/46(58) - 127/85(92)} mmHg\n RR: 27 (15 - 28) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,005 mL\n 540 mL\n PO:\n TF:\n IVF:\n 1,800 mL\n 420 mL\n Blood products:\n 725 mL\n Total out:\n 2,070 mL\n 600 mL\n Urine:\n 2,070 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 935 mL\n -60 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General: Alert, oriented, following commands, answering yes and no\n questions, no acute distress\n HEENT: Sclera mildly icteric, MMM, oropharynx clear\n Lungs: Scattered expiratory wheezes, no rales, ronchi, dry cough\n CV: Regular rate and rhythm, normal S1, split S2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, pitting edema on left to ankle,\n Right knee w/ mild effusion, +warmth, right wrist/knee contracted, righ\n foot drop, no other joint effusions\n Skin: faint rash over arms/trunk, + blanching, RLE without\n erythema, warmth, few scabbed over abrasions on 5th digit.\n Labs / Radiology\n 152 K/uL\n 8.3 g/dL\n 104 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 8 mg/dL\n 99 mEq/L\n 132 mEq/L\n 23.9 %\n 0.7 K/uL\n [image002.jpg]\n PT: 13.5\n PTT: 21.6\n INR: 1.2\n Fibrinogen: 287\n Ca: 7.6 Mg: 2.0 P: 1.7\n ALT: 57\n AP: 92\n Tbili: 2.3\n Alb:\n AST: 34\n LDH: 537\n Dbili:\n TProt:\n : 430\n Lip: 763\n UricA:1.6\n 08:56 AM\n 02:21 PM\n 09:40 PM\n 05:14 AM\n WBC\n 0.4\n 0.5\n 0.7\n Hct\n 21\n 21.2\n 24.0\n 23.9\n Plt\n 118\n 130\n 152\n Cr\n 0.5\n 0.4\n 0.5\n Glucose\n 100\n 105\n 104\n Other labs: PT / PTT / INR:13.5/21.6/1.2, ALT / AST:57/34, Alk Phos / T\n Bili:92/2.3, Amylase / Lipase:430/763, Fibrinogen:287 mg/dL, Lactic\n Acid:0.6 mmol/L, LDH:537 IU/L, Ca++:7.6 mg/dL, Mg++:2.0 mg/dL, PO4:1.7\n mg/dL\n CMV Viral Load-PENDING\n CRYPTOCOCCAL ANTIGEN-PENDING\n MRSA SCREEN-PENDING\n Blood Culture, Routine-PENDING\n HIV-1 Viral Load/Ultrasensitive-PENDING\n Blood Culture, Routine-PENDING\n - VIRUS VCA-IgG AB-PENDING; - VIRUS EBNA IgG\n AB-PENDING; - VIRUS VCA-IgM AB-PENDING\n CMV IgG ANTIBODY-PENDING; CMV IgM ANTIBODY-PENDING\n LYME SEROLOGY-PENDING\n CT Chest : bilateral PE\ns that appear chronic. FR pending.\n Assessment and Plan\n PANCYTOPENIA\n 40 yo M with HIV, PML presents with malaise found to have pancytopenia,\n elevated LFTs, pancreatitis, and possible GI bleed.\n .\n # Pancytopenia - Elevated Indirect bili, LDH and low hapto, support\n ongoing hemolysis, inappropriately low retic count, MCV 118. Normal\n fibrinogen helps rule out DIC. ID and heme/onc feel this is to\n infectious cause. Infectious etiologies include parvo, malaria(but no\n travel history), encapsulated organisms (salmonella, staph),\n mycoplasma, EBv, CMV. Did recently complete course of bactrim/keflex\n but no evidence of drug-rxn. Must also consider Bartonella given Cats\n at home, but no skin lesions present.\n - Check collateral info re: his baseline MS as appears to be at\n baseline. Will hold w/u of meningitis for now as low likelihood\n - f/u serologies for parvo, EBV, CMV, lyme, f/u blood/urine cx\n - check DAT, have hematopathologist review smear, coombs\n - f/u lyme, smear for erlichia, babesia\n - neutropenic precautions, cte vancomycin/cefepime/azithro/acv\n - hold HIV meds and consider re-starting today pending ID recs\n - f/u ID and heme recs\n - When HSV VL returns if negative consider d/c acv\n # PE: Look chronic on CT\n - Will start hep gtt today and bridge to coumadin once sure will not\n have procedures and will need to check interactions between HAART meds\n and coumadin\n - monitor platelets prior to beginning coumadin/lovenox as heparin\n short-acting if platelets fall\n # pancreatitis\n gallstone pancreatitis. Concurrent elevated LFTs in a\n cholestatic pattern make gallstone pancreatitis more likely (see\n below). Currently without pain\n - advance diet today low fat\n - trend LFTs\n .\n # Neutropenic Fever - Unclear source. no evidence of cellulitis, lungs\n clear, CT ab w/out evidence of cholangitis\n - cover empirically with vancomycin/cefepime/azithro/acv\n - f/u culture data, lyme, serologies\n .\n # Elevated LFTS - Predominate AP/T.bili elevation w/ ALT >AST more\n consistent w/ cholestasis picture, although complicated by active\n hemolysis. AP improved on repeat labs supporting passed stone. Imaging\n documents stones but no current ductal obstruction. Differential\n includes resolved choledocholithiasis, but also must consider CMV/EBV\n and alcoholic hepatitis given patient's history.\n - trend LFTs daily\n .\n # Right Knee Effusion - Per HCP, has history of trauma to knee ramming\n wheel chair into door frames, etc. Joint fluid negative for polys or\n organisms. Tap c/w mild inflammation. Question of trauma or related to\n underlying infectious process. Patient is not sexually active to raise\n concern for gonorrhea. Images negative for fracture/dislocation.\n - f/u fluid cx and continue to observe\n .\n # GI bleed - No evidence of hematemesis, BRPBR. Hard to assess severity\n given above pancytopenia. Denies recent diarrhea, change in color of\n stools, hematemasis/BRBPR.\n - trend hct daily\n - transfuse to goal HCT >21\n .\n # ETOH Abuse - Last purchase of ETOH .\n - IV thiamine, folate, MVI\n - CIWA scale X 1 more day and if no need for meds will d/c tomorrow\n .\n # Right foot Abrasion - s/p course of bactrim/keflex, completed on\n . No evidence of cellulitis.\n - wound care, dry guaze\n .\n # HIV -\n - f/u VL, hold off on CD4 count given profound lymphopenia\n - hold home meds for now, confirm plan w/ ID\n - confirm outpt labs/meds w/ Dr. \n .\n # FEN: ADAT\n .\n # PPX: Pneumoboots, hold on SQ heparin given thrombocytopenia, bowel\n regimen prn, H2 blocker\n .\n # ACCESS: 18g, 16g PIV\n .\n # CODE STATUS: full\n .\n # EMERGENCY CONTACT: HCP - \n ICU Care\n Nutrition: low fat/HH\n Glycemic Control: None needed\n Lines:\n 20 Gauge - 09:32 AM\n 18 Gauge - 09:33 AM\n Prophylaxis:\n DVT: hep gtt\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU->call out to floor today\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 40M HIV (CD4 >300, VL UD), PML c/b R\n hemiparesis p/w recent fall, fevers, jaundice and lethargy over 3d.\n +EtOH use, but not for a few days. HD stable in ED, treated with\n volume, abx, xfusion but HCT decreased from 21 to 17. Smear without\n blasts based on prelim, findings to date most suggestive of infectious\n of toxic cause for pancytopenia. CTA with B PEs per report.\n Exam notable for Tm 98.9 BP 113/70 HR 80 RR 18 with sat 97 on 2LNC. WD\n man, L hemiplegia, aphasia. Coarse BS B. RRR s1s2, Soft obese, +BS, non\n tender. Trace edema. Small erosion L foot. Labs notable for WBC 0.7K,\n HCT 24, K+ 3.8, Cr 0.5. CTA c B PEs.\n 40M HIV, PML, pancytopenia, PEs and LFT abnormalities. For\n pancytopenia, will follow up parvo serologies, EBV / CMV / HSV VL,\n lyme, thick/thin smear for possible infectious causes, as well as DAT\n and Coombs. This may all be due to recent bactrim - will f/u c heme/onc\n re BMBX results. Will consider LP after d/w HCP and ID. Will continue\n neutropenic precautions and will cover with cefepime, vanco and azithro\n while awaiting cultures. For newly dx PEs, will start heparin IV while\n monitoring stool output (G+) and HCT carefully. For LFT abnormalities,\n suspect he passed a stone - will monitor with hydration and abx. Will\n provide thiamine, folate MVI, B12 and monitor with CIWA given EtOH\n abuse. Will continue H2B, PIV. Full code, will d/w HCP and PCP. \n call out to medicine. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:11 PM ------\n" }, { "category": "Radiology", "chartdate": "2187-07-18 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1084306, "text": " 9:16 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with generalized weakness, HIV, multiple lab abnormalities\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old male with generalized weakness, HIV, multiple lab\n abnormalities, here to evaluate for pneumonia.\n\n COMPARISON: None available.\n\n CHEST RADIOGRAPHS, AP UPRIGHT AND LATERAL VIEWS: Lateral view is limited due\n to the patient's inability to raise his arms. Allowing for technique and\n slight rotation of the patient, cardiomediastinal and hilar contours are\n likely normal. The lungs are moderately well inflated and appear grossly\n clear. No pneumothorax or pleural effusion is seen. The bony thoracic cage\n appears intact.\n\n IMPRESSION: No acute intrathoracic process seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-29 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1086005, "text": " 9:39 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for colitis, ileus(oral + IV contrast)\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with HIV and c. diff now with ab pain and vomiting\n REASON FOR THIS EXAMINATION:\n Please assess for colitis, ileus(oral + IV contrast)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc SUN 5:08 PM\n Right psoas abscess, discussed with Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 40-year-old man with HIV and C. diff. colitis, presenting with\n abdominal pain and vomiting.\n\n COMPARISONS: CT of the abdomen from with no comparison for the\n pelvis.\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with oral\n and intravenous contrast, and sagittal and coronal reconstructions were also\n performed.\n\n CT OF THE ABDOMEN WITH ORAL AND INTRAVENOUS CONTRAST: There is minor\n atelectasis at the lung bases with very small pleural effusions. Calcified\n prevascular and left hilar lymph nodes are noted, as well as coronary arterial\n calcifications.\n\n There are several very small calcified stones within the gallbladder, as well\n as layering hyperdense material consistent with sludge. The presence of fatty\n infiltration in the liver is difficult to assess on this study. There is no\n intrahepatic biliary ductal dilatation. The extrahepatic duct is minimally,\n prominent measuring up to 8 mm in diameter compared to 7 mm before. CT does\n not provide a sensitive evaluation for choledocholithiasis, but no calcified\n densities are visualized in the bile ducts.\n\n The pancreas appears normal. The pancreatic duct is nondilated. The adrenal\n glands and kidneys are unremarkable. The spleen is mildly enlarged measuring\n up to 15.5 cm in length. The stomach and small bowel are within normal\n limits.\n\n Fluid is present throughout the colon which is non-specific but can be seen\n with C. diff. colitis. There is fatty infiltration in the wall of the colon\n and terminal ileum that generally reflects old inflammation.\n\n The main change since the prior CT is that there is a new expanded appearance\n of the right psoas including a long hypodense area centrally within the muscle\n that measures up to 21 x 14 mm in axial dimensions, most consistent with an\n abscess. There is also a faint hypodensity in the right iliac itself, 10 mm\n in diameter, also suspicious for infection.\n (Over)\n\n 9:39 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please assess for colitis, ileus(oral + IV contrast)\n Admitting Diagnosis: PANCYTOPENIA;PANCREATITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH IV CONTRAST: The prostate shows central calcifications.\n The distal ureters and bladder are unremarkable. There are no enlarged lymph\n nodes or ascites.\n\n BONE WINDOWS: A fixation rod through the femoral neck is visualized with\n surrounding heterotopic bone. There are no suspicious lesions. Healed right\n posterior ninth through eleventh rib fractures are unchanged.\n\n IMPRESSION:\n 1. New inflammation and evidence for early abscess formation in the right\n iliopsoas musculature.\n\n 2. Cholelithiasis with no direct evidence for choledocholithiasis. If stones\n are suspected in the distal common bile duct, MRCP would provide the optimal\n imaging approach to visualize them.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-18 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1084294, "text": " 8:47 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for obstruction, cholecystitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HIV, generalized weakness, labs suggestive of gallstone pancreatitis/ biliary\n obstruction\n REASON FOR THIS EXAMINATION:\n eval for obstruction, cholecystitis\n ______________________________________________________________________________\n WET READ: DLrc WED 9:24 PM\n Cholelithiasis and gallbladder sludge. No intrahepatic or extraheaptic\n biliary dilation. Distal common bile duct and pancreas not well-visualized.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 40-year-old male with HIV, generalized weakness, and\n labs suggestive of gallstones/pancreatitis/biliary obstruction. Please\n evaluate for obstruction or cholecystitis.\n\n EXAMINATION: Focused abdominal ultrasound of the liver and gallbladder.\n\n COMPARISONS: No prior studies available for direct comparison.\n\n FINDINGS: There is diffusely increased echogenicity within the liver\n compatible with fatty infiltration. No focal abnormalities are seen. The\n gallbladder is non-distended with no gallbladder wall edema. There is\n cholelithiasis and sludge within the gallbladder. The common bile duct\n measures 0.39 cm and is not dilated. Limited views of the pancreatic head and\n body are unremarkable.\n\n IMPRESSION:\n\n 1. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n 2. Cholelithiasis and gallbladder sludge. No intra- or extra-hepatic biliary\n dilatation.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-18 00:00:00.000", "description": "RP KNEE (2 VIEWS) RIGHT PORT", "row_id": 1084323, "text": " 11:50 PM\n KNEE (2 VIEWS) RIGHT PORT Clip # \n Reason: please eval for fx / effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with erythema\n REASON FOR THIS EXAMINATION:\n please eval for fx / effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old male with erythema, here to evaluate for fracture or\n effusion.\n\n COMPARISON: None available.\n\n RIGHT KNEE, PORTABLE AP AND CROSS-TABLE LATERAL VIEWS: Small amount of knee\n joint fluid is seen, without evidence of acute fracture, dislocation, bony\n destruction, or radiopaque foreign body. Again, heterogeneous mineralization\n may be due to osteopenia.\n\n IMPRESSION: No acute fracture seen. Small knee joint fluid.\n\n" }, { "category": "Radiology", "chartdate": "2187-07-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1084333, "text": " 2:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL, AMS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with fevers and mental status changes - s/p fall\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:01 AM\n lt ventriculomegaly is chronic, but since prior MR of , there is interval\n increase in size of lateral ventricles and 3rd ventricle, without cause\n identified. periventricular white matter hypodensities again noted, non-\n specific, possible due to chronic microangiopathic ischemic disease vs\n transependymal migration of csf. right parafalcine hypodensity incompletely\n evaluated. recommend MR for further eval.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 40-year-old man with fevers and mental status changes, status post\n fall, here to evaluate for intracranial hemorrhage. Patient with a history of\n HIV and PML diagnosed in .\n\n COMPARISON: MRI head of .\n\n TECHNIQUE: MDCT axial imaging was performed to the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: Again noted is left ventriculomegaly however compared\n to relatively remote MR of , there is dilatation of both lateral\n ventricles as well as the third ventricle. There is mild increase in the siz\n eof the ventricles. Periventricular white matter hypodensities are noted,\n particularly along the left frontal, parietal and occipital regions as well as\n the right parietal and right frontal regions. In addition, there is a right\n falcine hypodense area measuring 16 x 10 mm which appears to displace the\n sulci along the superior convexity, likely related to chronic changes given\n the fluid density and 6-8HU. There is no shift of normally midline structures,\n nor effacement of the basal cisterns. The soft tissues and orbit as well as\n the skull appear intact. Large mucus retention cysts are noted in the right\n maxillary sinus, otherwise, the remainder of the visualized paranasal sinuses\n and mastoid air cells are normally aerated.\n\n IMPRESSIONS:\n 1. Left ventriculomegaly is chronic however, there has been increase in size\n of lateral ventricles and third ventricle since . There are areas of\n surrounding periventricular white matter hypodensities which are nonspecific\n and could represent either small vessel ischemic disease or transependymal\n migration of CSF. No obstructive cause is seen for increased ventricular\n distension.\n 2. Right parafalcine hypodensity- likely related to chronic ischemic changes\n and is of fluid attenutation.\n MR Is more sensitive if there is concern for acute ischemia/infarction.\n\n (Over)\n\n 2:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL, AMS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Mucous retention cysts in the right maxillary sinus.\n\n\n" }, { "category": "Radiology", "chartdate": "2187-07-19 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 1084335, "text": " 2:52 AM\n CT ABD W&W/O C Clip # \n Reason: eval for hemorrhagic pancreatitis.\n Field of view: 45 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with crit drop and pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for hemorrhagic pancreatitis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:40 AM\n cholelithiasis w/o CT evidence of cholecystitis, or pancreatitis (although\n this does not exclude pancreatitis). no biliary dilatation. splenomegaly.\n no free fluid, free air or hematoma seen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old male with hematocrit drop and pancreatitis, concerning\n for hemorrhagic pancreatitis.\n\n COMPARISON: Right upper quadrant ultrasound performed earlier on the same\n evening on , 8:57 p.m.\n\n TECHNIQUE: MDCT axial imaging was performed through the abdomen before and\n after IV contrast administration. Multiplanar reformatted images were then\n obtained. A total of 130 mL of IV Optiray was administered.\n\n CT ABDOMEN BEFORE AND AFTER IV CONTRAST: Dependent atelectasis is noted in\n the lung bases. The liver appears unremarkable. Tiny stones are noted in the\n gallbladder fundus. The spleen is enlarged measuring 15.8 cm. The\n gallbladder enhances homogeneously and is without evidence of peripancreatic\n fluid or stranding. The superior mesenteric, splenic, and portal veins remain\n patent. No biliary ductal dilatation is noted.\n\n The adrenal glands appear normal. Tiny subcentimeter hypodensities in both\n kidneys are too small to accurately characterize but likely represent small\n cysts. The non-opacified stomach and the visualized non-opacified small\n bowel, colon, and appendix appear unremarkable. No free air or free fluid is\n noted within the abdomen. Tiny retroperitoneal lymph nodes do not meet CT size\n criteria for adenopathy.\n\n Degenerative endplate changes are mild. Old healed rib fractures are noted on\n the right.\n\n IMPRESSIONS:\n 1. Cholelithiasis without CT evidence for cholecystitis. No biliary ductal\n dilatation. No definite CT evidence for pancreatitis or complications of\n pancreatitis, although this does not exclude the diagnosis.\n 2. Splenomegaly.\n (Over)\n\n 2:52 AM\n CT ABD W&W/O C Clip # \n Reason: eval for hemorrhagic pancreatitis.\n Field of view: 45 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2173-09-15 00:00:00.000", "description": "VISERAL SEL/SUPERSEL A-GRAM", "row_id": 799023, "text": " 6:48 PM\n HEPATIC Clip # \n Reason: ? Hepatic Artery Thrombosis/stenosis in liver transplant pat\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 40CC\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER VISERAL SEL/SUPERSEL A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p cadaveric liver transplant now with abdominal pain fever\n and concern for hepatic artery occlusion\n REASON FOR THIS EXAMINATION:\n ? Hepatic Artery Thrombosis/stenosis in liver transplant patient\n ______________________________________________________________________________\n FINAL REPORT\n PHYSICIANS: Dr. and Dr. . Dr. was present and\n supervising throughout the procedure. Dr. reviewed the exam.\n\n INDICATION: 42 year old man who is status post cadaveric liver transplant, now\n with abdominal pain and fever with concern for hepatic artery occlusion. Prior\n ultrasound revealed limited flow within the hepatic artery.\n\n ANESTHESIA: Local anesthesia.\n\n PROCEDURE AND FINDINGS: Signed and informed consent was obtained. The patient\n was brought to the angiography suite and placed supine on the table. The right\n groin was prepped and draped in the usual sterile fashion. The right common\n femoral artery was localized using palpation and fluoroscopy. 5 cc of 1%\n Lidocaine was administered into the subcutaneous tissues of the right groin.\n\n The right common femoral artery was entered using a 19 gauge single wall\n needle. An 0.035 Bentson guidewire was advanced through the needle and into\n the aorta. The needle was exchanged for a 5 French sheath. A 5 French Cobra\n catheter was then advanced over the wire and into the aorta under fluoroscopy.\n The wire was exchanged for an 0.035 angled Glidewire. Using the Glidewire and\n a 5 French Cobra C2 Glidecatheter, the celiac trunk was entered. An\n arteriogram was performed in the PA projection. The catheter was then advanced\n into the common hepatic artery. Another arteriogram was performed in the PA\n projection.\n\n At this time Dr. (Tranplant Surgery) was consulted in person\n regarding the findings. It was decided that no further intervention should be\n performed. The catheter and sheath were removed. Hemostasis was achieved with\n 20 minutes of direct compression.\n\n CONTRAST: A total of 40 cc of Optiray 320 was given intra-arterially.\n\n COMPLICATIONS: No immediate complications were observed.\n\n FINDINGS: There is occlusion of the proximal hepatic artery with no\n (Over)\n\n 6:48 PM\n HEPATIC Clip # \n Reason: ? Hepatic Artery Thrombosis/stenosis in liver transplant pat\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 40CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n opacification downstream within the liver. Multiple very small collaterals are\n present around the hepatic arterial stump and the gastroduodenal artery. There\n presence of these collaterals raises the suspicion of chronic or subacute\n hepatic arterial occlusion.\n\n IMPRESSION: Hepatic artery occlusion.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-19 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 802101, "text": " 8:18 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: duplex of transplant liver.elevation in lft's. eval flow in\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p OLT. Please perform U/S to eval hepatic art, hepatic\n vein, and portal vein.\n REASON FOR THIS EXAMINATION:\n duplex of transplant liver.elevation in lft's. eval flow in hepatic artery,\n portal vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abnormal LFT's.\n\n FINDINGS:\n\n The study is performed portably due to the medical condition. The\n liver is normal in echogenicity and size given the history of the hepatic\n transplant. The portal vein and main branches are patent with proper direction\n of flow. The hepatic artery and its main branches are also patent with proper\n direction of flow. The hepatic vein also demonstrates patency with proper\n direction of flow noting a normal appearance to the wave form. The common duct\n is not dilated. No anterior hepatic biliary ductal dilatation.\n\n Incidental note is made of a small right pleural effusion.\n\n IMPRESSION:\n\n 1) Patent hepatic vasculature.\n\n 2) Right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-25 00:00:00.000", "description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 802788, "text": " 5:07 PM\n HEPATIC Clip # \n Reason: hepatic agram with delayed portal vein images12d s/p re-live\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 246\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EA ADD'L VESSEL AFTER BASIC A- C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with 12d s/p re liver transplant and ? ischemic changes. portal\n narrowing vs hepatic art\n REASON FOR THIS EXAMINATION:\n hepatic agram with delayed portal vein images12d s/p re-liver transplant now\n with bili 17 and ct scan and biopsy: ischemia seg 7. and port vein study = ?\n narrowing.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 year old male status post second liver transplant 12 days\n previously with ischemic changes. Question portal venous narrowing versus\n hepatic arterial stricture.\n\n REFERRING PHYSICIAN: . .\n\n INTERVENTIONAL RADIOLOGIST: Dr. . Dr. , radiology resident,\n assisted during the procedure.\n\n ANESTHESIA: Propofol and Fentanyl administered by the anesthesia department.\n\n CONTRAST: 240 cc Optiray 320 60%.\n\n PROCEDURE: The procedure was described to the patient's family and informed\n consent was obtained. Access was gained into the right femoral artery using a\n 19 gauge single wall needle. wire was advanced without difficulty.\n The needle was exchanged for a 5 FR sheath. A C2 guide catheter (5 FR) was\n then advanced to the level of the celiac trunk, and a celiac arteriogram was\n performed. Multiple obliquities were then obtained at the level of the celiac\n axis. Over a wire, the catheter was then advanced into the common hepatic\n artery, and multiple arteriograms are repeated. The catheter was then placed\n in the superior mesenteric artery, and arteriogram with delayed images was\n performed to visualize both the arterial and portal venous phases.\n\n FINDINGS: A tortuous splenic artery was used for the anastomosis to the\n transplanted hepatic artery. The anastomosis is visualized with the catheter\n in the native common hepatic artery. There is a caliber change of\n approximately 50% from the native splenic artery to the transplanted hepatic\n artery, but this was not felt to represent a significant flow limitation.\n However, a guidewire could not be advanced through the proximal splenic\n artery, which may have been due to significant tortuosity or an occult focal\n (Over)\n\n 5:07 PM\n HEPATIC Clip # \n Reason: hepatic agram with delayed portal vein images12d s/p re-live\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 246\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lesion in this region. The native common hepatic artery is very large in\n caliber, with a large gastroduodenal artery and branches. This native system\n is potentially stealing blood flow to the transplanted hepatic artery and\n consideration should be given to coil embolization of this vessel.\n\n The superior mesenteric artery is patent. Delayed imaging demonstrates the\n the superior mesenteric vein and portal vein to be patent. The previously\n described portal vein narrowing is not appreciated in this delayed study, and\n is better visualized in the percutaneous portal venous angiogram performed\n previously.\n\n The catheter was then removed and compression was applied with the right groin\n until hemostasis achieved.\n\n IMPRESSION: The anastomosis is patent (native splenic artery to transplanted\n hepatic artery), but there is somewhat poor filling of the mid and distal\n hepatic arterial branches. This may be due in part to significant diversion\n of blood into the native common hepatic, gastroduodenal arteries and branches.\n Consideration might be given to occlusion of the native common hepatic artery\n with coils, in an attempt redirect blood flow into the liver.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-20 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 802290, "text": " 3:59 PM\n CATH CHEK/REMV Clip # \n Reason: 10 s/p re-liver transplant with inc lfts and nl duplex\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with olt pod #10\n REASON FOR THIS EXAMINATION:\n 10 s/p re-liver transplant with inc lfts and nl duplex\n ______________________________________________________________________________\n FINAL REPORT\n 42 year old male with a liver transplant. Angiogram on the 10th post\n operative day.\n\n TUBE CHOLANGIOGRAM: The patient was placed on the angiographic table and in\n the supine position contrast material under slow injection was injected into\n the tube and common duct with passage through the duct system into the\n duodenum filling the intrahepatic bile ducts. There is no evidence of\n extravasation.\n\n IMPRESSION: Intact biliary tree.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-21 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 802363, "text": " 12:38 PM\n BX-NEEDLE LIVER BY RADIOLOGIST; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) PORT\n Reason: s/p liver transplant.Scheduled for liver biopsy at 8 AM\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p OLT. Please perform U/S to eval hepatic art, hepatic\n vein, and portal vein.\n REASON FOR THIS EXAMINATION:\n s/p liver transplant.Scheduled for liver biopsy at 8 AM.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abnormal LFTS status-post liver transplant.\n\n FINDINGS:\n\n A limited preliminary ultrasound of the liver demonstrates an adequate spot in\n the liver for biopsy with subcostal approach.\n\n Ultrasound guided liver biopsy:\n\n After the risks and benefits of the procedure were explained to the patient,\n informed consent was obtained. The right upper quadrant was prepped and draped\n in the standard sterile fashion. Lidocaine was infiltrated subcutaneously down\n to the liver capsule in a subcostal location. Subsequently under ultrasound\n guidance a 16 gauge Monopte needle was advanced just within the liver capsule\n and a core sample was obtained. The specimen was hand delivered by Dr. \n from transplant to pathology.\n\n The patient tolerated the procedure well without immediate complication and\n left the department in satisfactory condition.\n\n The entire procedure was performed with and directly supervised by Dr. \n .\n\n IMPRESSION: Successful ultrasound guided liver biopsy.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-22 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 802440, "text": " 8:45 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: please eval for causes of sepsis/rising bilirubin\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 41 Contrast: OPTIRAY Amt: 190\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant s/p repeat liver transplant with h/o\n caval stenosis and now with rising bilirubin\n REASON FOR THIS EXAMINATION:\n please eval for causes of sepsis/rising bilirubin\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 year old man status post liver transplant with history of caval\n stenosis, now presenting rise in bilirubin.\n\n COMPARISON: Examination is compared with prior CT scan of the abdomen and\n pelvis performed .\n\n TECHNIQUE: Contiguous axial images were aquired through the abdomen at 5 mm\n intervals before the administration of IV contrast. Then, contiguous axial\n images were aquired at 5 mm intervals after the uneventful administration of\n 190 cc of Optiray contrast IV. The images were aquired after rapid bolus\n injection and reconstructed at 1.25 mm intervals. The images were aquired\n during early arterial, late arterial and portal venous phases.\n\n Delayed images through the abdomen and pelvis were then performed at 5 mm\n intervals.\n\n CTA LIVER AND CT RECONSTRUCTIONS: Multiplanar and volume rendering\n reconstructions were performed at the workstation.\n\n There is no aortic aneurysm. The celiac axis and branches, the superior\n mesenteric artery and branches and the renal arteries are patent and\n demonstrate normal vascular distribution. The hepatic arteries, although\n mildly attenuated are present and patent.\n\n Evaluation of the venous phase demonstrates patent hepatic veins draining into\n a transplant inferior vena cava which later joins the native inferior vena\n cava. There is no stenosis of either the transplanted or the native inferior\n vena cava. The portal vein and branches, the splenic vein and the superior\n mesenteric vein are all patent.\n\n Kinking and twisting of the portal vein is seen at the level of the\n anastomosis. This however, does not appear to compromise flow. Assessment of\n flow directionality and assessment of whether there is a significant gradient\n across this portion of the portal vein is not possible with CT angiography.\n Correlation of findings in the previously done Doppler ultrasound is\n recommended.\n\n CT ABDOMEN W/O&W IV CONTRAST: Again seen are moderately sized bilateral\n (Over)\n\n 8:45 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: please eval for causes of sepsis/rising bilirubin\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 41 Contrast: OPTIRAY Amt: 190\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pleural effusions with compressive atelectasis at the lung bases. These are\n unchanged when compared to the prior examination.\n\n Surgical staples are seen at the anterior abdominal wall correlating with the\n patient's recent history of surgery. A nasogastric tube is seen in place with\n tip at the pylorus. A biliary drainage is seen in place. A JP drain is also\n seen in place.\n\n There is evidence of periportal edema. An ill defined area showing\n heterogeneous contrast enhancement during all phases of injection is seen at\n segment seven which is consistent with a liver infarction. There are no liver\n masses. There is no evidence of intrahepatic biliary duct dilatation.\n\n There are various areas showing poor perfusion within the spleen on all phases\n of injection which are also consistent with small infarctions. The spleen is\n enlarged. There are multiple granulomas within the spleen.\n\n The pancreas is unremarkable. The extrahepatic biliary duct is normal.\n\n The kidneys demonstrate symmetric contrast enhancement and excretion. Various\n stones are seen within the right renal collecting system. No evidence of\n hydronephrosis. There are no renal masses.\n\n The left adrenal gland is normal. The right adrenal gland is enlarged and\n showing high average density values. These findings are again consistent with\n an adrenal hemorrhage.\n\n There are multiple mesenteric and retroperitoneal lymph nodes.\n\n There is evidence of significant ascites with some areas of loculation, the\n largest localized anterior to the pancreas and measuring 11.4 cm in widest\n diameter.\n\n The bladder and prostate are unremarkable. A Foley catheter is seen within\n the bladder. Again, there is evidence of significant ascites within the\n pelvis.\n\n There is evidence of inspissatd barium and a significant amount of stool\n within the rectum.\n\n BONE WINDOWS: No suspicious osseous lesions are seen.\n\n IMPRESSION: Again seen are bilateral pleural effusions with associated\n compressive atelectasis, unchanged since the prior examination.\n (Over)\n\n 8:45 AM\n CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; 200CC NON IONIC CONTRAST SUPPLY\n Reason: please eval for causes of sepsis/rising bilirubin\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 41 Contrast: OPTIRAY Amt: 190\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is evidence of periportal edema and significant ascites, which appears\n to be loculated at several parts of the peritoneum.\n\n Subtle perfusion changes are seen at segment seven consistent with a small\n liver infarct. Similar changes are also seen at the spleen.\n\n There is no evidence of inferior vena cava or hepatic venous obstruction.\n While the portal vein is patent, a small kink and twist is seen at the region\n of the portal anastomosis.\n\n There is right sided nephrolithiasis. A significant amount of inspissated\n barium and stool seen at the rectum.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-30 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 803315, "text": " 10:13 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evalauate for fluid collections in this patient s/p drainage\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant s/p repeat liver transplant with h/o\n caval stenosis and now with rising bilirubin\n REASON FOR THIS EXAMINATION:\n evalauate for fluid collections in this patient s/p drainage, use PO contrast.\n not IV\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P liver transplant and repeat liver transplant with history of\n caval stenosis and now rising bilirubin, evaluate for fluid collection.\n\n COMPARISON: \n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n pubic symphysis without intravenous contrast.\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There are small bilateral pleural\n effusions. There is atelectasis of the left lower lobe. The fluid collection\n within the upper abdomen adjacent to the spleen has decreased in size after\n interval placement of the pigtail drainage catheter. A JP drain is present\n along the left lateral border of the liver. The JP is not within a fluid\n collection. There is an NJ tube within the jejunum. There is a percutaneous\n transhepatic biliary drainage catheter entering from the anterior abdominal\n wall. This is unchanged in position.\n There is overall increase in the amount of free fluid within the abdomen.\n Contrast is present through the bowel without evidence of obstruction. There\n is a tiny stone within the upper pole of the right kidney. There is no\n hydronephrosis. There are multiple stones in the inferior pole of the right\n kidney. Several calcifications are noted throughout the spleen. The spleen is\n enlarged. The pancreas is unremarkable. The right adrenal gland is enlarged,\n unchanged. The left adrenal gland appears normal. There is no definite\n intrahepatic ductal dilatation. The evaluation of the liver is somewhat\n limited on this noncontrast study.\n\n CT PELVIS WITHOUT IV CONTRAST: A Foley catheter is present within the urinary\n bladder. Air is present within the urinary bladder likely due to\n instrumentation. Contrast extends through the length of the colon without\n obstruction. There is a large amount of free fluid within the pelvis. There\n are no focal fluid collections.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n 1) There has been decrease in size of the large perisplenic collection with a\n drainage catheter present adjacent to the stomach. There has been overall\n (Over)\n\n 10:13 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evalauate for fluid collections in this patient s/p drainage\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n increase in the amount of ascites. There are no new focal fluid collections.\n 2) Moderate bilateral pleural effusions with associated compressive\n atelectasis, unchanged.\n 3) Right nephrolithiasis, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-05 00:00:00.000", "description": "CT PELVIS W&W/O C", "row_id": 803880, "text": " 2:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate abd fluid collection s/p drainagealso r/o blood in\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant s/p repeat liver transplant with\n h/o caval stenosis and now with rising bilirubin\n REASON FOR THIS EXAMINATION:\n evaluate abd fluid collection s/p drainagealso r/o blood in abd w/ recent slow\n hct drop\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated bilirubin and falling hematocrit.\n\n TECHNIQUE: Pre and post contrast CT abdomen and pelvis.\n\n CONTRAST: 150 cc Optiray.\n\n COMPARISON: .\n\n FINDINGS:\n\n PRE AND POST CONTRAST CT ABDOMEN: Again seen are small bilateral pleural\n effusions with adjacent compressive atelectasis and/or consolidation of the\n left lung base.\n\n Again seen within the liver is a stable hypodense region in segment VII\n consistent with a small infarct. No other new areas of hypodensity are seen\n within the liver. The spleen is once again noted to be enlarged with stable\n hypodense regions also consistent with infarct in this region as well as\n several splenic granulomata. The kidneys enhance in a symmetric fashion\n noting a calcification in the upper pole of the right kidney which may be from\n prior infection. The adrenals are stable in their appearance.\n\n The pancreas also has a stable appearance. A locking loop catheter in the\n upper abdomen, noted to be placed within a biloma, is again seen and stable in\n position. An adjacent area of fluid has decreased in size now measuring 6.0 X\n 3.6 cm. This decrease in size is relative to the noncontrast study of , where the area measured 9.5 X 5.5 cm consistent with continued\n function of the pigtail catheter.\n\n The abdominal ascites is stable and large in its volume.\n\n PRE AND POST CONTRAST CT PELVIS: There is a stable large amount of pelvic\n ascites. The bladder is collapsed around a Foley catheter and contains a\n small amount of air.\n\n There is a large amount of formed stool within the rectum consistent with\n fecal impaction. This is increased in volume relative to the prior study of\n (Over)\n\n 2:12 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate abd fluid collection s/p drainagealso r/o blood in\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n .\n\n IMPRESSION:\n\n 1) Stable findings in the liver and spleen noting a stable appearance to an\n apparent infarct in segment VII of the liver.\n\n 2) Continued decrease in size of an abdominal biloma.\n\n 3) Stable ascites without evidence of a new drainable collection.\n\n 4) Fecal impaction.\n\n 5) The findings have been discussed with the intern in the transplant\n service, Dr. at 4:30 P.M. on .\n\n" }, { "category": "Radiology", "chartdate": "2173-09-15 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 798979, "text": " 10:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: LIVER TRANSPLANT/ FEVERS\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant , recent liver biopsy, admitted\n with fevers x1day.\n REASON FOR THIS EXAMINATION:\n Evaluate for abscess.** CT ABD & PELVIS **\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Fever x one day in a patient status post transplant,\n question abscess.\n\n TECHNIQUE: CT of the abdomen and pelvis with contrast. 150 cc Optiray were\n used for this examination. Optiray was used due to the patient's history of\n allergy.\n\n The prior CT scan from is not available for visual comparison.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH CONTRAST: There is atelectasis at the bibasilar lung\n bases with small bilateral pleural effusions. There are no focal\n consolidations. Within the porta hepatis region of the liver, there is a 4.5\n x 4.7 cm area of low attenuation measuring approximately 10 Hounsfield units.\n There is no peripheral enhancement or air within this area. There is a small\n amount of perihepatic fluid. The portal veins appear patent. There are areas\n of symmetric hypodensity along the left portal vein which may suggest\n lymphatic edema. There is no intrahepatic biliary ductal dilatation. The\n liver parenchyma is otherwise normal in appearance.\n\n There is a small amount of fluid adjacent to the superior aspect of the\n spleen. There is no peripheral enhancement of this fluid collection, nor is\n there any evidence of gas within the fluid collection. There are several\n areas of hyperintensity within the spleen, likely representing granulomas. The\n spleen is enlarged in size, but is otherwise normal in appearance. The\n adrenals, kidneys, pancreas, large and small bowels are otherwise unremarkable\n in appearance. The intra- abdominal vessels are normal in appearance. There\n is no lymphadenopathy within the abdomen. There is no free air within the\n abdomen.\n\n CT OF THE PELVIS WITH CONTRAST: There is a moderate amount of free fluid\n within the deep pelvis anterior to the rectum. There is no evidence of\n peripheral enhancement around this fluid collection. There is no lymph\n adenopathy within the pelvis. The rectum, sigmoid colon, bladder, and distal\n ureters appear unremarkable.\n\n The osseous structures reveal no suspicious lytic or blastic lesions.\n (Over)\n\n 10:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: LIVER TRANSPLANT/ FEVERS\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Low attenuation, likely fluid collection within the region of the\n intrahepatic porta hepatis as noted above. Given the patient's history of\n fever, this is concerning for potential early abscess. Alternatively, bile\n leak, ie. biloma is possible. This collection does not have Hounsfield units\n consistent with hemorrhage. The portal veins appear patent. There are two\n other fluid collections within the abdomen and adjacent to the spleen and in\n the pelvis as noted above. Neither of these fluid collections have peripheral\n wall enhancement or air within the collection suggestive of abscess.\n\n These findings were immediately communicated to the surgical house staff\n taking care of the patient.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-22 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 802500, "text": " 4:02 PM\n TRANSJUG LIVER BX Clip # \n Reason: Please assess the portal vein and intervene if possible.\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * PERC PORTAL VEIN CATH 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * 1SR ORDER BRANCH VENOUS SYSTEM -59 DISTINCT PROCEDURAL SERVICE *\n * -51 MULTI-PROCEDURE SAME DAY PERC TRANHEP PORTOGRAPHY WITH *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p re-liver transplant with ischemic injury on liver biopsy.\n REASON FOR THIS EXAMINATION:\n Please assess the portal vein and intervene if possible.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post re-liver transplant with ischemic injury seen on\n liver biopsy results. CTA demonstrating stricture of the portal vein.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. , Dr. , staff\n radiologist, who was present and supervised the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed written consent was obtained. The patient was\n placed supine on the angiography table with the right flank prepped and draped\n in usual sterile fashion. Through an anesthesized skin approach and utilizing\n fluoroscopic guidance a 21 gauge needle was used to access the right portal\n vein. The accustick wire was then advanced into the left portal vein. The\n puncture needle was then exchanged for the interdilator of the accustick\n system. Contrast injection was performed and confirmed that the catheter was\n in the portal vein. The accustick was then re-advanced into the left portal\n vein. The accustick system was re-advanced with the inner and outer dilators\n as well as the internal metal stiffener. This was then placed in the main\n portal vein confluence and the accustick wire and inner dilator and stiffener\n were removed. Contrast injection was performed and again confirmed position\n within the distal main portal vein. Using a 0.035 glide wire access was\n obtained to the splenic vein. At this point, the outer dilator of the\n accustick system was exchanged for a 4 FR angiographic sheath. The inner\n dilator was removed. Again contrast injection was performed to confirm the\n distal tip of the sheath was within the portal vein. The 4 FR straight\n multiside hole catheter was then advanced into the proximal portal vein over\n the 0.035 glide wire. The 0.035 glide wire was removed and a venogram was\n performed.\n\n This demonstrated two varices arising off of the splenic vein. The distal\n portal vein demonstrated a stenosis at the anastomosis which was eccentric\n from the lateral aspect of the portal vein. Hemodynamic pressures were\n obtained through the 4 FR angiographic sheath demonstrating measurements of 22\n mm Hg. Simultaneous measurement of pressures through the multiside hole\n straight catheter in the proximal portal vein demonstrated a portal venous\n pressure of 23. Pressure measurements were re-obtained through the 4 FR\n (Over)\n\n 4:02 PM\n TRANSJUG LIVER BX Clip # \n Reason: Please assess the portal vein and intervene if possible.\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n straight multiside hole catheter. With the catheter beginning in the splenic\n vein pressure within the splenic vein was 26 mm Hg. Pressure measurement\n within the proximal portal vein was 25 mm Hg and pressure measurement once\n crossing the lesion was 24 mm Hg. The diagnostic catheter was removed. The\n angiographic catheter was removed under fluoroscopic guidance and the tract\n was embolized with a gelfoam plug.\n\n COMPLICATIONS: None.\n\n CONTRAST/MEDICATIONS: 60 cc of Optiray contrast. 6 cc of 1% Lidocaine.\n\n IMPRESSION: Portavenogram demonstrating stenosis at the anastomosis which is\n eccentric from the lateral aspect of the vessel wall. There was approximately\n 1 mm of mmHg gradient across this lesion. After the discussion with Dr.\n , it was decided not to perform any interventions at this time.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-27 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 803055, "text": " 3:35 PM\n CT PERITONEAL DRAINAGE; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE; CT ABDOMEN W/O CONTRAST\n Reason: tap abd fluid collection\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p failed OLT, now with large biloma on CT.\n\n REASON FOR THIS EXAMINATION:\n tap abd fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Large collection seen on recent CT in the abdomen in an intubated\n patient.\n\n COMPARISON: .\n\n FINDINGS:\n\n Iniital limited CT abdomen: An initial CT of the abdomen was performed to\n localize the patient's fluid collection. The fluid collection is seen within\n the region of the lesser sac and deviates the stomach.\n\n CT-GUIDED NEEDLE PLACEMENT:\n\n The risks and benefits of the procedure were explained to the patient's sister\n by phone. Informed consent was obtained. The upper abdomen was prepped and\n draped in the standard sterile fashion. The skin location over the collection\n was localized with CT. Lidocaine was infused subcutaneously. Subsequently,\n under CT guidance, an 18-gauge needle was advanced into the patient's\n collection. Bilious material was aspirated with a sample sent to the lab for\n evaluation. At this time discussion was had with the Clinical Service, given\n the appearance of the fluid at aspiration. Clinical Service requested a\n catheter replacement.\n\n CT-GUIDED CATHETER PLACEMENT:\n\n Using CT guidance, a 10 French looking loop catheter was advanced into the\n patient's abdominal collection. The loop was formed and locked in placed.\n\n The patient tolerated the procedure well without immediate complication and\n left the department in satisfactory condition.\n\n The entire procedure was performed with and directly supervised by Dr.\n .\n\n IMPRESSION:\n\n Successful CT-guided needle placement and catheter placement in a large biloma\n in the upper abdomen.\n (Over)\n\n 3:35 PM\n CT PERITONEAL DRAINAGE; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n CT GUIDANCE DRAINAGE; CT ABDOMEN W/O CONTRAST\n Reason: tap abd fluid collection\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-10-27 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 803057, "text": " 4:10 PM\n IVC GRAM Clip # \n Reason: eval for stenosisPLEASE ALSO DO LIVER BIOPSY\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 50CC\n ********************************* CPT Codes ********************************\n * TRANSCATHETER BIOPSY 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * 1SR ORDER BRANCH VENOUS SYSTEM -51 MULTI-PROCEDURE SAME DAY *\n * TRANSCATHETER BIOPSY IVC GRAM *\n * HEPATIC VENOGRAM WITH PRESSURE -22 EXTRA CHARGE *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant c/b hepatic artery thrombosis, liver\n necrosis.\n REASON FOR THIS EXAMINATION:\n eval for stenosisPLEASE ALSO DO LIVER BIOPSY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver ischemia post second liver transplant. Assess for inferior\n vena cava stenosis and attempt a transjugular liver biopsy.\n\n FINDINGS/PROCEDURE: Telephone consent was obtained from the patient's family\n as critical illness and intubation prevented the patient's own consent. Drs.\n and performed the procedure, with Dr. , staff radiologist,\n present and supervising the entire procedure.\n\n As no suitable vein in the right neck could be visualized, and secondary to\n thrombocytopenia, the right internal jugular vein was accessed under\n ultrasound guidance. The vein was noted to be patent and compressible prior\n to access. The catheter was passed over a wire from the right internal\n jugular vein into the superior vena cava, right atrium, right hepatic vein,\n and IVC under direct fluoroscopic guidance. Pressures were obtained in the\n IVC and hepatic veins, and the pressure gradient was negligible (IVC 24/21\n with a mean of 22, hepatic vein 25/21 with a mean of 23). Venacavogram\n demonstrated a widely patent IVC into the right atrium. No areas of IVC\n stenosis were seen. A left hepatic venogram was done prior to liver biopsy to\n outline the hepatic venous anatomy which was unremarkable.\n\n Four biopsy specimens with a T- biopsy catheter were obtained.\n Subsequently, the 9 french introducer sheath was removed from the right\n internal jugular vein, and hemostasis was obtained.\n\n Contrast was subsequently hand injected into the newly placed biloma drain,\n which demonstrated a moderate to large sized biloma cavity. 150 cc of bile\n were subsequently aspirated from the biloma.\n\n ANESTHESIA: 5 cc of 1% lidocaine for local anesthesia.\n\n COMPLICATIONS: None apparent.\n\n (Over)\n\n 4:10 PM\n IVC GRAM Clip # \n Reason: eval for stenosisPLEASE ALSO DO LIVER BIOPSY\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 50CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) Widely patent IVC without evidence of stenosis. Negligible pressure\n gradients obtained.\n 2) Transjugular liver biopsy - four passes were made, and good samples\n obtained.\n 3) 150 cc of bile aspirated from the abdominal biloma.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-25 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 802728, "text": " 10:45 AM\n N-G TUBE PLACEMENT (W/ FLUORO) PORT; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n Reason: placement of post-pyloric nasogastric tube\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant\n REASON FOR THIS EXAMINATION:\n placement of post-pyloric nasogastric tube\n ______________________________________________________________________________\n FINAL REPORT\n FLUOROSCOPIC N-G TUBE PLACEMENT:\n\n HISTORY: 42 year old male s/p liver transplant requiring feeding tube.\n\n Under fluoroscopic guidance, a feeding tube was advanced via the left nare and\n was ultimately positioned with the tip at the approximate location of the\n duodeno-jejunal junction. Approximately 15 cc of Conray was then administered\n via the feeding tube and confirmed the placement. There were no\n complications.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-08 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 801059, "text": " 7:41 AM\n IVC GRAM Clip # \n Reason: angioplasty of ivc stenosis (demonstrated on angio ). no\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 45\n ********************************* CPT Codes ********************************\n * PTA VENOUS 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * INTRO CATH SVC/IVC -51 MULTI-PROCEDURE SAME DAY *\n * PTA VENOUS IVC GRAM *\n * CATH, TRANSLUM ANGIO NONLASER CATH, TRANSLUM ANGIO NONLASER *\n * STENT NOCOAT.NOCOVER W/ SYSTEM NON-IONIC LESS THAN 100CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant c/b hepatic artery thrombosis, liver\n necrosis.\n REASON FOR THIS EXAMINATION:\n angioplasty of ivc stenosis (demonstrated on angio ). no stent (awaiting\n re-transplant).\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant. Hepatic artery thrombosis. Known IVC stenosis\n with 7 mm gradient. Please perform angioplasty. No stent placement.\n\n RADIOLOGISTS PERFORMING PROCEDURE: Dr. and Dr. ,\n staff radiologist, was present and supervised the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed written consent was obtained. The right neck was\n prepped and draped in usual sterile fashion, including the right IJ central\n venous catheter. An 0.035 wire was advanced into the inferior vena\n cava. The indwelling central venous catheter was exchanged for a 12 FR sheath\n after sequential dilatation and application of local anesthestic. The inner\n dilator was removed and a 4 FR straight angiographic catheter was inserted\n through the sheath over the wire with tip in distal inferior vena cava.\n The wire was removed and an inferior vena cavagram was performed. This again\n demonstrated visual stenosis at the region of the very distal inferior vena\n cava near the cavoatrial junction. A super stiff Amplatz wire was advanced\n down the 4 FR straight catheter and the straight catheter was removed. This\n was replaced by an 18 mm x 4 cm balloon catheter. Balloon dilatation was\n performed of the stenosis. No waist was identified during balloon inflation.\n The balloon dilatation catheter was removed and exchanged for a 22 mm x 4 cm\n balloon catheter. Again balloon dilatation was performed of the stenosis.\n Again no waist was identified. The balloon catheter was then exchanged for\n the 4 FR straight multiside hole catheter. An inferior vena cavagram was then\n performed. Again the inferior vena caval stenosis was seen; however, it did\n appear to be less stenotic than prior to dilatation. No evidence for vessel\n injury was seen. There was no extravasation of contrast. Pressure\n measurements were obtained from the mid IVC and from the right atrium. Only a\n 5 mm gradient was seen distally after dilatation.\n\n COMPLICATIONS: None.\n\n CONTRAST/MEDICATIONS: IV conscious sedation consisting of incremental doses\n (Over)\n\n 7:41 AM\n IVC GRAM Clip # \n Reason: angioplasty of ivc stenosis (demonstrated on angio ). no\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of Versed and Fentanyl. 10 cc of 1% Lidocaine given for local anesthestic. 45\n cc of nonionic contrast were administered. Nonionic contrast was used to\n secondary to elevated creatinine.\n\n IMPRESSION: Dilatation of inferior vena caval stenosis with an 18 and a 22 mm\n balloon. There was mild improvement of the hemodynamic gradient. Pre\n procedure gradient was 7 mm Hg and post procedure gradient was 5 mm Hg.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2173-09-28 00:00:00.000", "description": "CT GUIDANCE DRAINAGE", "row_id": 800105, "text": " 12:43 PM\n CT HEPATIC DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n CT ABDOMEN W/O CONTRAST\n Reason: drainage of biloma\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p failed OLT, now with large biloma on CT.\n REASON FOR THIS EXAMINATION:\n drainage of biloma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 year old man status post failed liver transplant presenting\n with a large biloma.\n\n TECHNIQUE: Contiguous axial images were acquired from the base of the lungs to\n the iliac crests at 7 mm intervals. No intravenous or oral contrast was\n administered for this procedure.\n\n COMPARISONS: Examination is being compared with CT scan performed on , .\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Again seen are bilateral pleural\n effusions and dependent atelectasis.\n\n A nasogastric tube is seen with tip at the proximal jejunum.\n\n There is evidence of moderate to severe ascites. There is evidence of a large\n central collection at the liver measuring approximately 9.1 x 6.2 cm in\n diameter. Density measurements at this collection were an average of 8.4\n Hounsfield units. Additionally, a wedge-shaped area of hypodensity is seen at\n the periphery of the anterior segment of the right liver lobe and the medial\n segment of the left liver lobe. These findings are unchanged when compared to\n the prior exam. There are numerous punctate calcifications within the spleen\n consistent with granulomas. At the right kidney, there is evidence of multiple\n coarse calcifications within the collecting system and the renal cortex. These\n findings are unchanged when compared to the prior exam.\n\n CT LOCALIZATION: CT fluoroscopy was performed to localize an adequate puncture\n site for the drainage of the above described collection at the center of the\n liver. This localization was marked at the skin.\n\n After acquiring written informed consent and using the usual sterile technique\n the patient was prepped and draped.\n\n CT GUIDED NEEDLE INSERTION: Using CT fluoro, needle was inserted\n into the collection. Dark bilious material was observed draining through the\n needle.\n\n CT GUIDED CATHETER INSERTION: Under CT fluoro, a 10 french pigtail catheter\n was inserted into the collection. The catheter was then secured at the skin.\n (Over)\n\n 12:43 PM\n CT HEPATIC DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n CT ABDOMEN W/O CONTRAST\n Reason: drainage of biloma\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 100 cc of dark bilious material were drained through the catheter.\n\n Post procedure CT scan demonstrates adequate position of the pigtail catheter\n within the collection.\n\n There were no complications during or immediately after the procedure.\n\n Dr. , staff radiologist, was present during the entire procedure and\n directly supervised it.\n\n IMPRESSION: Successful CT guided drainage of a centrally located biloma at the\n liver.\n\n" }, { "category": "Radiology", "chartdate": "2173-09-26 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 799983, "text": " 2:02 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P LIVER TRANSPLANT, ? EXTENT OF BILEOMA,ABDOMINAL PAIN\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant with bileoma\n REASON FOR THIS EXAMINATION:\n ?extent of bileoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hepatic transplant with hepatic artery occlusion. Assess extent of\n biloma.\n\n COMPARISON: .\n\n TECHNIQUE: Pre and post contrast multiphasic CT examination of the liver with\n delayed enhanced images of the abdomen and pelvis.\n\n CONTRAST: 150 cc of Optiray.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The patient has developed\n small bilateral pleural effusions with adjacent compressive atelectasis in the\n interval. There is a geographically marginated wedge-shaped area of\n hypodensity in the central portion of the liver with its apex at the porta\n hepatis. This area demonstrates no enhancement centrally and heterogeneous\n enhancement at its periphery. Its margins are encompassing more of the liver\n parenchyma than on the previous study, now extending into segments 2 and 3\n medially and involving all of segments 5 and 8 as well as segment 4. The\n caudate lobe is spared. There is a large amount of ascites, more so than on\n the prior study. The spleen remains enlarged. There is no proper hepatic\n artery visualized, though the portal system is patent. The pancreas, adrenals\n and kidneys are unremarkable. The aorta is of normal caliber and there is no\n adenopathy. There is diffuse subcutaneous edema.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a post pyloric feeding tube in\n good position. The bowel is unremarkable. The bones reveal no suspicious\n findings.\n\n IMPRESSION: 1. Expanding area of hypodensity and poor enhancement involving\n the right and left hepatic lobes compatible with large area of infarction and\n biloma.\n 2. Large amount of ascites with diffuse subcutaneous edema and bilateral\n pleural effusions.\n 3. Known occlusion of proper hepatic artery.\n (Over)\n\n 2:02 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P LIVER TRANSPLANT, ? EXTENT OF BILEOMA,ABDOMINAL PAIN\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-09-20 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 799424, "text": " 5:09 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: hepatic art thrombosis and intrahepatic bile collection\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant , recent liver biopsy, admitted\n with fevers x1day.\n REASON FOR THIS EXAMINATION:\n hepatic art thrombosis and intrahepatic bile collection\n CONTRAINDICATIONS for IV CONTRAST:\n cr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant with recent liver biopsy with fevers\n for one day.\n\n COMPARISON: .\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis, without intravenous contrast.\n\n CT ABDOMEN W/O IV CONTRAST: There is minimal dependent atelectasis at the lung\n bases. There is a moderate sized pericardial effusion. There is a new large\n wedge- shaped region along the anterior right lobe of the liver, in\n combination with the extensive somewhat lobulated low attenuation within the\n porta hepatis. Again noted is the splenomegaly and numerous collateral vessels\n in the hilar region. The pancreas, adrenal glands and left kidney are\n unremarkable. The numerous calcifications throughout the spleen are again\n unchanged, consistent with prior granulomatous disease. Several\n calcifications are noted within the right renal collecting system. There is a\n moderate amount of stranding throughout the mesentery along with perihepatic\n and perisplenic ascites. There is no definite free air and the vasculature is\n grossly unremarkable on this unenhanced study.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon and bladder\n are unremarkable. There is a moderate amount of free pelvic fluid. No deep\n pelvic lymphadenopathy.\n\n The osseous structures are grossly unremarkable.\n\n IMPRESSION:\n 1. There is a new large wedge-shaped low attenuation region within the\n anterior right lobe of the liver, worrisome for a new infarction. Please note\n that as this is a noncontrast study the vasculature cannot be evaluated for\n thrombosis.\n 2. Bibasilar atelectasis and pericardial effusion.\n 3. Unchanged splenomegaly, numerous collaterals and splenic calcifications.\n 4. Unchanged ascites and stranding.\n (Over)\n\n 5:09 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: hepatic art thrombosis and intrahepatic bile collection\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-10-16 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 801847, "text": " 12:20 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: LIVER TRANS EVAL FOR ABSCESS/HEMATOMA\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 42 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant with bileoma\n\n REASON FOR THIS EXAMINATION:\n r/o abscess/hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 y/o man status post liver transplant with purulent drainage\n from a drain. Evaluate for abscess or hematoma.\n\n TECHNIQUE: Initially, non-contrast images were performed through the abdomen\n and pelvis. Then, despite the patient's elevated creatinine, it was deemed\n necessary to administer IV contrast to evaluate the hepatic enhancement and\n for any subtle fluid collections. The risks of IV contrast were discussed\n with the Surgical residents and by their report, Dr. assumes\n responsibility for the contrast administered in regard to the patient's renal\n function.\n\n Visipaque was administered to reduce the possibility of contrast nephropathy.\n\n CT OF THE ABDOMEN WITHOUT & WITH CONTRAST: There are moderate-sized bilateral\n pleural effusions with compressive atelectasis at the lung bases. Underlying\n infection in the lung bases cannot be excluded. There is a tiny pericardial\n effusion. There is a large JP drain seen over the superior surface of the\n liver, and another is seen in the porta hepatis. There is mild periportal\n edema. There is a subtle focal area of low density in Segment 7 of the liver.\n This persists on all three phases and may be due to a small biloma vs. a clamp\n injury. This has ill-defined margins and measures approximately 2 cm. There\n is stable splenomegaly. There is fluid stranding throughout the abdomen.\n There is no evidence of an intra-abdominal abscess or walled-off fluid\n collection. There are punctate areas of high density on the non-contrast scan\n in the right kidney, compatible with right nephrolithiasis. There is no left\n nephrolithiasis. On the delayed images, the kidneys symmetrically enhance and\n excrete contrast. There is a new focal low-density lesion within the right\n adrenal gland, which measures 2.2 x 3.0 cm and is consistent with an adrenal\n hemorrhage. The left adrenal appears normal. The pancreas is unremarkable.\n There are punctate calcifications within the spleen, indicative of prior\n granulomatous infection. The bowel loops are unremarkable.\n\n CT OF THE PELVIS WITHOUT & WITH CONTRAST: There is a mild amount of free\n fluid within the pelvis. The bowel loops are unremarkable. The urinary\n bladder is collapsed around a Foley catheter.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n\n (Over)\n\n 12:20 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: LIVER TRANS EVAL FOR ABSCESS/HEMATOMA\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 42 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. No evidence of intra-abdominal abscess or walled-off fluid collection.\n 2. Mild amount of intra-abdominal ascites.\n 3. Moderate-sized bilateral pleural effusions with consolidations of the lung\n bases, most likely compressive atelectasis. However, an underlying pneumonia\n cannot be excluded.\n 4. New small right adrenal hemorrhage.\n 5. Right nephrolithiasis.\n\n" }, { "category": "Radiology", "chartdate": "2173-10-07 00:00:00.000", "description": "HEPATIC VENOGRAM WITH PRESSURES", "row_id": 800957, "text": " 7:28 AM\n IVC GRAM Clip # \n Reason: Please also look at hepatic vein-IVC anastomosis.\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * 1SR ORDER BRANCH VENOUS SYSTEM HEPATIC VENOGRAM WITH PRESSURE *\n * IVC GRAM C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p failed OLT secondary to thrombosed hepatic artery, .\n REASON FOR THIS EXAMINATION:\n Please also look at hepatic vein-IVC anastomosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post failed orthotopic liver transplant secondary to\n thrombosed hepatic artery. New onset of lower extremity swelling and ascites.\n\n PROCEDURE: The procedure was performed under self-hypnotic relaxation with\n additional local anesthetic. After sterile preparation of the right neck the\n right internal jugular vein was localized by ultrasound. It was found to be\n patent and compressible. After instillation of 5 ml 1% lidocaine the right\n internal jugular vein was entered with a 21 gauge needle. An 018 guidewire\n was advanced into the superior vena cava under fluoroscopic guidance. A 4.5\n French micropuncture dilator set was advanced. Then a Bentson guidewire was\n advanced into the inferior vena cava, exchange was made for a 5 French sheath.\n A 5 French head catheter was then advanced into the middle hepatic vein\n and a venogram was performed. Pressure measurements were taken during pull\n back. They demonstrated that there was a gradient of only 2 mm between the\n hepatic vein and the right atrium which is normal.\n\n The catheter was then advanced into the inferior vena cava and a cavogram was\n performed with oblique angling of the tube. Pressure measurements were taken.\n There was a 7 mm pressure gradient between the high inferior vena cava and the\n right atrium. The catheter was removed. The sheath was secured to the neck\n to enable another procedure on the following day.\n\n There were no immediate complications.\n\n IMPRESSION: The inferior vena cava just at the level of the venous\n anastomosis shows an indentation from the left lateral side narrowing the\n lumen to about 50% and having an abnormal pressure gradient of 7 mm Hg. The\n hepatic vein confluence enters at this level, however and is patent in its\n entirety without a stenosis or significant gradient in its course.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-03 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 800580, "text": " 3:28 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEASE EVAL INTERVAL CHANGE OF HEPATIC FLUID COLLECTION\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant with bileoma\n\n REASON FOR THIS EXAMINATION:\n PLEASE EVAL INTERVAL CHANGE OF HEPATIC FLUID COLLECTION\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess interval change in biloma status post liver transplant.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases through\n the pubic symphysis after the administration of 100 cc of Optiray contrast\n intravenously. Optiray was used per patient debility.\n\n CONTRAST: 100 cc Optiray.\n\n COMPARISON: .\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: Trace bilateral pleural effusions. The\n lung bases are otherwise clear. The liver is again notable for a\n geographically marginated hypodense region predominantly involving segments\n 2, 3, 4, 5 and 8. There is slight interval decrease in size (previously 11.3\n x 16.7 and currently 9.3 x 14.6 cm in the largest axial dimensions). In the\n interval since the prior study, a pigtail catheter has been placed\n percutaneously and is coiled in proximity to the portal vein branch points.\n There are no new regions of hypodensity or other new hepatic lesions.\n THe portal and hepatic veins are patent. Granulomas in the spleen and one in\n the left hepatic lobe are again seen. The spleen is again noted to be enlarged\n measuring approximately 15.5 cm. The pancreas, adrenal glands, kidneys,\n ureters, and bowel loops are unremarkable. There is massive ascites which has\n increased in the interval since the prior study. There is also increase in\n edema of the subcutaneous soft tissues. A feeding tube is positioned with the\n tip in the third part of the duodenum.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: There is a large amount of pelvic\n peritoneal fluid. There is no lymphadenopathy. The sigmoid colon and rectum\n are unremarkable. There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Slight interval decrease in the hypoattenuating region involving segments\n 2, 3 4, 5 and 8 with interval placement of a pigtail catheter. No new hepatic\n lesions.\n 2. Interval decrease in extent of small bilateral pleural effusions.\n 3. Massive ascites, markedly increased in the interval since the prior study.\n\n (Over)\n\n 3:28 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: PLEASE EVAL INTERVAL CHANGE OF HEPATIC FLUID COLLECTION\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2173-10-11 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 801304, "text": " 9:28 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: request hepatic duplex to evaluate flows in patient s/p live\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p OLT. Please perform U/S to eval hepatic art, hepatic\n vein, and portal vein.\n REASON FOR THIS EXAMINATION:\n request hepatic duplex to evaluate flows in patient s/p liver transplant with\n elevation of LFTs.\n ______________________________________________________________________________\n FINAL REPORT\n LIVER ULTRASOUND:\n\n INDICATION: S/P liver transplant.\n\n There is a sharply marginated, wedge-shaped area of hyperechogenicity in\n segment VI of the liver. There is flow within this section. This may be\n a liver lesion, such as hemangioma, or perhaps related to trauma during the\n transplant procedure. The liver is otherwise normal in echogenicity. Analysis\n of the left, right, and main portal vein demonstrate normal flow. Good\n arterial wave forms are seen in the left hepatic artery, right hepatic artery,\n and main hepatic artery. The hepatic veins are patent. No perihepatic fluid\n collections are identified.\n\n IMPRESSION:\n 1) Wedge-shaped area of increased echogenicity in segment VI of the liver,\n of indeterminate etiology.\n 2) Hepatic venous, portal venous, and hepatic arterial vessels are patent\n with normal wave forms.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-10-14 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 801665, "text": " 2:13 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: us and duplex of liver transplant post op day 4 now with ris\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p OLT. Please perform U/S to eval hepatic art, hepatic\n vein, and portal vein.\n REASON FOR THIS EXAMINATION:\n us and duplex of liver transplant post op day 4 now with rising bili.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post orthotopic liver transplant.\n\n LIMITED ABDOMEN ULTRASOUND: Evaluation was performed of the transplanted\n liver. Comparison was made to prior study of . The prior seen wedge\n shaped echogenic area in the right lobe of the liver has faded in the\n interval. This likely indicates that the lesion was post- surgical in nature.\n The liver parenchyma is otherwise unremarkable. The portal venous, hepatic\n venous, and hepatic arterial wave forms are all normal in appearance. No\n vessel abnormalities are observed. There is no ascites. A small right\n pleural effusion is present.\n\n IMPRESSION: Status post liver transplant with good arterial and venous flow.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-25 00:00:00.000", "description": "RELATED PROCEDURE DURING POSTOPERATIVE PERIOD", "row_id": 805797, "text": " 3:03 PM\n CATH CHEK/REMV Clip # \n Reason: please perform cholangiogram via patient's T tube\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 20CC\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C 78 RELATED PROCEDURE DURING POSTOPER *\n * TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42M s/p OLT, now with increasing JP output containing bilirubin\n REASON FOR THIS EXAMINATION:\n please perform cholangiogram via patient's T tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man status post orthotopic liver transplant with\n increase in JP output containing bilirubin.\n\n RADIOLOGISTS: Drs. and , the Attending Radiologist, who was\n present and supervising the entire procedure.\n\n CHOLANGIOGRAM: Scout image demonstrates postpyloric tube with tip at the\n duodenal-jejunal junction. The pigtail catheter is noted as well overlying the\n left upper quadrant. Approximately 50 cc of Conray was injected inro the\n biliary tube demonstrating no evidence of intrahepatic or extrahepatic biliary\n duct dilatation. No free spillage of contrast is identified and the contrast\n empties readily into the duodenum. Slight irregularity along the midportion of\n the common duct is again noted, which is unchanged from the previous studies.\n\n IMPRESSION: Unchanged appearance of the biliary tract, without evidence of\n obstruction or leakage.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-26 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 805945, "text": " 2:37 PM\n FISTULOGRAM/SINOGRAM; 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n Reason: pls inject gastrografin into patient's JP before KUB\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42M s/p OLT #2 (1st rejected from HAT), with bilious drainage from JP.\n REASON FOR THIS EXAMINATION:\n pls inject gastrografin into patient's JP before KUB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 y/o male status post liver transplant, now with bilious\n drainage from a left upper quadrant pigtail catheter.\n\n Water-soluble contrast was administered via the pigtail catheter. This\n demonstrates a small cavity measuring approximately 2 x 3 cm. This cavity is\n quite vascular, as contrast immediately refluxed into surrounding arteries and\n veins. There is no evidence of a fistulous connection with any adjacent\n structures.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-30 00:00:00.000", "description": "CT PELVIS W&W/O C", "row_id": 806310, "text": " 10:50 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: POST LIVER TX/WITH PERSISTENT ABD PAIN\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 38 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant , known kidney stones, remains\n inpatient with persisting abdominal pain.\n REASON FOR THIS EXAMINATION:\n CAT SCAN ABD/PELVIS WITH IV CONTRAST with FINE CUTS THROUGH KIDNEYS.Evaluate\n for pathology that may be causing patients persisting abdominal pain.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42 year old status post liver transplant with known kidney stones.\n Patient continues to have persistent abdominal pain.\n\n TECHNIQUE: Multiple axial images were obtained helically through the abdomen\n and pelvis in multiple phases before and after contrast administration.\n Reformatted images were obtained.\n\n CONTRAST: 150 cc of Optiray were administered secondary to patient history of\n debility.\n\n COMPARISON: .\n\n CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST: In the visualized portion of the\n lungs there is a small amount of either left pleural thickening or residual\n pleural effusion. There is bilateral dependent atelectasis. The visualized\n portion of the heart and pericardium are unremarkable.\n\n The wedge shaped hypodense lesion in the posterior segment of the right lobe\n is unchanged. There are no new lesions in the liver and there is no biliary\n dilatation. The T tube catheter is unchanged in position. There is a pigtail\n catheter seen in the mid abdomen that has a very small collection around its\n tip. There is a feeding tube in place with its tip at the ligament of Treitz.\n There are splenic granulomas and hypodensities in the spleen which are\n unchanged. The left adrenal gland is normal and the right mass in the adrenal\n gland is unchanged in size and characteristics.\n\n There are multiple calculi in the the right kidney, unchanged in size or\n location since the prior study of Ictober 28, . There is no hydroureter or\n hydronephrosis. There are no stones seen in the left kidney. There are no\n enhacing renal masses. Within the body/tail of the pancreas there is a 1.4 x\n 1.9 cm hypodense cystic lesionas previously demonstrated. There is diffuse\n ascites within the abdomen which has decreased in its amount compared to the\n prior study.\n\n CT OF THE PELVIS WITH AND WITHOUT CONTRAST: Small and large bowel is normal in\n caliber. There is a moderate amount of stool in the colon. There is free fluid\n throughout the pelvis which is decreased compared to the prior study. The\n (Over)\n\n 10:50 AM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: POST LIVER TX/WITH PERSISTENT ABD PAIN\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 38 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n distal ureters are normal. The bladder is not adequately distended and cannot\n be evaluated.\n\n Reformatted images confirm the above findings.\n\n BONE WINDOWS: There are no suspicious lytic lesions.\n\n IMPRESSION: 1. Interval improvement in the ascites. 2. Multiple right sided\n renal nonobstructing stones, unchanged since prior studies and without\n hydroureter or hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-14 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 804718, "text": " 3:58 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: f/u, please evaluate collectionNO IV CONTRAST PLEASE\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p liver transplant s/p repeat liver transplant with\n h/o caval s/p collection drainage\n REASON FOR THIS EXAMINATION:\n f/u, please evaluate collectionNO IV CONTRAST PLEASE\n CONTRAINDICATIONS for IV CONTRAST:\n recent createnine rise\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post liver transplant, history of caval collection status\n post drainage. Evaluate for fluid collection.\n\n TECHNIQUE: Axial images of the abdomen and pelvis were acquired helically\n with 100 cc of Optiray contrast. Nonionic contrast was used secondary to\n patient's slightly elevated creatinine.\n\n FINDINGS: Comparison is made to the study of . There is a\n small right pleural effusion, and a smaller left pleural effusion, the volumes\n of which have not significantly changed. There is an unchanged moderate sized\n pericardial effusion. Dependent changes are seen within the lung bases.\n\n There is a focus of decreased attenuation within segment 8 of the liver, which\n is unchanged in appearance and likely represents a retractor injury. The\n spleen again demonstrates focal areas of decreased attenuation and numerous\n granulomas. A feeding tube is present with the tip in the third portion of\n the duodenum, and appears to be pulled back slightly since the prior study.\n Again seen is a pigtail catheter within the mid-abdomen. There is continued\n improvement in the amount of surrounding fluid (biloma). An additional\n drainage catheter is present with the tip in the porta hepatis. There is a\n stable large ascitic volume within the abdomen. Again noted are bulky\n calcifications within the right kidney. There is no hydronephrosis. The\n pancreas is unremarkable. Minimally opacified small bowel loops are slightly\n prominent, but there is no evidence of obstruction. There is a stable rounded\n soft tissue mass in the right adrenal gland. The left adrenal gland is normal.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a large volume of free fluid\n within the pelvis. The amount is unchanged. The bladder contains a Foley\n catheter. The previously seen fecal impaction is no longer present. No\n pathologically enlarged inguinal or pelvic nodes are seen.\n\n No suspicious lytic or sclerotic osseous lesions are identified.\n\n IMPRESSION:\n 1. Stable appearance of the abdomen. No new free intra-abdominal air or\n evidence of abscess formation.\n 2. Continued decrease in size of abdominal biloma.\n (Over)\n\n 3:58 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: f/u, please evaluate collectionNO IV CONTRAST PLEASE\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Stable focal areas of decreased attenuation in liver and spleen.\n\n\n" }, { "category": "Radiology", "chartdate": "2173-11-25 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 805806, "text": " 4:01 PM\n US ABD LIMIT, SINGLE ORGAN; DUPLEX DOPP ABD/PEL Clip # \n Reason: Please doppler to eval hepatic art, hepatic vein, and portal\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42M s/p repeat OLT (1st had HAT).\n REASON FOR THIS EXAMINATION:\n Please doppler to eval hepatic art, hepatic vein, and portal vein at porta &\n intrahepatically\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42 year old male patient status post repeat liver transplant.\n\n RIGHT UPPER QUADRANT ULTRASOUND:\n\n Real-time evaluation of the right upper quadrant was performed in multiple\n planes using -scale, color and pulsed Doppler imaging with special\n emphasis on the intrahepatic vasculature.\n\n No focal lesions are identified within the hepatic parenchyma. The\n echotexture of the liver is normal. No peritransplant collections are\n identified. There is no intrahepatic biliary ductal dilatation.\n\n The main portal vein, the right and left portal veins, the right hepatic and\n middle hepatic veins, the main hepatic artery, right and left hepatic\n arteries, and the inferior vena cava are all patent, demonstrate forward flow\n and normal physiologic waveforms.\n\n IMPRESSION: Unremarkable liver Doppler ultrasound.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-17 00:00:00.000", "description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD", "row_id": 805026, "text": " 3:54 PM\n N-G TUBE PLACEMENT (W/ FLUORO); 79 UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIODClip # \n Reason: please replace post-pyloric feeding tube. thanks. page \n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with non-functional Dobhoff feeding tube (originally placed\n ), with continued requirement for tube feeds\n REASON FOR THIS EXAMINATION:\n please replace post-pyloric feeding tube. thanks. page with ?s\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Feeding tube placement. Existing feeding tube non-functional.\n\n Under fluoroscopic visualization, a feeding tube was advanced via the left\n naris, and the tip was ultimately positioned at the duodenojejunal junction.\n Approximately 15 cc of nonionic contrast was administered through the tube and\n confirmed tip placement. There were no complications and the feeding tube is\n ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2173-11-23 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 805571, "text": " 10:12 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for interval changes. no contrast necessary\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p repeat liver transplant with draining lesser sac collection\n (decreasing output).\n REASON FOR THIS EXAMINATION:\n please eval for interval changes. no contrast necessary\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreasing output from the patient's upper abdominal pigtail\n catheter.\n\n TECHNIQUE: Non-contrast axial CT images of the abdomen and pelvis.\n\n COMPARISON: .\n\n FINDINGS:\n\n NON-CONTRAST CT ABDOMEN: There are very small bilateral pleural effusions.\n The lung bases are otherwise clear. The non-contrast evaluation of the liver\n demonstrates the presence of a T-tube catheter. This is stable. The low-\n density area seen in the posterior segment of the right lobe is also stable in\n appearance. The spleen is again noted to be enlarged and heterogeneous in\n density with multiple calcifications.\n\n There is no hydronephrosis bilaterally, noting calcification in the right\n kidney which is also stable. The pancreas is grossly unremarkable. There is\n stable appearance to a right adrenal nodule.\n\n Again noted is the patient's upper abdominal pigtail catheter. A previously\n seen area of fluid to the left and posterior to the catheter has resolved.\n There is no evident residual collection surrounding the catheter. No new\n suspicious collection is seen in the abdomen, noting stable appearance to\n ascites. There is residual contrast within the colon.\n\n NON-CONTRAST CT PELVIS: There is again noted pelvic ascites. No abnormal\n thickening or dilatation of pelvic bowel loops noting residual contrast within\n pelvic bowel loops, in particular the colon. The bladder is distended with\n fluid.\n\n No lytic or blastic destructive osseous lesions.\n\n IMPRESSION:\n\n 1) Improvement in the intraabdominal fluid surrounding the patient's pigtail\n catheter with no evidence of suspicious residual collection in the region.\n\n 2) Stable ascites.\n (Over)\n\n 10:12 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for interval changes. no contrast necessary\n Admitting Diagnosis: S/P LIVER TX; FEVER; MALAISE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3) Stable right adrenal lesion.\n\n" }, { "category": "ECG", "chartdate": "2173-10-15 00:00:00.000", "description": "Report", "row_id": 171342, "text": "Sinus rhythm. Left atrial abnormality. Early precordial R wave progression.\nCompared to the previous tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2173-10-10 00:00:00.000", "description": "Report", "row_id": 171343, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of : no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-23 00:00:00.000", "description": "Report", "row_id": 1302675, "text": "CONDITION UPDATE\nVSS. PROPOFOL DECREASED GRADUALLY TO FINAL RATE OF 10MCG/KG/MIN. PT TO VOICE - BUT STILL QUITE LETHARGIC. NOT FOLLOWING COMMANDS. PUPILS EQUAL AND REACTIVE. LOCALIZING PAIN. LUNGS COARSE THROUGHOUT. OCCASSIONAL SUCTIONING FOR THICK COLORED SPUTUM. SPUTUM SENT FOR CULT. PT WEANED TO CPAP, W/ RESULTING ACCEPTABLE ABG'S. ABD SOFT. POSITIVE BOWEL SOUNDS. ABD INCISION C/D. MOD AMT OF BILIOUS DRAINAGE FROM TTUBE. MIN. DRAINAGE FROM JP. U/O QS. NO STOOL THIS SHIFT. HCT AND PLATELET STABLE. LEVEL DUE THIS P.M. CULT SENT OF BILE AND URINE. CONT SERIAL LABS. WEAN FROM VENT AS TOLERATES. MONITOR FOR S/S OF BLEEDING. S/S OF INFECTION. CONT CURRENT TREATMENT PLAN.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-23 00:00:00.000", "description": "Report", "row_id": 1302676, "text": "Resp CAre\nremains ett/vent support. changed from simv to psv mode, weaned peep, all tolerated well. presently 12/5/40%. sxning tan/rusty sputum. appears comfortable on spont mode. no further changes anticipated tonight.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-20 00:00:00.000", "description": "Report", "row_id": 1302667, "text": "Nursing note:\nNEURO: Alert, oriented x1-2, appropriate, reorients easily. Follows commands. Morphine PRN for pain.\nRESP: Lung sounds coarse, diminished to bases. Extubated this am, ABGs acceptable post-extubation. Encouraged to cough and deep breathe w/minimal effect, pools secretions at back of throat. Suctioned frequently w/Yankauer. Weak cough, resists CPT. Sats 96-99% on 3-4L NC.\nCV: Afebrile. SR in 60s-70s, no ectopy. SBP 170-180s, Lopressor/Hydralazine w/some effect. CVP 0-7. PA cath and cordis changed over wire to multi-lumen, tips sent for culture. +Pitting edema to bilat LEs. CXR for line placement done, results pending. Platelets given for plt. count 54.\nGI: +BS, abdomen softly distended. +flatus, -stool. T-tube patent for dark bilious drainage. JP for serosang drainage. T-tube cholangiogram done today. Remains NPO, pt. self d/c'd NGT this am. Team aware. TPN infusing.\nGU: Foley patent amber urine.\nENDO: Covered w/SSRI.\nA/P: Stable post-extubation.\nEncourage pulm hygeine, increase activity level - PT consult pending. Cont. to monitor platelets , all systems for change.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-21 00:00:00.000", "description": "Report", "row_id": 1302668, "text": "NPN\nNEURO: PT ALERT, NOT SLEEPING OVER NIGHT. ORIENTED TO HOSPITAL AND WHY HE'S HERE, HOWEVER NOT ALWAYS ANSWERING QUESTIONS, UNSURE OF DATE/ YEAR. MAE. CONFUSED AT TIMES, MD AWARE.\nCV: BP 170'S-180'S OVERNIGHT. HR 70'S WITHOUT ECTOPY. PLATELETS GIVEN FOR 54, SECOND DRAW POST PLATELETS PENDING. RBCS ALSO GIVEN FOR HCT DROP TO 28.3\nRESP: PT NEEDS ENCOURAGEMENT TO COUGH AND DEEP BREATHE, VERY RELUCTANT TO COUGH DEEPLY AND RAISE SPUTUM. INCENTIVE SPIROMETER DONE SEVERAL TIMES, CHEST PT AND DEEP BREATHING DONE WHEN PT AWAKE. LUNGS CLEAR TO COARSE AND DIMINISHED AT BASES, LEFT CLEARER THAN RIGHT. ABGS THIS AM 7.42/37/171/0/25, DR. AWARE.\nGI/GU: UOP 100-200CC/HR. APPEARING SLIGHTLY TINGED THIS AM, DR. AWARE AND SENT UA. ABD SOFT. MEDS GIVEN PO LAST EVE, NO NG TUBE, DR. AWARE, PT SWALLOWING WITH NO PROBLEMS, NO COUGHING.\nTMAX 97.8\n" }, { "category": "Nursing/other", "chartdate": "2173-10-21 00:00:00.000", "description": "Report", "row_id": 1302669, "text": "STATUS\nD: CONFUSED AT TIMES BUT FOLLOWS COMMANDS..PICKING @ LINES PULLING OFF O2 & ATTEMPTING TO CLIMB OOB..HCT/PLTS LOW\nA: PLTS REPLETED & GIVEN 1U PC'S..LIVER BX DONE OOZING FROM SITE HO AWARE WILL REPLETE PLT CT & HCT..ADQUATE HUO'S..ABD DSG SM AMT OOZING FROM AROUND T-TUBE & JP SITES..DSD APPLIED..LUNGS CONGESTED CPT Q2-3H PT POOR BUT UNABLE TO NT SUCTION DUE TO LOW PLTS & BLEEDING SAT'S GOOD >97% ON 3L NP & OCC OFM FOR HUMIDIFICATION\nR: POOR PULMONARY STATUS\nP: CONTINUE WITH GOOOD PULMONARY TOILET..MONITOR PLTS & CLOSELY PT CONSULT\n" }, { "category": "Nursing/other", "chartdate": "2173-10-22 00:00:00.000", "description": "Report", "row_id": 1302670, "text": "FOCUS: RESPIRATORY STATUS\nDATA:\nPT VERY CONFUSED AND AGITATED. EPISODE OF DESAT TO 88, HR 110-120, TO 200. LUNGS BILAT COARSE W/RHONCHI, PT UNABLE TO COUGH TO EFFECTIVELY CLEAR SECRETIONS. NO GAG NOTED. NT SUCTION WITH BRADYCARDIA TO 48. ABG POOR AND TEAM CALLED TO INTUBATE. HE WAS EASILY INTUBATED W/7.5 ETT, 100SUCC,100PROPOFOL. PROPOFOL DRIP STARTED WHICH IS CURRENTLY AT 50MCG/KG/MIN AND PT IS BREATHING COMFORTABLY ON AC 650X20, PEEP 8. CXR CONFIRMED PLACEMENT OF ETT AND NGT WHICH WAS ALSO INSERTED W/O BLEEDING NOTED. ABG IMPROVED. CONTINUES TO HAVE LARGE AMOUNTS OF TINGED ICTERIC SECRETIONS. SPUTUM CX SENT. AFEBRILE.\n\nPLAN:\nCONT AC VENTILATION OVERNIGHT. SX SECRETIONS AS NEEDED. ABG IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-25 00:00:00.000", "description": "Report", "row_id": 1302682, "text": "Nursing progress note\nNeuro:remains sedated on proprofol 10mcg. lethargic but follows simple commands. MAE's spont. some purposeful movmts. afebrile\n\nCV:SR, no ectopy. CVP 7. BP remains MD aware- lopressor increased and 5mg x1. p-boots on. remains with =3 periph edema. Platelet 58-team aware-no transfusion at this point.\n\nRESP:LS coarse to clear. Copius thick tan to white secretions. PS increased to 12 secodnary to tachypnea to 30 and TV in 40's. On PS 12- RR in teens and TV 600's.\n\nGI:Abd soft,nt,nd. t-tube and JP . Large abd drsg c/d/i. Post pyloric feeding tube placed in angio via fleuro and nepro tube feeds initiated at 10cc/hour-to titrate up as tolerated. no BM. On TPN for nutrition.\n\nGU:foley patent icteric urine.\n\nENDO:BS WNL.\n\nSKIN:remains with mult bruising but .\n\nsocial: family calling for updates.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-25 00:00:00.000", "description": "Report", "row_id": 1302683, "text": "Respiratory Care Note:\n Patient remains on PSV with Q1 hour sucitioning for thick whitish secretions. He was trasnported to radiology this am without event. ET tube is secure. Vent alarms set and functional. CXR reveals improvement in patchy bilat infiltrates which are now more concentrated in bases and he has a samll R sided pleural effusion. Positive for gram + cocci in sputum.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-26 00:00:00.000", "description": "Report", "row_id": 1302684, "text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Returned from angio earlier in shift without event. Kept sedated overnoc, left on SIMV. BS's coarse, sxing thick tan secretions. See flowsheet for further pt data.\nPlan: Wean vent as pt can tolerate.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302661, "text": "Nursing note:\nNEURO: Awake, following commands, medicated prn for pain w/Morphine. Consistently acknowledges pain when asked, but appears comfortable most of day and able to doze on and off. Remains restrained as pt. picks at tubes and lines occ.\nRESP: Remains on CPAP 40%. No vent changes today. Suctioned for copious amounts thick white secretions. Lung sounds coarse. Sputum spec sent.\nCV: Afebrile. NSR 60s-70s. Remains to 180s, lopressor/hydralazine w/minimal effect. Team aware. PA line , see Carevue for details. CVP 8-12. PADs in teens. Platelets 64, no intervention at this time. Hct stable.\nGI: +BS, -Stool. Abdomen soft, distended. NGT in place for small amounts bilious drainage. 2 JPs and T-tube patent , see I/O's for amounts. DSD . TPN infusing.\nGU: Foley patent adequate amounts amber urine.\nENDO: Insulin gtt titrated frequently.\nACT: MAE on bed, assists w/turning and repositioning.\n\nA/P: Hemodynamically stable. Large amounts of secretions remains issue.\nCont. w/pulm. hygeine and attempt vent wean, follow labs, platelets. ? D/C PA cath.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302662, "text": "Nursing note:\nNEURO: Alert, oriented x2-3. Vague w/answers at times but appropriate and easily reorients. Visting w/family.\nRESP: Lung sounds coarse, dim to bases , wheezy at times. Nebs w/effect. Using I/S w/good technique, +strong productive cough for thick white secretions. Tolerating 4L NC w/sats 93-99%. FT 70% worn for humidity for comfort PRN. ABGs acceptable.\nCV: SR in 60s, no ectopy. Afebrile. SBP 120s-140s. CVP 0-4. Negative fluid balance for day by 2L. No cardiac c/o's. +Diuresis after Lasix this am.\nGI: +BS, abdomen softly distended. +flatus and small amount liquid stool. 2 T-Tubes and patent for dark bilious drainage, JP for serosang. drainage. Tolerating sios clears w/o incident.\nGU: Foley patent amber urine.\nENDO: Minimal amount SSRI given today, glucose 113-124.\nACT: OOB to chair all day, up to use commode and to give skin a rest at times, steady gait. PT consult pending.\n\nA/P: Stable w/improving resp. status. Cont. w/aggressive pulm hygeine, increase activity level, ADAT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302663, "text": "Disregard above note - written on incorrect pt. Thanks.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-20 00:00:00.000", "description": "Report", "row_id": 1302664, "text": "Nursing note\nPt slept well tonight, arouses easily and follows commands more briskly. Morphine PRN for pain. Afebrile. Lopressor/hydralazine cont for htn. NSR, no ectopy. 5 pack plt x1 for plt 43-post plt 64. md aware. to be rechecked in AM. cont with copious white thick to thin secretions. CPT done. Remains on CPAP . Lateral JP pulled by MD. . dark amber urine. cont with dependent edema.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-20 00:00:00.000", "description": "Report", "row_id": 1302665, "text": "Respiratory Care:\npt had a fairly quiet noc. RSBI was 47 this AM and was left on Spontanious breathing trial for up to two hours as tolerated. See CareVue for details.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-20 00:00:00.000", "description": "Report", "row_id": 1302666, "text": "Respiratory Care Note:\n Patient extubated earlier today without incident. Voice and cough . SpO2 adequate on 40% cool neb. BS bilat, without stridor. CXR noted to have bibasilar collapse. Plan for aggressive pulmonary hygiene and use of incentive spirometer.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-24 00:00:00.000", "description": "Report", "row_id": 1302677, "text": "Nursing note:\nNEURO: Remains on 10mcg Propofol gtt, lethargic, following simple commands. PERRLA. Slept in naps overnight.\nRESP: Lung sounds coarse, suctioned for thick tan sputum and copious oral secretions. No vent changes, appears comf. RR in low 20s, spont TVs350-550. ABGs pending this am.\nCV: Afebrile. NSR in 70s, no ectopy. Remains to 180-190s - cuff 150-170s. Hydralazine and Lopressor PRN w/some effect. CVP 10. Platelets 58, no transfusion ordered per Dr. . Repeat count 60.\nGI: +BS, -stool. Abdomen soft. DSD . JP , serosang drg in small amounts. T-tube patent dark green bile. NPO, NGT to sxn.\nGU: Foley patent adequate amounts amber urine.\nENDO: No SSRI required.\n\nA/P: Stable, remains . Cont. current plan of care, aggressive pulm hygeine, monitor platelets, wean vent as tolerated, pain control.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-24 00:00:00.000", "description": "Report", "row_id": 1302678, "text": "Resp CAre\nremains ett/vented spont mode. ps at 10. appears comfortable with rr 20-22. abgs acceptable. sxned sm tannish/ secretions. good cough reflex. c/w slow wean. ?retry sbt in a.m.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-24 00:00:00.000", "description": "Report", "row_id": 1302679, "text": "CONDITION UPDATE\nVSS. AFEBRILE. CONT TO BE SOMEWHAT - SICU TEAM AWARE. MUCH MORE ALERT TODAY. CONSISTENTLY FOLLOWING COMMANDS. MOVING UPPER EXTREMITIES ON BED. ABLE TO LIFT AND HOLD LEGS. LARM NOTED TO BE MORE SWOLLEN THEN RIGHT - SICU AND TEAMS NOTIFIED. LUNGS CLEAR THROUGHOUT. OCCASSIONAL SUCTIONING FOR THICK TAN SPUTUM. MIN VENT CHANGES. SEE FLOWSHEETS. STARTED ON TROPHIC TUBE FEEDS. TOLERATING W/O DIFFICULTY. ABD INCISION UNCHANGED. MIN DRAINAGE FROM JP. MOD BILIOUS DRAINAGE OUT TTUBE. U/O QS VIA FOLEY. REMAINS ON TPN, PROPOFOL. TRANSFUSED W/ 1PACK OF PLATELETS. CONT TO MONITOR CBC. CONT SLOW VENT WEAN AS TOLERATES. MONITOR FOR S/S OF BLEEDING. S/S OF INFECTION. CONT CURRENT TREATMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-25 00:00:00.000", "description": "Report", "row_id": 1302680, "text": "Nursing note:\nNEURO: Sedated on Propofol gtt at 10mcg, following simple commands, slept in naps.\nRESP: Lung sounds coarse, dim to bases. No vent changes overnight. Spont TVs 400-550. RR in low 20s. Suctioned for thick tan secretions via ETT and copious amounts secretions to back of throat.\nCV: Afebrile. SR 70s, no ectopy. Remains to 190s/100s, Lopressor /Hydralazine w/minimal effect. Cuff pressure consistently 20-30 pts lower. L. arm noted to be more swollen than R. US ordered for am, teams aware. Platelets transfused for level of 48, repeat level pending. Vanco given for level of 12.\nGI: +BS, -stool or flatus. Trophic TFs at 10cc/hr, no residuals. Abdomen soft, non-distended., DSD . JP for small amounts serosang. drainage and T-tube patent for bilious output. Travasol infusing.\nGU: Foley patent for amber urine, qs.\nENDO: Covered w/SSRI.\n\nA/P: Cont w/large amounts secretions, frequent suctioning. Remains . Cont. current ICU care and treatments, vent wean as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-25 00:00:00.000", "description": "Report", "row_id": 1302681, "text": "pt remained on PSV throughout PM without incidence. BBS coarse. sx'd for medium amounts of thin secretions\n" }, { "category": "Nursing/other", "chartdate": "2173-10-13 00:00:00.000", "description": "Report", "row_id": 1302643, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: ALERT. ORIENTED X3. CONVERSATION CLEAR, AT TIMES INAPPROPRIATE. MEDICATED AS ORDERED WITH IV MSO4 X2 FOR PAIN WITH STATED RELIEF. MAEW. PERRL.\nRESP: EXTUBATED THIS AM. CPT, COUGHING AND DEEP BREATHING PRACTICED WITH PT. LS CLEAR BUT DIMINISHED AT BASES. ABG'S STABLE.\nCV: TMAX 99.3. NSR 60S TO 70S. TRANSFUSED WITH 1 BAG PLT FOR PLT CT 83, POST 101. R RADIAL A-LINE D/C'D DUE TO MALFUNCTION. REQUIRED 30 MIN DIRECT PRESSURE TO CONTROL BLEEDING. L RADIAL ALINE PLACED. ? FLING, ABP DOES NOT CORRELATE WITH CUFF. SICU TEAM AND MD INFORMED. SBP 160S-170S BY CUFF. ? ADD HYDRALAZINE. R FOOT COOLER THAN L, PEDAL PULSES PALPABLE. SICU TEAM IN TO ASSESS THIS AM. SEE FLOWSHEET FOR PA NUMBERS.\nGI: ABD SOFTLY DISTENDED. NO FLATUS. NGT WITH SM AMTS BROWNISH O/P. BILE DRAIN WITH MOD BILIOUS O/P. LATERAL JP O/P MAROON, MEDIAL SEROSANG. NO N/V.\nGU: AUTODIURESING VIA FOLEY. U-LYTES/OSM SENT.\nENDO: INSULIN GTT TITRATED PER RISS. FLUID BAL NEG.\nPLAN: CONT TO MONITOR. KEEP PLT CT >100. MONITOR RESP STATUS. ENCOURAGE TC&DB. TITRATE INSULIN GTT TO RISS 80-120. ? FURHTER BP CONTROL.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-14 00:00:00.000", "description": "Report", "row_id": 1302644, "text": "Nursing progress note\nPt less restless tonight, answers approp. slept well. afebrile. COnt with jerking movements of all extremeties. SR, no ectopy. Hydralazine started to keep SBP <200 with effect in combo with lopressor. @ 5 pack platlets given and 1unit PRBC for HCT 28.5. abd remains soft, JP x2 with serosang drng and t-tube with bilious drng. original post op drsg with old staining. foley patent, cont's with 1/2cc per cc of NS fluid replacement a/o. red blotchy rash noticed on sides and back. feet warm/red. MD aware. see flowsheet for further details.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-14 00:00:00.000", "description": "Report", "row_id": 1302645, "text": "STATUS\nD: CONFUSED..FOLLOWS COMMANDS..TREMOROUS..MOANING DIFFICULT TO UNDERSTAND.. REMAINS ON INSULIN & HCL GTT'S..PLTS 47\nA: HCL CHANGED TO 150meq @ 30CC/H..INSULIN GTT @ 7U..PLTS REPLETED.. 1/2 CC/CC REPLACEMENT DC'D..ADQUATE HUO'S..PT BS COARSE/CONGESTED SAT'S 94-97%..GOOD ABG'S CPT & GOOD PULMONARY TOILET WITH IMPROVED RESP STATUS SAT'S NOW >97%..ABD ULTRASOUND DONE>>GOOD FLOW PER TECH\nR: STABLE\nP: CHECK PLT CT..GOOD PULMONARY TOILET\n" }, { "category": "Nursing/other", "chartdate": "2173-10-15 00:00:00.000", "description": "Report", "row_id": 1302646, "text": "FOCUS UPDATE\nPLEASE SEE FLOWSHEET FOR DETAILS\nSBP SELF MAINTAINED 180-200 AT GOAL PER LIVER TEAM.NSR 80S INSULIN GTT CONT AT 7-9 U/HR.\n\n3 PACKS PLATLETS GIVEN FOR PLATLET COUNT 53,70, 90RESPECTIVELY- POST COUNT WAS 134 AFTER THE 3RD PACK WAS COMPLETED. GOAL PLATLETS OVER 100. 1 UNIT PRBCS GIVEN FOR HCT 27- POST HCT 27- ANOTHER POST HCT PENDING.\n\nAFTER PLAT TRANSFUSIONS PT SUCTIONED FOR THICK MODERATE AMOUNTS OF TAN- YELLOW SPUTUM.\n\nNEURO: PT ABLE TO ANSWER QUESTIONS WITH MUCH PROMPTING : NAME- PLACE- AND DATE, FOLLOWS COMMANDS INCONSISTENTLY, MOANING ALL NIGHT C/O PAIN X2 AND MEDICATED WITH MSO4 X 2 WITH EFFECT.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-15 00:00:00.000", "description": "Report", "row_id": 1302647, "text": "Resp Care\npt was reett this afternoon d/t hypoxic/hemoptysis/tachypneic. requiring sedation to ventilate effectively. presently on simv mode. tolerating well with sedation. able to wean to 50%. sxning brb. low pips/plats. c/w full support, evaluate for spont mode as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-15 00:00:00.000", "description": "Report", "row_id": 1302648, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT ALERT AND ORIENTED X3 THIS AM. FOLLOWING COMMANDS. MAEW. MOANING CONTINUOUSLY, BUT DENIED PAIN WHEN QUESTIONED. CURRENLTY SEDATED ON PROPOFOL GTT. PERRL. MAE. DOES NOT OPEN EYES, BUT LOCALIZES PAIN.\nRESP: LS COARSE THROUGHOUT. PT INCREASINGLY TACHYPNEIC TO RR 50S, O2 SAT DOWN TO 93%. ABG SENT: PAO2 DOWN TO 54%. FIO2 VIA COOL NEB FACE TENT INCREASED TO 60% WITH MIN IMPROVEMENT IN O2SATS. CPT DONE, AND PT SUCTIONED FOR VERY THICK, TENACIOUS BLOODY SPUTUM (SENT FOR CX). AFTER NTS, PT WITH COPIOUS EPISTAXIS. PT SAT AT SIDE OF BED WITH ASSISTANCE AND DIRECT PRESSURE APPLIED TO NOSE FOR ~10 MIN TO STOP BLEEDING. MD PRESENT. REPEAT ABG WITH PAO2 UP TO 70S AND O2SATS 98-99%, BUT PT'S RESP STATUS QUICKLY DECOMPENSATED, LS AUDIBLY COARSE, COPIOUS BLOODY SECRETIONS, RR UP TO 50S, REQUIRED FREQUENT DEEP ORAL SUCTIONING AND ENCOURAGEMENT TO COUGH. 100% NRB PLACED WITH O2SATS ONLY ~92%. SICU TEAM AND TEAM PRESENT. PT INTUBATED AT APPROX 1300 WITH 100MG SUCC AND 100MG PROP. PT PLACED ON SIMV 16X600 AT 100% FIO2, BUT CONTINUED WITH RR 50S WHEN AWAKE. NO RELIEF WITH IV MSO4 AS ORDERED. PER TEAM, PT STARTED ON PROPOFOL GTT, AND RR/RESP STATUS MUCH INPROVED WITH MODERATE SEDATION. VENT SETTINGS CURRENTLY SIMV 16X650, 50% FIO2 WITH STABLE ABG'S (METAB ALK CONT'S). POST INTUBATION PT INITIALLY REQUIRED FREQUENT ET SUCTION FOR COPIOUS AMTS THICK BLOODY SPUTUM, CURRENTLY SM AMTS.\nCV: TMAX 98.8. NSR TO ST 110S IMMED POST INTUBATION, CURRENTLY RESOLVED. RIJ PA CATH AND CORDIS D/C'D THIS AM, TIP SENT FOR CX. NEW HEPARIN FREE CCO PA PLACED RIJ THIS EVE. CXR READ PENDING. PT 190S TO 200S, DOWN TO 150S TO 170S WITH SEDATION. TEAM INFORMED. PT 2 BAG PLT FOR PLT CT <100 AND EPISTAXIS. TO GET 1U PRBC'S FOR HCT 29.5 THIS EVE AND 1 BAG PLT FOR CT 85.\nGI: ABD SOFT. POS FLATUS AND SM COLORED BM (HEME NEG). NGT WITH 250CC BRIGHT RED BLOODY O/P, RETURNING TO BILIOUS THIS EVE. LAT JP WITH MAROON/ O/P, MEDIAL JP WITH SEROSANG O/P, AND BILE DRAIN WITH DK GOLDEN O/P (TRANSPLANT MD IN TO WITNESS).\nGU: TO AMBER U/O. ~100CC/HOUR, DECREASING TO <30CC/HOUR THIS EVE. TEAM INFORMED. PT STARTED ON IVF 1/2NS AT 50CC/HOUR, AND ALBUMIN ORDERED.\nENDO: INSULIN GTT TITRATED TO RISS.\nPLAN: AWAIT CXR READ FOR PA CATH. CONT PULM TOILET. ALBUMIN AND IVF AS ORDERED. TRANSFUSE PRBC'S AND PLT AS ORDERED. MONITOR LABS FREQUENTLY. TITRATE INSULIN GTT. CONT PER CURRENT MGMT/PER PROTOCOLS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-22 00:00:00.000", "description": "Report", "row_id": 1302671, "text": "Resp care\nPt intubated for resp failure/airway protection\nPt placed in AC mode & sedated, B/S course\nSx mod amounts of thin bloody secretions\nNo RSBI= Pt sedated\nPlan: transport CT, continue support\n" }, { "category": "Nursing/other", "chartdate": "2173-10-22 00:00:00.000", "description": "Report", "row_id": 1302672, "text": "RESPIRATORY CARE: PT. W/ 8.0 ORAL ETT. REMAINS ON\nSIMV MODE AS PER CAREVUE AFTER BEING REINTUBATED\nLAST NITE. ABG W/ STABLE ACID-BASE AND OXYGENATION.\nSX. BLOODY SPUTUM. TRANSPORTED TO CT SCAN TODAY FOR\nABDOMINAL CT WITHOUT INCIDENT.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2173-10-22 00:00:00.000", "description": "Report", "row_id": 1302673, "text": "STATUS\nD: SEDATED ON PROPOFOL GTT..AROUSABLE OPENS EYES TO STIMULI & WILL OCC FOLLOW SIMPLE COMMANDS\nA: HCT & PLTS LOW BOTH REPLETED..? BILIARY OBSTRUTION >>ABD A CT DONE >>TO ANGIO FOR ? STENT UNABLE TO STENT OR BALLOON KINK..\nVENT CHANGES(SEE FLOW SHEET)ADQUATE ABG'S..ABD INCISION C&D JP DRAINING SM AMT SEROUS..GOOD AMT BILE FROM T-TUBE\nR: AWAITING FURTHER TX PER LIVER TEAM\nP: CONTINUE TO MONITOR PLTS/HCT'S CLOSELY & REPLETE AS ORDERED\n" }, { "category": "Nursing/other", "chartdate": "2173-10-23 00:00:00.000", "description": "Report", "row_id": 1302674, "text": "focus update note\nplease see flowsheet for details.\n\nat 2345 pt temp 94.3 orally, re-taken rectally 96.4- bair hugger and warm blankets applied Dr resident aware- temp increase to 95.5 at 01 (oral) 96.3 at 02 and 97.1 at 0300.\n\nplatlet and RBCs stable at 2400- at 0400 platlets 67 - no order to transfuse with plat at this time.\n\nresp: at 0100 pt not opening eyes to voice- propofol decreased to 30 mcq/kg/min. at 0345- pt breathing spont RR 25-30 prop increased to 40mcq/kg/min at -3, RR cont to be 25-30 this was discussed with Dr and propofol was increased to 60 mcq/kg/min- ABG pao2 196. will cont to monitor as shift continues.\n\nplan: monitor platlet and HCT levels closely and transfuse as ordered, goal SBP 150-200, monitor temp and utilize bair hugger PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-06 00:00:00.000", "description": "Report", "row_id": 1302723, "text": "Respiratory Care Note:\n Patient weaning on PSV as tolerated. After 6 hours he appeared tired with increased amount of foamy clear secretions, placed back on PSV. See carevue flowsheet.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-07 00:00:00.000", "description": "Report", "row_id": 1302724, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds rhonchi improving with suct for mod th white sput. Pt cont to have increase in secretions. No vent changes made overnoc. Pt on minimal vent support. Cont PSV to extub once secretions diminish.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-07 00:00:00.000", "description": "Report", "row_id": 1302725, "text": "Respiratory Care Note:\n We continue to have patient do long spontaneous breathing trials, all ending with the addition of PEEP due to increased suctioning for foamy/frothy secretions. See Carevue flowsheet.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-07 00:00:00.000", "description": "Report", "row_id": 1302726, "text": "Condition Update A:\nPlease refer to careview for details.\nNEURO: , . Communicating via mouthing, nodding, and writing. 1600 c/o (L) ear pain described as intermittent sharp pain. Denies change in hearing or pressure. Dr. notified. MSO4 2 mg amdin with fair effect.\n\nCV: Clonidine PNGT started with good effect on BP (150-160's down from 180-190's). Cont's with hydralazine and Labetalol IVPB. Generalized 1+ edema. CVP 10->5.\n\nRESP: LS coarse all fields, clears with suctioning. Required suctioning q1 - 1.5 h. Sputum sent for cx and gram stain. 1445 became tachypneic and anxious, suctioned for copious white frothy secretions. PEEP increased from 0 to 5.\n\nPLAN: Monitor resp status, suction as needed, monitor for readiness for extubation. Monitor hemodynamics, goal SBP 110-170, monitor effectiveness of clonidine. Monitor I/O for goal negative 2L. Monitor (L) ear discomfort. Monitor all labs. Call H.O. with any changes.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-08 00:00:00.000", "description": "Report", "row_id": 1302727, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds sl coarse suct sm-mod th white sput. No vent changes made overnoc. Cont PSV wean Pt cont with significant secretions.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-08 00:00:00.000", "description": "Report", "row_id": 1302728, "text": "Condition Update A:\nPlease refer to careview for details.\n\nNEURO: and oriented x3, slight confusion, easily redirected. Speach soft and clear. (L) ear exam performed by Dr. noted for ear wax.\n\nCV: BP well controlled with current med. No edema. Denies CP, palp.\n\nRESP: Extubated at 1130. Maintaining Pox 100% on hummidified face mask 40%. ABGs reflect metabolic acidosis. NSICU and Transplant teams aware. Requires max cues and encouragement to C&DB, not able to comply with IS at this time. (R) lung fields and LUL CTA, LLL with diminished air flow. Air flow increases when pt complies with deep breathing.\n\nPLAN: Monitor pulmonary status, assist with C&DB. Monitor hemodynamics. Monitor labs. Cont ICU care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-09 00:00:00.000", "description": "Report", "row_id": 1302729, "text": "nsg progress note\npt is a+o, follows simple command, moves all ext. lungs coarse at times, diminished left base. cpt and cough/deep breathe done q4. weaned to nasal , sao2 >95. to rec 2 units prbc hct 27.5. wbc up to 3.5 at 2400 am labs.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-16 00:00:00.000", "description": "Report", "row_id": 1302649, "text": "Resp Care Note, Cont to wean FIO2 for good ABG'S. Sedated on propofol.Given platlets and cells. Suctioned for scant amts loose bld tinged secretions.Cont to monitor resp status. RSBI 79.3\n" }, { "category": "Nursing/other", "chartdate": "2173-10-16 00:00:00.000", "description": "Report", "row_id": 1302650, "text": "RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nSIMV MODE AS PER CAREVUE. STABLE ACID-BASE AND\nOXYGENATION. SX. FOR BLOODY SPUTUM. TRANSPORT\nTO CT SCAN WITHOUT INCIDENT.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2173-10-18 00:00:00.000", "description": "Report", "row_id": 1302655, "text": "respiratory Care\nPt remain intubated and on vent support, he weaned on cpap 5 peep and 5 ps for 4 h , changed to imv fo ovrenight , good Am RSBI, changed to CPAP.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-18 00:00:00.000", "description": "Report", "row_id": 1302656, "text": "Nursing note:\nNEURO: Alert, oriented x1 , PPF gtt d/c'd. Following commands. Attempting to communicate, mouthing words. PERRLA.\nRESP: Lung sounds coarse, diminished at bases, clearing after suctioning. Sats/ABGs acceptable on CPAP 40%, 5 PEEP, 10 IPS. Spont TVs in 600s. Suctioned for copious amounts thick white secretions. Strong cough, CPT done.\nCV: Afebrile. Skin/sclera remain jaundiced. NSR in 70s-80s, no ectopy. SBP 160-180s, Lopressor/Hydralazine w/some effect. PA cath , CO 7-8.3. Not wedging swan per sicu team. CVP 4-7. Plts given for 64, repeat pending. HCT stable. IVFs concentrated. Lytes stable.\nGI: +BS, abdomen softly distended. NGT patent for bilious drainage. DSD to abd. . JPs patent, Ttube as well. See I/O's for amounts. +flatus, no stool.\nGU: Foley patent adequate amount urine. >100cc/hr.\nACT: MAE in bed, assists w/turning and repositioning.\nENDO: Insulin gtt titrated to keep glucose <120.\n\nA/P: Hemodynamically stable s/p liver transplant. Rec'd plts. x1 today. Tolerating vent wean, copious secretions.\nCont. w/current plan of care, pulm. hygeine, monitor labs.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-18 00:00:00.000", "description": "Report", "row_id": 1302657, "text": "resp care\n\npt remains intubated and mech ventilated, ps weaned today - pt tol well w/good abg's. b/s coarse, ess clear w/sxn. sxn copious thk wh. plan: cont w/mech support, wean ps as tol.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302658, "text": "Nursing Note\nPt sleeping on/off, appropriate with care. Remains restrained for safety-pills at o2 sensor and ngt at times. Afebrile. Sys remians >160 lop and hydral given a/o, remains on cpap with TV mid 500's. LS coarse, mod amts white thin sputum. Cont on TPN, no BM. JP x2 and t-tube . incluin gtt titrated - see flowsheet for details.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302659, "text": "Respiratory Care\nPt remain intubated and on vent support , Good RSBI this am, remain on CPAP for overnight, Bs coars SX large amout white thick .\n" }, { "category": "Nursing/other", "chartdate": "2173-10-19 00:00:00.000", "description": "Report", "row_id": 1302660, "text": "resp care:pt remains intubated and sedated with no remarkable changes in resp status.b/s diminished bilat,secretions minimal and pale/yellow.present vent settings ps10 peep5 40% and tol well with no resp distress noted.will cont with present coarse,re-assess as needed and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-16 00:00:00.000", "description": "Report", "row_id": 1302651, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: SEDATED THIS AM. PROPOFOL GTT OF THIS EVE. PT APPROPRIATE. FOLLOWS COMMANDS. MAE. PERRL.\nRESP: LS CAORSE THROUGHOUT. ET SUCTIONED FOR COPIOUS AMTS BLD TINGED TO BLOODY SPUTUM. NO TACHYPNEA. ABGS STABLE. NO VENT CHANGES. LG AMTS BLOODY ORAL SECRETIONS. MD INFORMED. ? SOME CONTIUOUS OOZING FROM NASOPHARYNX.\nCV: AFEB. NSR 50S-80S. LOPRESSOR AND HYDRALAZINE Q6. SBP 170S TO 180S. SEE FLOWSHEET FOR PA NUMBERS. PLT X2 FOR CT < 100, POST AFTER 2ND TO BE DRAWN. 1U PRBC FOR HCT< 30, POST 33. SEE FLOWSHEET FOR OTHER LABS. VANCO DOSE GIVEN FOR LEVEL <15. FLUID BAL POS >3L SINCE MN. MD INFORMED.\nGI: ABD SOFTLY DISTENDED. POS BOWEL SOUNDS. TOL 2 BOTTLES BARACAT FOR CT. ABD/PELVIC CT SHOWED SM FLUID COLLECTION AROUND LIVER MD , NOT DRAINED. NGT WITH BILIOUS O/P, OCCASIONAL CLOTS, MD INFORMED. SM AMT BARACAT RAINED WHEN NGT TO SXN POST CT. T-TUBE WITH BILIOUS DRG. MED JP SEROSAN, LAT TEA-COLORED.\nGU: U/O VIA FOLEY.\nENDO: INSULIN GTT TITRATED TO FSBG.\nPLAN: CONT TO MONITOR CLOSELY. PULM TOILET. MONITOR PLT AND HCT AND TRANSFUSE AS ORDERED. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-17 00:00:00.000", "description": "Report", "row_id": 1302652, "text": "Resp Care Note, Pt remains on current vent settings. Good ABG'S. Pt got cells and platlets this AM. Sedated with propofol.Unable to complete RSBI. RR increased to 51. Will cont to monitor resp status for further weaning.Suction scant amts from ett mostly oral secretions,thick clear.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-17 00:00:00.000", "description": "Report", "row_id": 1302653, "text": "RESPIRATORY CARE: PT. REMAINS INTUBATED AND ON\nSIMV MODE AS PER CAREVUE. ABG C/W GOOD ACID-BASE\nAND OXYGENATION. TAPER RR A BIT TO ALLOW\nSOME SPONTANEOUS BREATHING AS PER DR. .\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2173-10-17 00:00:00.000", "description": "Report", "row_id": 1302654, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PROPOFOL GTT DECREASED TO 10MCG/KG/MIN. PT ALERT AND CALM. APPROPRIATELY FOLLOWING COMMANDS. MAEW. PERRL.\nRESP: LS COARSE TO CLEAR. ET SXN'D FOR MOD AMT TAN TO WHITE SPUTUM, THICK. PT EXERCISED ON PSV 5/14, RR 20S, ABG STABLE. PLAN TO RETURN TO IMV OVERNOC.\nCV: NSR. BP STABLE. PAS 20S TO 30S. CCO QUESTIONABLE, ABOUT 9 THIS AM, UP TO 19.9 THIS AFTERNOON (SQI ON MONITOR AT 4). MD INFORMED. CCO CURRENTLY 11. TRANSFUSED 1 BAG PLT FOR CT 83 THIS AM, 113 POST. TRANSFUSED PLT FOR CT 88 THIS EVE, POST TO BE DRAWN. FLUID BAL POS ~600CC SINCE MN THUS FAR.\nGI: NO CHANGE.\nGU: FOLEY AND PATENT.\nENDO: INSULIN GTT TITRATED TO RISS.\nPLAN: CONT TO MONITOR. CONT PULM TOILET. RETURN TO IMV AT PREVIOUS SETTINGS AT . CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-11 00:00:00.000", "description": "Report", "row_id": 1302734, "text": "Nursing Transfer Note\n42 y.o. male admitted with fevers, N+V found to have hepatic artery thrombosis after liver tx . Second liver tx performed . Hospital course complicated by pneumonia and prolonged intubation/extubation/reintubation and bronchoscopy, flank hematoma- requiring freqent PRBC's, liver bx x2 secondary to rising bilirubin that were negative (bilirubin now trending down), and CT guided pigtail drainage catheter inserted in abcess. Pt still requiring platelets approx QOD.\nPMH: HEP C, HTN, ETOH, Bipolar dz.\nAllergies: Heparin related products- probable HIT.\nPrecations: \n\nNeuro: A+O x3, confused at times when first awakens. Voice weak/raspy. Minimal c/o pain well controlled with morphine. Afebrile.\nCV: requiring hydralazine, labetolol, and clonodine. SBP 140-170. NSR, 80-90's. no ectopy. Remains with dependent edema +1. Weight trending down. +PP, P-boots on. No heparin SQ. OOb to chair with 2 assit- PT/OT consulting. Periph line placed R hand with bruising around site but flushed wihtout difficulty.\nRESP:LS diminished in bases. o2 sat 99-100% on RA. NEeds frequent encouragement of C+DB and periodic CPT. weak cough but does bring up to throat and swallows.\nGI:tol at goal of 75cc/hr via post-pyloric feeding tube. BM colored x1 today, x4 yesterday. Passed swallow eval- tol liquids- refusing to eat solids. T-tube wiht bilious drng. Pigtial drain wth murky greenish/yellow drng.\nGU:foley patent dark amber-icteric urine amounts.\nSkin:buttocks reddened but . Incision with steri-strips and OTA.\nSocial: suppotive sisters and mother. : (sister) H 1- W 1-.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-09 00:00:00.000", "description": "Report", "row_id": 1302730, "text": "Nursing progress note\nNeuro:A+O x3. Weak voice but able to express needs/pain. Min pain in abd tx with morphine.\nCV:SBP <160, remains on labetolol, hydralazine and clonodine. NSR. Periph line placed post pt. accidently CL when getting OOB to cahir. remained OOB x1.5hrs. to get out, 2 assist back. PT requested. Cont with dep edema. Plt remain >50, HCT on rise.\nRESP:CPT done, pt swallows sputum but does raise. C+DB encouraged.\no2 sat RA 100%\nGI:tol probaalance at goal. 2 soft BM's- incont. T-tube with bilious drng, abcess pigtial with murky green drng.\nGU:cont with amoutn amber dark urine.\nSKin:, reddened buttcks.\nsocial:sister calling for update.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-10 00:00:00.000", "description": "Report", "row_id": 1302731, "text": "nsg note\nweaned to room air, lungs clear bilat but at left base. sao2 >95 and rr <20. cont hydralazine, labatolol and clonidine for bp control. plan swallow study today before advancing diet, ? to 6 today.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-10 00:00:00.000", "description": "Report", "row_id": 1302732, "text": "Nursing progress note\nNeuro:A+O x3. min c/p pain controlled with mso4 2mg iv. afebrile\nCV: SBP goal <170. meds changed to PO, prn labetolol x1. p-boots on. remains with dependent edema. OOB to chair with 2 assist. Pt ordered. Periph line h/l- c/d/i.\nRESP: LS diminished at bases. C+DB encouraged. RA o2sat 100$\nGI: passes swallow test. cl liq ordered. tol without problems. cont at 75cc/hr. Mult sm BM's, soft and colored\nGU:foley patent dark icteric urine-\nsocial: family visiting-\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-11 00:00:00.000", "description": "Report", "row_id": 1302733, "text": "NEURO: PT SLEEPING ON/OFF MOST OF NIGHT, A&OX3, FLAT AFFECT, FOLLOWING COMMANDS, MAE, APPROPRIATE CONVERSATION. C/O ABD PAIN AND MEDICATED W/ MSO4 2MG IVP W/ GOOD RELIEF.\n\nCV: HR 73-81 NSR, NO ECTOPY, SBP 130-170'S, MEDICATED W/ LABETOLOL 100MG PGT PRN GOR SBP>140 PER TRANSPLANT PARAMETERS.+PULSES.\n\nRESP: LUNGS CTA AND VERY DIMINISHED AT BASES, ENC TO DO IS + DEEP BREATHE/COUGH. O2 SAT 99-100% ON R/A.\n\nGI/GU: ABD SOFT NT/ND, +BS, TOLERATING TF PEROBALANCE @ GOAL @ 75CC/HR VIA PEDI TUBE. TOLERATING PO LIQUIDS W/OUT N/V. FOLEY DRAINING CLEAR AMBER U/O.\n\nENDO: REG INS S/S FOR FS >120.\n\nPLAN: MONITOR RESP STATUS AND ENC COUGHING/DEEP BREATHING & IS, ENC INDEPENDENCE, ADV DIET AS TOL, ? TRANSFER TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-26 00:00:00.000", "description": "Report", "row_id": 1302685, "text": "Condition Update B:\nPlease refer to careview for details.\nNEURO: Pt remained sedated on PPF gtt to keep RLE straight per Angio orders. Pt opening OU to pain -> verbal stimuli. PERL 3mm/3mm bilat brisk. Impaired gag/cough. Withdraw to painful stimuli all extremeties. No indications of discomfort.\n\nCV: Afebrile. NSR-> ST with rare PAC's. SBP remains with in parameter 150-200 with Lopressor and hydralazine IV. DBP continues to be high 91-106, Dr. aware. (R) fem and (R) DP/PT strong palp. Generalized 2+ pit edema. PLT 78. Hct stable. T-bili 20.3.\n\nRESP: Remained on IMV 650x14 0.40 overnight d/t level of sedation. Suctioned q2h for moderate amounts of yellow/tan secretions, although LS CTA BUL and dim BLL.\n\nGI/GU: Tol TF at 20cc/h. BS pos x4quad. Pos flatus, no stool. Foley draining adequete amounts icteric urine.\n\nSKIN: JP drainign pink serosang fluid. T-tube w. fluid. Y-abd inc D/I w/ staples OTA. JP and T-tube insert sites dsg changed. Air mattress ordered to prevent skin breakdown. Multipodus splints to bilat feet for foot drop.\n\nSOCIAL: Updates provided to family.\n\nPLAN: Monitor bilirubin, LFT's, BUN/Cr, and PLTs. Wean sedation and resume vent weaning as pt tolerates. Provide pulmonary tiolet and monitoring of ABG's. Advance TF per order to goal 40cc/h.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-26 00:00:00.000", "description": "Report", "row_id": 1302686, "text": "Resp Care\nremains ett/vent support , changed back to spont mode today. tolerating well with ps at 15. sxning sm tan sputum. no abgs this shift, sats 99-100%. c/w support.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-20 00:00:00.000", "description": "Report", "row_id": 1302625, "text": "NEURO; A&O x3,MAE, FOLLOWS COMMANDS, SPEECH CLEAR, MEDIC WITH PERCOCET AND MORPHINE FOR ABD DISCOMFORT,\n\nCARDIOVASCULAR; HR 80'S SR, NO ECTOPY, RT IJ CENTRAL LINE PLACED ALONG WITH RT RADIAL A LINE, SYS BP 130'S-140'S, PALE FACIAL TONE, EXTREMITIES WARM, HCT THIS PM 25.9-WILL RECEIVE TWO UNITS PRBC, PLATELETS 47, WILL RECEIVE 2 FIVE PACK PLATELETS ALSO, RPT COAG AND FULL LABS Q 6 HRS\nNA LEVEL 129-MAINTENANCE IV CHANGED TO NSS AT 75/HR\n\n\nRESPIR; LUNGS CLEAR BUT DIM AT BASES, ON R/A WITH 02 SAT AT 100%, P\nPT TAKEN TO CAT SCAN FOR ABD SCAN-DR. EVALUATED SCAN, WORSENING LIVER STATUS,\n\nPLAN PT TO RECEIVE BLOOD PRODUCTS, PAIN CONTROL AND WATCH FOR CHANGES IN MENTAL STATUS\n" }, { "category": "Nursing/other", "chartdate": "2173-09-21 00:00:00.000", "description": "Report", "row_id": 1302626, "text": "Condition Update\nD: Temp WNL, afebrile. BP stable 120-130/60 HR 80's NSR. Pt received 2u PRBC and 2 5pack plts without difficulty. AM HCT 29.6, Plts 70 (goal to keep >70). Urine output 100-150/hr. See flowsheet for details.\n Pt remains lethargic but arousable. A/Ox3. MAE. Wakes up and c/o abd pain but then falls back to sleep and RR @10. MSO4 given x1 with no effect on vitals.\n Started on travasol for nutrition. Blood sugars stable. Abd soft/distended with hypoactive bowel sounds.\nPLAN:\n Cont with Q6hr labs\n Monitor mental status closely\n Ordered for transhepatic cholangiography this AM\n Notify H.O. with any changes.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-21 00:00:00.000", "description": "Report", "row_id": 1302627, "text": "NPN\nNEURO: PT ALERT AND ORIENTED, OCCASIONAL LETHARGY. COMPLAINS OF PAIN IN LOWER LEFT QUADRANT, TRANPLANT AND ICU TEAM AWARE. MSO4 2MG IV Q 4. PT STATING THAT MSO4 HELPS BUT DOESN'T LAST LONG ENOUGH, TEAMS VERY RELUCTANT TO INCREASE NARCOTICS. MAE.\nCV: BP STABLE 140'S-150'S AND HR WITHOUT ECTOPY. CVP 1-4.\nRESP: LUNGS CLEAR, DIMINISHED IN BASES. DENIES SOB, NO LABORED BREATHING.\nGI/GU: ABD SOFT, TENDER TO TOUCH WITH HYPOACTIVE BS. REMAINS NPO EXCEPT MEDS. FOLEY PATENT TO GRAVITY DRAINING 80-100/HR CLEAR URINE\nID: PT REMAINS AFEBRILE\n" }, { "category": "Nursing/other", "chartdate": "2173-09-22 00:00:00.000", "description": "Report", "row_id": 1302628, "text": "Condition Update\nD: See carevue flowsheet for details\n No significant events overnight. Pt slept well. When awake c/o constant abd pain at rest. Medicated Q4hr with MSO4 2mg IV with good effect but only lasting about 2hrs (team notified by RN -no change in frequency ordered).\n Abd soft distended with bowel sounds. Pt ate small amt house diet in evening. Remains on TPN with coverage per SSI for blood sugars.\n Continues to voice reservations with having son as donor. \"How can I ask him to do this\". Will have social worker see pt in AM.\n Vital signs stable, afebrile. Urine output adequate.\nPLAN:\n Awaiting possible liver transplant\n Pain management with MSO4 prn\n Social worker consult\n Provide emotional support\n Notify H.O. with any changes.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-20 00:00:00.000", "description": "Report", "row_id": 1302624, "text": "Social Work Note\nReferred by - SW on 6 for f/u with pt. Met with pt , just transferred from floor, coping with long and trying admission and now facing liver failure and need for a 2nd TP. He appears very discouraged with flat affect and speaks openly about his fears of dying and of \"never leaving the hospital\" and of feeling the weight of \"a dark black cloud of death\" hovering over him. He is unable to recall a time when the cloud hasn't been there. He reports his niece (who shares his blood type) and son are both being worked up as potential donors. He describes his reluctance to share his feelings and thoughts of death with them, anticipating they might reconsider being donors. Anticipate pt will benefit from close SW and psych f/u. Will continue to talk with pt re: increasing family involvement. SW will follow\n\n\n , LICSW #\n" }, { "category": "Nursing/other", "chartdate": "2173-10-27 00:00:00.000", "description": "Report", "row_id": 1302691, "text": "Resp Care\nremains ett/vented simv mode.seems comfortable on present settings. sats 99-100%, transported to ctscan and angio. sxning tan sputum.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-27 00:00:00.000", "description": "Report", "row_id": 1302692, "text": "UPDATE:PT WENT TO CT HAD CT GUIDANCE DRAINAGE FROM LEFT SIDE OF ABD AND PIGTAIL DRAIN TO BAG WAS PUT IN DUE TO INCREASED DRAINAGE.PT THEN WENT TO ANGIO AND HAD IVC GRAM DONE AND LIVER BIOBSY.PT REMAINED MONITORED DURING ALL PROCEDURES.PT COMPLETED PLATELETS WITHOUT SIGNS OF REACTION.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-28 00:00:00.000", "description": "Report", "row_id": 1302696, "text": "Condition Update A:\nPlease refer to careview for details and remarks.\nNEURO: Sedated on PPF gtt. Opening OU to verbal stimuli. PERL 3-4mm/3-4mm bilat brisk. Inconsistently following commands, MAE.\n\nCV: Tmax 100.9 rectal. Tylenol PNGT x1. HR ST->NSR, rare PAC's. Lopressor IV admin over 45-60 minutes w/ short effect on HR. Per transplant team SBP goal 110-190. CVP 11->7. Cont w/ generalized 2+ pit edema. (R) fem pos pulse, pos bilat DP/PT. Multipodus splints on/off q2-3h. Plts stable 65, hct 32. Vanco held for random level >15 (17.9). Mycophenolate on hold d/t WBC 3.5.\n\n\nRESP: LS coarse and rhonchorus. Suctioned q1-2h for mod yellow thick secretions. Tachipnea ^40's, Pox to 93%, pH 7.33. Per Dr. left lung fields white on CXR done this evening.\n\nGI/GU: TF goal. FSBS q6h required regular insulin 2units sc. ABD hypoactive BS x4 quad. Maroon stool changing from liquid to loose. Foley draining icteric clear urine in adequete amounts. Monitoring BUN and Cr.\n\nSKIN: JP with serosang icteric fluid. T-tube draining fluid. Pigtail draining green fluid. Insertion sites of drains cleaned with chlorhexidine then covered with DSD. Tiny tears on (R) buttock covered with tegaderm. Skin barrier cream applied to buttocks and coccyx.\n\nPLAN: Bronchoscopy to be done at bedside in the morning. TF- Nepro w/ Promod to start in the afternoon, until then cont with Nepro FS. Monitor BS, quality/quantity of stool, call HO for any changes. Monitor all labs, call HO if plts<60, hct<30 and any other abnl results. Consider changing CVL tomorrow. Cont with ICU care.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-29 00:00:00.000", "description": "Report", "row_id": 1302697, "text": "Nursing note:\nNEURO: Remains sedated on PPF gtt, opens eyes, follows commands when lightened. PERRLA. MAE weakly on bed.\nRESP: No vent changes, lung sounds coarse. Suctioned for copious amounts thick tenacious oral secretions and yellow secretions via ETT.\nABGs acceptable.\nCV: Tmax 100.1. ST 90-100, no ectopy. SBP 150-190s, Hydralazine held , Lopressor given over 1/2 hour. Cont. w/+ pitting edema to extremities, L arm >R. Hct/platelets stable, to receive plts at 0600 prior to am bronch.\nGI: Abdomen softly distended, hypo BS. TFs held for am bronch. T-tube and Pigtail patent for bilious drainage. JP patent for serosang drainage. DSD to abd. . Pigtail fluid sent for culture. Pink tinged liquid stool x2.\nGU: Foley patent for icteric urine in adequate amounts.\nENDO: Covered w/SSRI 2 units.\nSKIN: Small skin tear to buttock, healing well. Buttocks remain reddened, skin barrier cream applied. Skin/sclera jaundiced.\n\nA/P: Coarse BS, to be bronched in am. Cont. current ICU care and treatments. Skin care, monitor labs, platelets to be given this am, ? repeat CXR.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-28 00:00:00.000", "description": "Report", "row_id": 1302693, "text": "Nursing note:\nNEURO: Sedated on Propofol gtt, opens eyes to voice or stim. PERRLA. Inconsistently following simple commands when sedation lightened. MAE weakly on bed, poor strength. Appears comf.\nRESP: Lung sounds coarse, suctioned for copious amounts thick white oral secretions and via ETT for thick tan secretions. No vent changes, remains on SIMV w/acceptable ABGs.\nCV: Afebrile. SR in 70s, Lopressor/Hydralazine held except for one dose for SBP 130-150s. to 180s w/stimulation. Given 2 U PRBCs for hct 25 and plts. for plt count 54. Angio site to R. groin w/band-aid . +dependent edema to all extremities.\nGI: +Hypo BS, abdomen softly distended. +Liquid stool in small amounts , -tinged. TFs restarted via Dobhoff tube @40cc/hr. TPN d/c'd per tx team. T-tube patent for bilious drainage. Pigtail patent for dark ascitic drainage. DSD to abd. changed, oozing noted to pigtail drain site. Each 1L replaced w/25% Albumin per transplant team, given x2 overnight. JP patent small amounts serosang. drainage.\nGU: Foley patent adequate amount icteric urine.\nENDO: Covered w/SSRI.\nSKIN: Buttocks reddened, skin barrier cream applied, small open area to coccyx. LOTA. Skin/sclera jaundiced.\nSOCIAL: Several family members called, Dr. called sister for update and she will talk to rest of family.\n\nA/P: Stable s/p CT-guided pigtail drain placement and IVC gram. Given 2 U PRBCs and 5 pack platelets. Cont. to monitor labs, vent wean as tolerated, drain replacement w/Albumin. Cont. current ICU care and treatments.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-28 00:00:00.000", "description": "Report", "row_id": 1302694, "text": "Respiratory Care Note\nPt. RSBI completed on PSV 5. RSBI=169. Will continue on current vent settings. ABG's fine on these settings. Airway remains patent. Sxn moderate amount yellow-tan secretions.\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2173-10-28 00:00:00.000", "description": "Report", "row_id": 1302695, "text": "Resp.care note - Pt. remaines intubated and vented, bs coares, suctioned for yellow secritiones.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-12 00:00:00.000", "description": "Report", "row_id": 1302638, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT ALERT, APPROPRIATE, FOLLOWING COMMANDS. MAEW, PERRL. SL AGGITATED THIS AM, C/O PAIN. MEDICATED WITH IV MSO4 Q1HOUR AS ORDERED X4 HOURS WITH IMPROVEMENT IN AGGITATION AND STATED RELIEF OF PAIN.\nRESP: LS OCCASIONALLY COARSE. STRONG PRODUCTIVE COUGH. ET SUCTIONED FOR SM AMTS THICK WHITE SPUTUM. VENT SETTINGS CHANGED TO CPAP 5/5. ABGS CONT TO SHOW METABOLIC ALKALOSIS.\nCV: NSR, REGULARLY IRREG AT TIMES. HR 70S TO 100S. TACHYCARDIA IMPROVED WITH IV LOPRESSOR (DOSE INCREASED), BUT BP REMAINS ELEVATED. SBP 170S THIS AM, NIPRIDE GTT OFF MD , SBP CURRENTLY 190S. TRANSPLANT RES VIN INFORMED. DOPAMINE GTT CONTINUES. LASIX GTT D/C'D. FLUID BAL NEG >5000CC SINCE MN THUS FAR. CVP 2-6. SEE FLOWSHEET FOR PA NUMBERS. PLT CT DOWN TO 76, TO BE TRANSFUSED. K 3.8. MD VIN INFORMED.\nGI: ABD NONTENDER. NGT WITH MOD AMTS CLEAR O/P. PT SM AMT CLEAR FLUID WHEN NGT CLAMPED AFTER AM MEDS. NO S/S ASPIRATION. MD INFORMED. T-TUBE WITH BILIOUS DRG. JPS BOTH WITH SEROSANG DRG MEDIAL > LATERAL.\nGU: COPIOUS AMTS CLEAR YELLOW U/O VIA FOLEY.\nENDO: INSULIN GTT TITRATED TO RISS.\nPLAN: CONT TO MONITOR CLOSELY. PA CATH TO BE CHANGED TO NONPACER. TRANSFUSE PLT WHEN AVAIL. ? INCREASE BETA BLOCKERS OR ADD OTHER FOR SBP CONTROL. ? EXTUBATE IN AM. CONT PER CURRENT MGMT, TRANSPLANT PROTOCOLS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-12 00:00:00.000", "description": "Report", "row_id": 1302639, "text": "ADDENDUM\nPT SBP UP TO >200. MD VIN PRESENT. DOPAMINE GTT D/C'D. SBP CURRENTLY DOWN TO 160S. U/O REMAINS >200CC/HOUR. PA CATH CHANGED TO VIP. CXR DONE, READ PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-13 00:00:00.000", "description": "Report", "row_id": 1302640, "text": "Pt remains on CPAP 5, PS 5, .40. Pt restless/agitated, even w/sedation. No vent changes made this shift.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-13 00:00:00.000", "description": "Report", "row_id": 1302641, "text": "CONDITION UPDATE\nISSUES W/ HYPERTENSION. LOPRESSOR MIN EFFECT BP. TEAM AWARE. HOWEVER LOPRESSOR SIGNIFICANTLY LOWERING HR - AS LOW AS 50'S TEAM AWARE. A.M. LOPRESSOR DOSE HELD FOR HR OF 60. PT AFEBRILE. ALERT. PUPILS EQUAL AND REACTIVE. MAE. FOLLOWING COMMANDS. LUNGS COARSE TO AUSCULTATION BILAT. FREQUENT SUCTIONING FOR MIN SECRETIONS. NO VENT CHANGES. ABG'S PERSISTENTLY ALKALOTIC (METABOLIC) - STARTED ON HCL DRIP PER TXPLANT TEAM. ABD SOFT DISTENDED. ABSENT BOWEL SOUNDS. JP'S PATENT - MOD AMT OF SANGUINOUS DRAINAGE OUT. MOD AMT OF BILIOUS DRAINAGE OUT TTUBE. PT CONT TO AUTODIURESE LARGE AMT OF URINE. CONT ON INSULIN DRIP. BSUGARS STABLE. PLATELETS PERSISTENTLY LOW - TRANSFUSED W/ 3 FIVE PACKS OF PLATELETS. CONT SERIAL LABS. MONITOR FOR S/S OF BLEEDING/ INFECTION/ REJECTION. CONT CURRENT TREATMENTS AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-13 00:00:00.000", "description": "Report", "row_id": 1302642, "text": "Respiratory note:\nPt was extubated and placed on 40% face tent, spo2 100%.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-03 00:00:00.000", "description": "Report", "row_id": 1302714, "text": "focus update note\ngoal keep sbp 120-170, SBP controlled with lopressor IV and hydralazine. propofol gtt and bicarb gtt d/ced per Dr . pt awake following commands, opening eyes spontaneously, tracking with eyes and nodding head to questions, MAE. resp: goal to slow wean on vent tommorrow am, LSC to coarse- copius clear secretions from oral pharynx and ETT, o2sat 100%. please see flowsheet for further details\n" }, { "category": "Nursing/other", "chartdate": "2173-10-11 00:00:00.000", "description": "Report", "row_id": 1302634, "text": "Condition Update A:\nPlease refer to careview for details.\n\nNEURO: PPF gtt off at 1200. Pt remained unresponsive until 1800 when he nodded head appropriately to questions and wiggled toes to command. BUE remained unresponsive to nailbed pressure. PERL 3-4mm/3-4mm brisk.\n\nCV: Afeb. HR ST coverted to NSR after Lopressor IV started. SBP 150-170. PAP WNL. CO/CI hyperdynamic. Wedge 16->11. CVP 10-6, received albumin x1 w/ short effect, and fluid boluses w/ poor effect. Generalized 3+ pit edema. Trauma line removed and CVL placed over wire for clean port to admin TPN.\n\nRESP: Following abg's and making vent changes for ^PaCO2 and acidosis (7.33).\n\nGI: Scant drainage from NGT. BS absent, no flatus.\n\nGU: Lasix gtt increased to 8mg/h per Dr. to improve u/o w/ good effect(u/o 50-80cc/h).\n\nENDO: Insulin gtt started d/t gluc levels >250.\n\nSKIN: Primary surgical dsg intact. To be changed by transplant only. Healing skin tears noted on abd. Lat JP w/ red serous drainage. Dr. in to assess output in am and in pm. Med JP w/ pink serosang. T-tube w/ green/ bilious drainage.\n\nPLAN: Monitor NS. Monitor hemodynamics, CVP>=10 and SBP 110-170. Monitor abg's, pulmonary status. Monitor labs and abg q4h. Titrate insuoin gtt to keep glucose 80-120. Call h.o. for any changes.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-12 00:00:00.000", "description": "Report", "row_id": 1302635, "text": "attempt was made to get pt's pH below 7.4 but without \"alot \" of sedation. attempts were not successful and PSV was tried but appeared to be too uncomfortable. Therefore pt returned to 600 * 14\n" }, { "category": "Nursing/other", "chartdate": "2173-10-12 00:00:00.000", "description": "Report", "row_id": 1302636, "text": "CONDITION UPDATE\nAFEBRILE. BP INCREASINGLY HYPERTENSIVE AS SHIFT PROGRESSED. STARTED ON NIPRIDE THIS A.M. MORE AWAKE TO ALERT THIS SHIFT. CONSISTENTLY FOLLOWING COMMANDS. MAE ON BED. PUPILS EQUAL AND REACTIVE BILAT. PT ABLE TO NOD HEAD IN RESPONSE TO QUESTIONING. C/O PAIN. MULT DOSES OF MORPHINE GIVEN W/ LITTLE EFFECT. MULT VENT CHANGES MADE PER ABG RESULTS - PT REMAINS ALKALOTIC. SEE FLOWSHEETS FOR CHANGES. LUNGS CTA BILAT. OCC SUCTIONING FOR THICK TAN/WHITE SPUTUM. ABD FIRMLY DISTENDED. NO BOWEL SOUNDS AUSCULTATED. ABD DRSG . NO INCREASE IN PREVIOUS S/S DRAINAGE. BOTH JP'S PUTTING OUT SANGUINOUS DRAINAGE. TTUBE PUTTING OUT MOD AMT OF BILIOUS DRAINAGE. NGT PUTTING OUT SMALLL AMT OF CLEAR TO BILIOUS DRAINAGE. REMAINS ON TPN. REMAINS ON INSULIN DRIP. BSUGARS VERY LABILE. BSUGAR LOW OF 57 - GIVNE 1/2AMP OF D50 PER DR. . STARTED ON RENAL DOSE DOPAMINE PER TXPLANT TEAM - DIURESING WELL. WILL CONT CURRENT TREATMENT PLAN. CONT SERIAL LABS. MONITOR FOR S/S OF BLEEDING/REJECTION/INFECTION. MAINTAIN PT SAFETY AND COMFORT. CONT CURRENT TX PLANS AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-12 00:00:00.000", "description": "Report", "row_id": 1302637, "text": "the pt remained stable .despite a RSBI =140 pt tolerated cpap 5/5.\nabg=7.45/39/118.bs:coarse.sxn small amt of tan secretion.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-04 00:00:00.000", "description": "Report", "row_id": 1302715, "text": "nsg progress note\nPlease see carevue for full asess and detail.\n\nPt alert, following commands. MAE with generalized weakness. nods yes to pain-medicated with 2 mg MSo4 x1. SR, no ectopy. cont on hydral/lop shceduled doses to keep SBP 120-170. Cont with dependent edema, CVP 5-8. LS coarse, thick white copius at times. Probabalnce TF advanced to goal 75cc/hr. U/o remains dark/icteric- amounts.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-04 00:00:00.000", "description": "Report", "row_id": 1302716, "text": "Resp Care: Pt remains on SIMV/PS with no changes made to vent all shift.B/S coarse with sct rhonchi,sx'd for mod to lg thick white secretions.RSBI of 39, will attempt SBT.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-04 00:00:00.000", "description": "Report", "row_id": 1302717, "text": "Resp. Care Note\nPt remains intubated and vented on settings PSV 5 peep 5 and 40%. PSV level decreased from 10 today. Pt has done well on current settings maintaining TV 0f 500-700cc and MV of 11-14L. Good ABG's on present settings. Sxn for small amount white secretions. Plan is for trache possibly tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-04 00:00:00.000", "description": "Report", "row_id": 1302718, "text": "STATUS\nD: AWAKE FOLLOWS COMMANDS NODS APPROPRIATELY..HTN..HCT 26\nA: TRANSFUSED WITH 2U PC'S..LOPRESSOR DC'D>> CONTINUES WITH SBP >160/..VENT CHANGED TO C-PAP/IPS TOL WELL & WEANED TO WITH ADQUATE STV'S & SAT'S ABD INCISION C&D..DRAINING SEROUS FROM PIGTAIL & BILIOUS FROM T-TUBE..INCT MOD AMT SOFT YELLOW STOOL X2..ADQUATE HUO'S\nR: STABLE\nP: AWAITING TRACH IN AM\n" }, { "category": "Nursing/other", "chartdate": "2173-11-05 00:00:00.000", "description": "Report", "row_id": 1302719, "text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th white sput. No vent changes made overnoc. ABGs stable. Cont wean PSV.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-05 00:00:00.000", "description": "Report", "row_id": 1302720, "text": "NURSING UPDATE\nPT MUCH MORE ALERT, PARTICIPATING IN TURNS AND MOVING SPONT IN BED SIDE TO SIDE. MSO4 PRN FOR PAIN. SBP REMAINS BORDERLINE HIGH-TEAM AAWRE, ON HYDRAL AND LABETOLOL IV. TACHY THIS AM. HCT DOWN- TEAM AWARE. CVP 8-12. IVF KVO. PROBALANCE AT GOAL 75CC/HR. PIGTAIL DRAIN WITH CLOUDY GREENISH DRNG, T-TUBE WITH BILIOUS DRNG. SM BM X2. U/O.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-11-05 00:00:00.000", "description": "Report", "row_id": 1302721, "text": "status\nD: AWAKE FOLLOWS SIMPLE COMMANDS..HCT/PLTS DOWN\nA: TRANSFUSED WITH 2U PC'S & PK PLTS..GIVEN 40MGM LASIX X1 WITH GOOD EFFECT..ABD CT DONE..VENT WEANED TO PEEP 5 & IPS 5 TOL WELL ACIDOTIC BUT IMPROVED FROM YESTERDAY..ABD STABLES REMOVED..JP DRAINING SM AMT BILIOUS..PIGTAIL DRAINING SM AMT SEROUS..BM X1\nR: ? REASON FOR DROPPING HCT\nP: MONITOR HCT/PLTS CLOSELY..CONTINUE TO WEAN AS TOL WILL HOLD OFF ON TRACH FOR NOW\n" }, { "category": "Nursing/other", "chartdate": "2173-11-05 00:00:00.000", "description": "Report", "row_id": 1302722, "text": "Respiratory Care Note:\n Patient transported to CT this afternoon without incident. He has done well on weaning trials, see Carevue flowsheet. However this afternoon PSV was increased due to increased WOB noted post CT scan and flat positioning. Suctioned for more frequent, thin, loose secretions/ almost frothy as day progressed.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-01 00:00:00.000", "description": "Report", "row_id": 1302707, "text": "condition update\nneuro: pt remains on propfol at 30. opens eys to name and responded to family. inconsistently follows commands.\ncardiac: nsr rate 70-80 pt continues on lopressor and hydralazine. sbp remains 150-180.\nresp: pt's breath sounds are coarse bilaterally. suctioned for thick white secretions copious . pt still with acidosis and started on 1/4ns with one amp of bicarb at 35cc/hr, abg unchanged this am. see flowsheet.\nheme: tranfused with one pack of platlets and post transfusion count was 58. dr. aware and no treatment at this time. this am platelet cound 57.\ngi/gu: urine output greater than 100cc/hr. tf nepro with promote at 40cc/hr. pt continues to have soft stools.\nskin: abd incision clean and dry. no areas of breakdown noted.\na: continue with aggressive pulmonary toilet. monitor platelet counts as ordered.\nr: no change in patient. abgs unchanged on bicarb drip.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-01 00:00:00.000", "description": "Report", "row_id": 1302708, "text": "Resp Care: Pt received on SIMV/PS and has remained on saame settings all shift,no changes.B/S clear after sx with bases decreased.Sx'd for mod sticky plae yellow to white.Plan is to continue on vent.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-02 00:00:00.000", "description": "Report", "row_id": 1302709, "text": "NPN\nPT SLEEPING MOST OF NIGHT. ALERT AND OPENING EYES TO VOICE, ONLY MILDLY SEDATED ON PROPOFOL. FOLLOWING COMMANDS INCONSISTENTLY. MAE. PERRL.\nBP INCREASING TO 190'S DESPITE SCHEDULED LOPRESSOR AND HYDRALAZINE. DR. AWARE. A-LINE WITH FLING THEREFORE QUESTIONING ACCURACY, DR. AND DR. IN TO SEE. CUFF PRESSURE DIFFERENCE OF 30. LOPRESSOR GIVEN EARLY X 1 AS WELL AS AN EXTRA DOSE OF HYDRALAZINE WITH GOOD EFFECT, SBP DECRESING TO 160'S-170'S. HR 70-80'S WITHOUT ECTOPY.\nABD SOFT WITH SMALL LIGHT BM X 1. DRESSING CLEAN AND .\nAFEBRILE.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-02 00:00:00.000", "description": "Report", "row_id": 1302710, "text": "ADD:\nPLATELETS GIVEN X 1 FOR COUNT OF 47. POST TRANSFUSION LEVEL 68. DR. AWARE AND WILL REDRAW IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-02 00:00:00.000", "description": "Report", "row_id": 1302711, "text": "Resp Care: pt continues intubated and on ventilatory support with simv with acceptable abg, no vent changes overnoc; bs coarse crackles, sxn thick white secretions, rsbi marginal, will cont full support.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-03 00:00:00.000", "description": "Report", "row_id": 1302712, "text": "Resp Care: Pt remains on SIMV/PS with no changes made to vent settings over night.B/S coarse and decreased with sct rhonchi,sx'd for mod thick white.Plan is to continue vent support.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-03 00:00:00.000", "description": "Report", "row_id": 1302713, "text": "NEURO; MAE RANDOMLY, BUT NOT TO COMMAND, OPENS EYES OCCAS TO VOICE AND STIMULATION, DOES NOT TRACK, PROPOFOL INCREASED TO 40 MCG/'KG/MIN FOR INCREASED RESTLESSNESS WITH INCREASE IN SYS BP, DR. NOTIFIED, PROPOFOL PRESENTLY AT 35 MCG/KG/MIN,\n\nCARDIOVASCULAR; HR 80-90'S, SYS 190'S-200 AT BEGINNING OF SHIFT, GIVEN HYDRALAZINE 20 MGM IV AND SYS BP PRESENTLY 150'S-160, BICARB GTT CONTINUES AT 35CC/HR\n\nRESPIR; SUCTIONED FOR SMALL THICK WHITE SECRETIONS VIA ET TUBE, COPIOUS FROTHY WHITE SECRETIONS FROM MOUTH, LUNGS COARSE, RISBE 120 THIS AM\n\nGI; INCONTINENT OF SOFT FORMED STOOL X 3, TUBE FEEDS AT GOAL OF 40CC/HR\n\nWOUND; ABD DSG CHANGED, SUTURES , BILIOUS DGE FROM T TUBE, GREEN OPAQUE DGE FROM PIGTAIL\n" }, { "category": "Nursing/other", "chartdate": "2173-10-27 00:00:00.000", "description": "Report", "row_id": 1302689, "text": "Respiratory Care Note:\n Patient remains on SIMV due to failure of RSBI (200). Patient changed over to SIMV last evening and at that time his BS were extremely decreased in the bases L>R with pleural rubbing, rales and rhonchi noted. Suctioned for small to med amounts of secretions. This am BS with improved aeration though he was not ready for SBT.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-27 00:00:00.000", "description": "Report", "row_id": 1302690, "text": "nursing progress note see careview for details all alarms secured.\n\nneuro:opens eyes to voice,remains on propofol for sedation,appears comfortable no grimaces or change in vital signs with stimulation.pupils perl,at times will follow some commands.\n\ncv:remains in nsr to st rate 100 to 120 without ectopy,bp systolic 110 to 140,lopressor and hydralazine have been held.extremites warm to touch with palpable dp and pt pulses present.right groin angio site has no evidence of bleeding,bandaid .bil femoral pulses palpable.\n\nresp:breath sounds coarse and diminished on left lower lobe.suctioned for moderate amount of tan secretions,copious thick white oral secretions.no vent changes,going for procedures today.remains on simv,40%,with 5 of peep and 5 of pressure support resp rate 15 to 20.chest xray done today.\n\ngu:foley to cd draining icteric urine with sediment,urine outputs good.\n\ngi:tube feeds have been on hold for procedures today.abd is soft with positive bowel sounds present.has had liquid stool with which has been diluted to pink in color.team does not want to give oral agents for constipation due to this in stool.tpn continues.\n\nangio:plan for ivc gram with potential angioplasty or stent with liver biopsy also.followed by ct guidance and drainage of ascitic fluid.currently getting additional platelets for procedure.\n\nendocrine: sugar followed by sliding scale.\n\nsocial:family in, mother and sister of pt,who spoke with md about condition of pt and procedure for today.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-23 00:00:00.000", "description": "Report", "row_id": 1302631, "text": "nursing progress note\nNeuro:pt remains confused to place although knows in hospital. needs frequent reminders to stay in bed and of when he received pain med.\nPt fall risk. Afebrile. remians on contact for in hx. C/o pain freqently, team aware. receiving MSO4 2 mg Q2 and team does not want to increasae frequency secondary to liver status. Pt reports freqent pain although is sleeping on arrival into room with pain med.\n\nCV:SR to SB when asleep. OOB with guard assist to chair. SBP per flow mostly 140-160's/70's. TLCL r IJ C/D/I. CVp <4. Teds on. +PP. no periph edema\n\nRESP:LS clear, dimin in bases secondary to pain. IS encouraged. Pt able to use to 500ml. O2 sat 96%RA. Upper airway congestion, weak cough. Pt able to get up small amounts of plegm and then swallows.\n\nGI: tolerating reg diet but wiht small appetite. Pt likes ot eat candy brought from home. BS slightly elev, covered with sliding scale insulin. Abd firm distended, diffusely tender. +BS, +flatus. No BM.\n\nGU:foley patent clear yellow urine. good diuresis post standing dose of po lasix.\n\nSkin: intact.\n\nsocial:family and sisters calling for updates.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-11 00:00:00.000", "description": "Report", "row_id": 1302632, "text": "Respiratory Care:\n\nPatient S/P redo liver transplant. Intubated with 7.5 ETT/taped at 21cm. Bs equal/slightly coarse bilaterally. Initial vent settings Vt 650, Simv 12, Fio2 100%, and Peep 5. Adequate Abg. Fio2 weaned to 70% with O2 sats 100%. Plan: Continue with mechanical support and wean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-11 00:00:00.000", "description": "Report", "row_id": 1302633, "text": "s/p liver transplant\npt arrived from or, intubated, sedated on propofol, lasix drip at 4 mg/hr. 2 jp's, 1 t tube, foley. abd dsg c+d.\nneuro: pt sedated, opens eyes with stimulation at times, perl.\ncardiao-vasc: vss, co/ci hyperdynamic, see flow sheet for details.\npulm: vent down to 50% with good abg's, will continue to wean as tol. sats 100%.\ngi: ng tube in place, draining min blood tinged, bowel sounds absent.\ngu: foley draining mod to borderline urine, lasix drip at 4 mg/hr.\nincision: dsg d+i, 2 jp's draining sero-sang, t tube draining bilious.\nskin: intact.\nsocial: family of 4 sisters in to visit .\nsee flow sheet for labs.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-31 00:00:00.000", "description": "Report", "row_id": 1302703, "text": "condition update\nD: neuro: pt remains sedated on propofol which was increased to 30mcgs due pt pt awake and more hyppertensive and touching ettube. on 30mcgs pt opens eyes to name and voice. he intermittanly follows commands.\ncardiac: pt with sbp in the 180's. Dr. aware and no treatment ordered. hr nsr rate of 70-90. after scheduled hydralazine dose sbp down to 160's.\nresp: pt remains on imv. abg is unchanged and dr. is aware. pt suctioned for a large amt of white thic sputm. also pt continues to have a large amt of oral secretions. bs remains course throughout.\nheme: platelet count down ot 42 and pt transfused with one bag of platelets. post platelet count was in the 70's.\nskin: abd incision is dry and . no drainage. no breakdown noted on pressure areas.\ngi/gu: pt on tf nepro at 40cc/hr. 5 maroon colored stools. soft and semi formed. colace held. hct remains stable. urine output remains adequate.\na: continue to monitor labs as ordered. maintain on propofol at this time.\nr: no change pt continues to be slightly hypothermic. await culture results. continue to monitor stool color and hct counts. continue to monitor platelet count and transfuse as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-26 00:00:00.000", "description": "Report", "row_id": 1302687, "text": "Nursing note\nNeuro:Propofol weaned to 10 mcg/kg/min. Pt opening eyes spont, following simple commands-i.e. opening mouth. Poor motor control, moving all extrem on bed spont but poor strength throughout. Tmax 100.0. Pan cx'd secondary to increased WBC, tachycardia\n\nCV: ST to 120's. team aware. multiple doses of lopressor given with no effect (see ). Hydral held. lopressor routine held secodnary to parameters. SBP labile- transplant team want SBP >110- neo written for in case pt. drift below 110sys. Remians with dependent edema throughout. +pp- multipodus boots on.\n\nRESP:LS clear, diminished. Thick tan secretions. Weaned to PS 15, PEEP 5. ? trach soon.\n\nGI:Abd large, distended, soft. Dulc supp given- mult loose liquid stools- FIB placed. CDIFF sent. Nepro via post pyloric tube at goal of 40cc/hr. JP and t-tube .\n\nGU:foley patent icteric urine amounts.\n\nSKIN:remains jaundiced- buttocks reddened.\n\nSOCIAL:sister in to visit- spoke with MD .\n" }, { "category": "Nursing/other", "chartdate": "2173-10-27 00:00:00.000", "description": "Report", "row_id": 1302688, "text": "Condition UpdateB:\nPlease refer to careview for details and remarks.\nNEURO: PPF gtt increased briefly during enemas d/t RR ^45, Pox to 80's, and pt's inabilty to remain on (L) side. PERL 3-4mm/3-4mm bilat brisk. MAE, weakly, attempts to help turn.\nCV: Afeb. ST ^ 126, rare PAC's, one PVC. While in 9l0 side lying position arterial SBP decreased to 99/68, NBP 114/60. CVP 8-13. Transfused w/ one bag plts for a level of 48, post plt 58. Cont's with generalized dependent 2+ pit edema.\nRESP: LS coarse to rhonchorus with frequent periods of hiccups. Pt appeared tired from CPAP as evidenced by ABG, RR^45, dropping Pox to 93%( change for pt). Pt placed on IMV 650x14. Dr. notified. Suctioned for thick white secretions.\nGI/GU: Abd soft distended w/ BS x4 quad. Passing /pink liquid stool. FIB unable to keep seal and removed. Digital exam revealed rectal vault full of hard stool. No evidence of N/V. Dr. notified. Fleet and soap suds enema admin with out immediate results. Foley draining icteric urine in adequete amounts.\nSKIN: Skin jaundiced. Tiny skin tears on (R) buttock cleaned and covered with transparent dsg to protect from stool. Bard cream applied to buttocks. T-tube draining fliud. JP draining serosang fluid.\n\nPLAN: Monitor stool output, provide PRN enema. Monitor resp status, suction PRN. Monitor hemodynamics, hold lopressor and hydralazine per parameters. Monitor all labs. Cont with ICU care.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-31 00:00:00.000", "description": "Report", "row_id": 1302704, "text": "Resp Care: Pt continues intubated and on ventilatory support with simv, no vent changes overnoc, good oxygenation with persistent met acidosis; bs coarse crackles, sxn white secretions, will wean when ready.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-31 00:00:00.000", "description": "Report", "row_id": 1302705, "text": "nuero: pt open his eyes when you call his name, pt intermittently following commands. pt on 30mcg of propfol for sedation. pt remains juadiced.\n\npulm: pt continues on simv, rate14 ps 5 peep 5. last abg 7.33/34/221/19,-6, dr. , dr. aware. suctioning pt for thick whitish secretions.\n\ncards: pt in sr, no vea noted. pt continues on hydralazine and lopressor, sbp has been b/w 150-180's. cvp 2-5. please see flow sheet for vs. cellcept continues to be held per dr. .\n\ngi: pt conitinues on tube feedings at goal. pt with 2 mod. size bm, guiac positive, dr. , dr. aware.\n\ngu: u/o has been greater than 100cc/hr.\n\nheme: repeat plt this morning after pt recieved plts 62, plts rechecked 52 this afternoon, pt to recieve plts.\n\nincision: jp removed by dr. this morning, pt with sutures which are , dsd remains over site.\n\nplan: continue to monitor, monitor labs, electroyles, resp. status. lfts, plt to be rechecked an hour after pt recieves plts. monitor lfts.\n" }, { "category": "Nursing/other", "chartdate": "2173-11-01 00:00:00.000", "description": "Report", "row_id": 1302706, "text": "Resp Care: Pt continues intubated and on ventilatory support with simv with good oxygenation, mild met acidosis, no vent changes overnoc; bs rhonchorous, sxn thick white secretions, rsbi , wean when ready.\n" }, { "category": "Nursing/other", "chartdate": "2173-09-22 00:00:00.000", "description": "Report", "row_id": 1302629, "text": "Social Work Progress Note\nMet with pt for cont support. Pt appears more lethargic and uncomfortable today, and voices poor pain control. Pt expressed frustration with ongoing medical problems and expressed that \"no one is doing anything about it.\" He believes his son is undergoing w/u as potential donor. His family has been visiting frequently, but due to persistent pain and feelings of helplesness regarding his medical situation, he describes not always wanting their company. Also offered visit from catholic priest which pt declines at this time. Will relay pt's concern re: pain control to Rn/ICU team.\n\nPt continues to cope with complicated medical situation and ongoing pain and seems appropriately frustrated re: feeling helpless and loss of control at present. SW wil lcont to follow daily.\n\n , LICSW #\n" }, { "category": "Nursing/other", "chartdate": "2173-09-22 00:00:00.000", "description": "Report", "row_id": 1302630, "text": "SICU TRANSFER NOTE\n42 y.o. male admitted secondary to fever to 102.7, malaise, pain in side. Work up revealed hepatic artery occlusion and ? vile leak. Pt has been relisted for new liver. Per pt, son is being considered as donor.\n\nPMH: Pt is s/p liver transplant secondary to ETOH and HEP C. Post op course complicated by lithotripsy for renal stones as well as pleural effusion which was tapped via thoracentesis. pt was encephalopathic and in acute renal failure. Other PMH signif for GERD, DM, bipolar dz., remote hx DVT (20 yrs ago), smoker ( cig/day).\n\nNeuro: Pt confused at times re:time of day and meds given. However, appropriate with commands and conversation. Arms and legs shake at times. Pain cont. in abd- MSo4 2mg increased to q2 from q4 and pt appears more comfortable. Pt rates pain as 8 at worst. Afebrile\n\nCV: Sr, no ectopy. SBP 120-150, on lopressor . CP. minor periph edema- +3 PP. Teds on. OOB with minimal assist to chair. L periph line h/l'd. R IJ triple lumen C/D/I. D5NS at 30cc/hr.\n\nRESP:LS coarse, diminsh at bases. abd pain limiting deep breaths. O2 sat 96+% on RA. C=DB with splint pillow encouraged.\n\nGI: tolerated house diet, min intake. pt taking in candy from home. No BM, +BS. NO nausea/vomiting although pt states he does not want to eat because he \"fears\" being nauseated. abd large, distended, tender to left side. TPN.\n\nGU: foley patent clear yellow uinre adeq amounts- (60-170/hr).\n\nEndo: rmains on sliding scale secodnary to limited PO intake. Pt normally takes NPH in AM only.\n\nSocial: pt lives with supportive sister. Mother/sisters and son come to visit. Pt depressed at htought of re-do of liver tx. Sone possible donor per pt and pt upset by this.\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-29 00:00:00.000", "description": "Report", "row_id": 1302698, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, MECH VENTED IN SIMV/PS, NO CHANGES MADE THIS SHIFT. BS GROSSLY CTA. PT WELL SEDATED AND IN SYNCH W/VENT, OVERBREATHING TO TOTAL RR IN 20'S, STABLE. AM ABG W/NORMAL ACID-BASE & HYPEROXEMIA. RSBI 133. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-29 00:00:00.000", "description": "Report", "row_id": 1302699, "text": "Nursing Progress Note\nNeuro: Remains on Propofol at 30mcg/kg/min. Pt opens eyes periodically to stimulation and name calling. Some spnt mvmt of extrem. Appears lethargic. Does not follow commands. PERL. Afebrile.\n\nCV: SR, no ectopy. Brief brady to 59 during bronch. please see carevue for details. Remains on hydral/lopressor for HTN. One extra dose hydral given this AM but AM dose had been held. PLT 63 this PM, HCT stable. TLCL remains C/D/I. CVP 6-12. +3 periph edema remains. +pp.\n\nRESP: copious secretions thick white to yellow this AM. Bronch done and cultures sent. LS diminished on L but less markedly in PM. Remains on 40% SIMY 146/50/5/5. pt over vent RR 20's.\n\nGI:Abd soft, NT, distended. +BS. BM x2 of pink tinged stool. JP drng serosand, T-tube drng bilious, Abscess drain dnrg cloudy dark yellow. CT without contrast planned for AM.\n\nGU:foley patent drng icteric urine amounts. CR cont to rise.\n\nSocial:sister calling for updates. Aware that (POA) will receive daily reports.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2173-10-30 00:00:00.000", "description": "Report", "row_id": 1302700, "text": "CONDITION UPDATE\nREMAINS SEDATED ON PROPOFOL. TO VOICE. MAE ON THE BED. AT TIMES FOLLOWING SIMPLE COMMANDS. VSS. CONT W/ LOW TEMP. TMAX 96.4. CONT TO REQUIRE FREQUENT SUCTIONIG FOR THICK WHITE/TAN SPUTUM. MOSTLY ORAL SECRETIONS. NO VENT CHANGES THIS SHIFT. ABD SOFTLY DISTENDED - POSITIVE BOWEL SOUNDS. TOLERATING TUBE FEEDS. NO STOOL THIS SHIFT. U/O QS VIA FOLEY. HCT AND PLT COUNT STABLE. MIN AMT OF DRAINAGE FROM PIGTAIL DRAIN. MOD AMT OF BILIOUS DRAINAGE FROM TTUBE. MIN DRAINAGE FROM JP. PT MD'S ORDERS BEGINNING OF SHIFT. CONT TO ASSESS FOR S/S OF INFECTION, BLEEDING. AGGRESSIVE PULMONARY TOILET. MAINTAIN PT . CONT CURRENT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2173-10-30 00:00:00.000", "description": "Report", "row_id": 1302701, "text": "Resp care\nPt remains intubated & supoported in SIMV/PS mode\nB/S clear-course, Sx mod amounts of thick white secretions\nRSBI= 103, Pt placed back in SIMV/PS mode due to ^^HR\nPlan: continue support\n" }, { "category": "Nursing/other", "chartdate": "2173-10-30 00:00:00.000", "description": "Report", "row_id": 1302702, "text": "Nursing Progress Note\nPlease see carevus for full details.\n\nNeuro: Remains on propofol and titrated to 20 mcg/kg/min. Pt spont arouses, tracks RN in room, tries to mouth words over ET tube. Spont moving all extre,. follows simple commands- i.e open mouth move left arm. very lethargic. Afebrile. Lithium level sent.\n\nCV: SR to ST. No ectopy. SBP goal 150-170- on hydralazine and lopressor (increased freqency). CVP 7-12. Cont with + dependent pitting edema. P-boots on. +pp.\n\nRESP:LS coarse, decreased LLL. O2 sat 100% on 40%FIO2. Remains on SIMV 14/650/5/5. Thick white secretions via ET. Copious yellow with bood clots orally. Gram + cocci in pairs and clusters in sputum from bronch yesterday.\n\nGI:Nepro at 40cc/hr via DH. +sm BM x2- maroon- look sclay mixed iwth . MD aware.\n\nGU:foley patent drng icteric urine amounts. Renal consulted.\n\nSocial:family calling for updates. Plan to come and visit tonight.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2133-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445388, "text": "81 year old female admitted from Rehab with sudden onset\n dyspnea, tachycardia, hypoxia, trached, chronic vent s/p failure to\n wean; admit to MICU with PE, pna, UTI, trached, chronic vent\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt admitted with sob and tachycardia,CTA final read was positive for\n PE.\n Action:\n Remains on heparin drip @1425u/hr, PTT therapeutic at 62 at 11pm. Pt.\n started on Coumadin.\n Response:\n PTT sent at 5am with aml.\n Plan:\n Cont the heparin gtt,follow up on am PTT, adjust gtt as needed.\n Respiratory failure, chronic\n Assessment:\n Known chronic resp failure following gastric mass resection. Recvd on\n psv,suctioned small to moderate amount of thick\n secretions,ronchorous beath sounds.\n Action:\n Pt. with low tidal volumes on , changed to 8/5. Receiving iv\n vanco/zozyn for pna.\n Response:\n Afebrile,sats 96-100%,pt. becoming tachycardic to 150\ns in A-fib.\n Given 5mg IV Lopressor times 1. HR down to 70\ns-80\ns still in\n A-fib/flutter. HR currently 90\ns to 100\n Plan:\n Wean vent settings as tolerated. CTM hemodynamics.\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 445516, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 y/o f with recent gastrectomy at NWH (?path), tx to Rehab on\n s/p trach and J tube, developed sudden tachycardia, SOB, low grade\n temp. Here found to be in afib. CTA showed LUL PE, RLL PNA, LLL\n collapse with effusion. U/A positive. Given diltiazem 10 mg IV which\n improved HR. Started levo/vanc/ctx. Placed on vent and 0.4.\n Unclear what vent settings she was on at Rehab.\n 24 Hour Events:\n Changed to vanco/zosyn/levoflox for VAP. CE neg X2. ABG 7.44/55/76 on\n 0.4. Lactate down from 2.9 to 1 with IVF.\n INVASIVE VENTILATION - START 01:37 AM\n EKG - At 03:40 AM\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:39 AM\n Infusions:\n Heparin Sodium - 1,275 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.7\nC (98.1\n HR: 89 (84 - 112) bpm\n BP: 114/54(70) {98/40(54) - 159/97(108)} mmHg\n RR: 24 (18 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,054 mL\n PO:\n TF:\n IVF:\n 354 mL\n Blood products:\n Total out:\n 0 mL\n 1,135 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 919 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 433 (312 - 433) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 124\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.44/55/76./30/10\n Ve: 12 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 306 K/uL\n 116 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n WBC\n 9.5\n Hct\n 28.6\n Plt\n 306\n Cr\n 0.5\n TropT\n 0.05\n TCO2\n 39\n Glucose\n 116\n Other labs: PT / PTT / INR:17.2/143.6/1.6, CK / CKMB /\n Troponin-T:40//0.05, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n URINARY TRACT INFECTION (UTI)\n PNEUMONIA, OTHER\n RESPIRATORY FAILURE, CHRONIC\n 81 y/o f with recent gastrectomy s/p trach and J tube, p/w VAp from\n rehab, possible LUL PE.\n 1. Resp failure: New VAP with multifocal infiltrate throughout R\n -vanco/levoflox/zosyn\n -f/u cx, suspect MRSA\n -get records from Rehab about prior vent settings\n -try , if she tolerates try TC\n 2. Possible PE:\n -f/u final PE\n -cont. heparin gtt\n -f/u LENIs\n 3. afib with RVR: Unclear if she has had this before\n -cont. home meds\n -check TTE\n 4. htn: Held BP meds\n -restart metoprolol if BP tolerates\n -restart dig\n 5. abd pain: Now resolved\n -LFTs normal\n 6. UTI:\n f/u UCx, cont. vanco/zosyn\n 7. CAD: Unclear history\n -complete rule out with CE\n -restart meds\n 8. DM2: SSI for now\n 9. FEN: restart TF\n 10. readdress code status\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n I have seen and examined the patient with the fellow and reviewed and\n agree with the assessment and plan with the following\n modifications/emphasis:\n 81 year old female with history of gastrectomy with course complicated\n by chronic vent dependence and j tube being treated at Rehab who\n presented to the ED with fevers, tachycardia, and SOB. Found to have\n combination of pneumonia and pulmonary embolism. Treated with fluids,\n antibiotics, heparin and improved significantly.\n Currently, on PS/CPAP at 10/5 and appears comfortable\n T 37.6 HR 89 BP 114/54 RR 18 Sat: 95%\n Gen: Trach in place, awake, alert\n Chest: CTA bilat\n Heart: S1 S2 reg\n Abd: Soft NT ND\n Ext: no edema, cyanosis\n A:\n 1) Pneumonia\n 2) Pulmonary Embolism\n 3) Acute on Chronic Respiratory Failure\n Plan:\n 1) Continue antibiotics for VAP\n 2) Heparin for PE\n 3) PS/CPAP\n wean PS as tolerated\n Critical care: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:26 ------\n" }, { "category": "Nursing", "chartdate": "2133-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445314, "text": "81 year old female admitted from Rehab with sudden onset\n dyspnea, tachycardia, hypoxia, trached, chronic vent s/p failure to\n wean; admit to MICU with PE, pna, UTI, trached, chronic vent\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt admitted with sob and tachycardia,CTA s/o PE,final mresult pending\n recvd on heparin drip\n Action:\n Restarted the heparin drip @1275u/hr,rpt PTT sent after 6 hrs,pt had\n undergone LENI\n Response:\n PTT 54.9,no s/s of bleeding\n Plan:\n Cont the heparin gtt,follow up on final result of CTA,if positive\n bridge with coumadin\n Respiratory failure, chronic\n Assessment:\n Known chronic resp failure following gastric mass resection,recvd on\n psv,suctioned small amount of thick secretions,ronchorous beath\n sounds,CXR s/o chf\n Action:\n Changed to 5/5,received iv vanco/zozyn for pna,prophylactically put on\n precautions given long hospitalizations and rehab stay,pt had undergone\n echo\n Response:\n Afebrile,sats 96-100%,no sob RR 16-26,HR 70\ns,does go to 110\ns with\n exertionsbp 100-120\n Plan:\n Cont the current vent?may try trach color in am,follow up on sputum\n cx,follow fever curve.\n Alteration in Nutrition\n Assessment:\n Recvd the pt NPO,pt had J tube,consulted nutrition\n Action:\n Started on tube feed\n Response:\n Tolerating good\n Plan:\n Advance the tube feed to goal\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 445483, "text": "Chief Complaint:\n 24 Hour Events:\n - Digoxin resumed (Dig level=0.9)\n - LENI's negative\n - TTE showed dilated RV\n - PE confirmed on final chest CT report\n - Started Coumadin 2.5 mg qHS\n - NWH records obtained\n - Episode of tachycardia to 150's overnight, resolved with Lopressor 5\n mg IV\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:52 PM\n Piperacillin/Tazobactam (Zosyn) - 04:37 AM\n Infusions:\n Heparin Sodium - 1,425 units/hour\n Other ICU medications:\n Metoprolol - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 107 (74 - 131) bpm\n BP: 126/54(72) {92/43(55) - 130/71(114)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 66 Inch\n Total In:\n 3,323 mL\n 524 mL\n PO:\n TF:\n 129 mL\n 237 mL\n IVF:\n 1,364 mL\n 288 mL\n Blood products:\n Total out:\n 1,785 mL\n 440 mL\n Urine:\n 725 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 345 (138 - 345) mL\n PS : 8 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 13 cmH2O\n SpO2: 99%\n ABG: ///35/\n Ve: 5.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 267 K/uL\n 9.6 g/dL\n 142 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.4 %\n 7.0 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n 11:28 AM\n 05:15 AM\n WBC\n 9.5\n 7.0\n Hct\n 28.6\n 29.4\n 28.4\n Plt\n 306\n 267\n Cr\n 0.5\n 0.4\n TropT\n 0.05\n 0.03\n TCO2\n 39\n Glucose\n 116\n 142\n Other labs: PT / PTT / INR:15.6/62.5/1.4, CK / CKMB /\n Troponin-T:30//0.03, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 81 yo female with PMH of ?, p/w acute onset\n dyspnea, hypoxia, and tachycardia found to have a left upper PE, right\n pna, uti, and afib with RVR.\n .\n # PE: Both her clinic presentation of sudden onset dyspnea,\n tachycardia, and hypoxia as well as her positive CTA are consistent\n with PE. She was started on heparin ggt in the ED. Risks for PE in\n her include living in rehab, possible CA. RV strain by EKG and RV free\n wall hypokinesis on TTE.\n - lovenox bridge to coumadin\n .\n # PNA: Noted to have pna by CXR and CT, which could also contribute to\n her hypoxia. She received vanc/levo/ctx in the ED. Given chronic\n trach dependence and residence in a rehab/nursing home, consideration\n to pseudomonal/MDR coverage should be given. BP stable on the floor.\n Growing 4+ GPCs in sputum (good sample).\n - f/u sputum culture\n - prn fluids\n - cont broad spectrum antibiotics vanc/levo/zosyn for MDR and double\n pseudomonal coverage for 8 day course\n - wean PSV as tolerated\n - f/u BCx\n .\n # Afib/aflutter: intermittent afib/aflutter, mostly in sinus with good\n rate control in ICU. no known history of afib, though on dig and\n metoprolol. rate controlled with diltiazem in ED. Ruled out for MI.\n - restart dig\n .\n # vent dependence: difficulty weaning after intubation for stomach mass\n resection. Trached. On PSV 10/5. Compensated hypercapnea on ABG with\n elevated bicarb on chemistries. Has LLL collapse and small pleural\n effusion in addition to pna and PE to complicate weaning. No mucous\n plugging per CT.\n - wean vent as tolerated. today\n .\n # abdominal pain: diffuse TTP with benign exam o/n. Not apparent on\n exam this am. Lactate improved.\n - LFTs, pancreatic labs wnl\n - trend lactate\n - follow clinically\n .\n # UTI: Positive UA in ED. Cx's sent.\n - antibiotics as above\n - f/u cultures\n .\n # HTN: history of HTN on multiple antihypertensives at home. SBP\n ranging 100s to 140s in ICU.\n - restart digoxin as above\n - hold other antihypertensives for now given infections with\n possibility for SIRS, sepsis as well as for PE with risk for right\n heart failure.\n - restart PRN\n .\n # Hx of MI in : not on aspirin (allergy). No known stents. EKG\n showing NS STTW changes. First 2 set of CEs negative. Aspirin allergy\n reported as duodenal ulcer. Could likely benefit from low dose ASA\n with ulcer prophylaxis.\n - ROMI one more set\n - asa 81mg\n - H2 blocker\n .\n # DM: ISS, holding metformin while in ICU\n .\n # FEN: No IVF, replete electrolytes, tube feeds, appreciate nutrition\n consult\n .\n # Prophylaxis: heparin gtt, H2 blocker\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Contacts: husband: . cell .\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:53 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2133-02-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 445498, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Shiley\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: D/C to rehab later this evening\n Reason for continuing current ventilatory support:\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 445460, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Final CT confirmed RUL PE. LENI's neg. TTE with mild dil RV and mild\n free wall HK.\n ULTRASOUND - At 10:12 AM\n LENI\n TRANSTHORACIC ECHO - At 03:52 PM\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:37 AM\n Vancomycin - 09:30 AM\n Infusions:\n Heparin Sodium - 1,425 units/hour\n Other ICU medications:\n Metoprolol - 03:12 AM\n Famotidine (Pepcid) - 08:04 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 80 (79 - 131) bpm\n BP: 123/55(73) {92/43(55) - 130/78(114)} mmHg\n RR: 19 (19 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,323 mL\n 1,190 mL\n PO:\n TF:\n 129 mL\n 421 mL\n IVF:\n 1,364 mL\n 689 mL\n Blood products:\n Total out:\n 1,785 mL\n 675 mL\n Urine:\n 725 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 416 (138 - 416) mL\n PS : 10 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 15 cmH2O\n SpO2: 98%\n ABG: ///35/\n Ve: 8.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 267 K/uL\n 142 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.4 %\n 7.0 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n 11:28 AM\n 05:15 AM\n WBC\n 9.5\n 7.0\n Hct\n 28.6\n 29.4\n 28.4\n Plt\n 306\n 267\n Cr\n 0.5\n 0.4\n TropT\n 0.05\n 0.03\n TCO2\n 39\n Glucose\n 116\n 142\n Other labs: PT / PTT / INR:15.6/62.5/1.4, CK / CKMB /\n Troponin-T:30//0.03, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n URINARY TRACT INFECTION (UTI)\n PNEUMONIA, OTHER\n RESPIRATORY FAILURE, CHRONIC\n 1. PE/resp failure/PNA: HD stable\n -heparin gtt, starting coumadin\n - PS for SOB, wean as tolerated\n -f/u cx, cont. vanco/zosyn/levoflox for 8 days\n -change to lovenox then stop heparin\n -was doing CPAP 8 vs TC at Rehab\n -check NIF\n 2. Afib: Now rate controlled on dig\n -coumadin\n 3. Abd pain: Improved, LFTs OK, making stool\n 4. UTI: On abx\n -on abx\n 5. CAD: Allergic to ASA\n -restart home meds\n 6. DM2: Holding metformin, SSI\n 7. FEN: TF\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:53 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:53 AM\n 20 Gauge - 07:09 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 445470, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Final CT confirmed RUL PE. LENI's neg. TTE with mild dil RV and mild\n free wall HK.\n ULTRASOUND - At 10:12 AM\n LENI\n TRANSTHORACIC ECHO - At 03:52 PM\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:37 AM\n Vancomycin - 09:30 AM\n Infusions:\n Heparin Sodium - 1,425 units/hour\n Other ICU medications:\n Metoprolol - 03:12 AM\n Famotidine (Pepcid) - 08:04 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 80 (79 - 131) bpm\n BP: 123/55(73) {92/43(55) - 130/78(114)} mmHg\n RR: 19 (19 - 30) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,323 mL\n 1,190 mL\n PO:\n TF:\n 129 mL\n 421 mL\n IVF:\n 1,364 mL\n 689 mL\n Blood products:\n Total out:\n 1,785 mL\n 675 mL\n Urine:\n 725 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 416 (138 - 416) mL\n PS : 10 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 15 cmH2O\n SpO2: 98%\n ABG: ///35/\n Ve: 8.3 L/min\n Physical Examination\n Gen: Alert and OX3, Interactive\n HEENT: mmm, Trach in place\n CV: RRR no m/r/g\n Pulm: few basilar rhonchi bilat\n Abd: s/nt/nd +BS, J tube in place\n Ext: 1+ edema bilat, warm\n Skin: No rashes\n Labs / Radiology\n 9.6 g/dL\n 267 K/uL\n 142 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.4 %\n 7.0 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n 11:28 AM\n 05:15 AM\n WBC\n 9.5\n 7.0\n Hct\n 28.6\n 29.4\n 28.4\n Plt\n 306\n 267\n Cr\n 0.5\n 0.4\n TropT\n 0.05\n 0.03\n TCO2\n 39\n Glucose\n 116\n 142\n Other labs: PT / PTT / INR:15.6/62.5/1.4, CK / CKMB /\n Troponin-T:30//0.03, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n URINARY TRACT INFECTION (UTI)\n PNEUMONIA, OTHER\n RESPIRATORY FAILURE, CHRONIC\n 1. PE/resp failure/PNA: HD stable\n -heparin gtt, starting coumadin\n - PS for SOB, wean as tolerated\n -f/u cx, cont. vanco/zosyn/levoflox for 8 days\n -change to lovenox then stop heparin\n -was doing CPAP 8 vs TC at Rehab\n -check NIF\n 2. Afib: Now rate controlled on dig\n -coumadin\n 3. Abd pain: Improved, LFTs OK, making stool\n 4. UTI: On abx\n -on abx\n 5. CAD: Allergic to ASA\n -restart home meds\n 6. DM2: Holding metformin, SSI\n 7. FEN: TF\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:53 PM 45 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:53 AM\n 20 Gauge - 07:09 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2133-02-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 445166, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Shiley\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL / Air\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2133-02-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 445284, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Shiley\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: trach collar trial as tol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2133-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445277, "text": "81 year old female admitted from Rehab with sudden onset\n dyspnea, tachycardia, hypoxia, trached, chronic vent s/p failure to\n wean; admit to MICU with PE, pna, UTI, trached, chronic vent\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt admitted with sob and tachycardia,CTA s/o PE,final mresult pending\n recvd on heparin drip\n Action:\n Restarted the heparin drip @1275u/hr,rpt PTT sent after 6 hrs,pt had\n undergone LENI\n Response:\n pending\n Plan:\n Cont the heparin gtt,follow up on final result of CTA,if positive\n bridge with coumadin\n Respiratory failure, chronic\n Assessment:\n Known chronic resp failure following gastric mass resection,recvd on\n psv,suctioned small amount of thick secretions,ronchorous beath\n sounds,CXR s/o chf\n Action:\n Changed to 5/5,received iv vanco/zozyn for pna,prophylactically put on\n precautions given long hospitalizations and rehab stay,pt had undergone\n echo\n Response:\n Afebrile,sats 96-100%,no sob RR 16-26,HR 70\ns,sbp 100-120\n Plan:\n Cont the current vent?may try trach color in am,follow up on sputum\n cx,follow fever curve.\n Alteration in Nutrition\n Assessment:\n Recvd the pt NPO,pt had J tube,consulted nutrition\n Action:\n Started on tube feed\n Response:\n Tolerating good\n Plan:\n Advance the tube feed to goal\n" }, { "category": "Nursing", "chartdate": "2133-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445511, "text": "81 year old female admitted from Rehab with sudden onset\n dyspnea, tachycardia, hypoxia, trached, chronic vent s/p failure to\n wean; admit to MICU with PE, pna, UTI, trached, chronic vent, neg\n for DVT,echo s/o EF 55%,pt afebrile,started on lovemox Coumadin bridge\n ,heparin stopped,\n VS stable today afebrile,denied pain sats 98% on ,pt transferred to\n rehab at 1700 hrs via ACLS,belongings sent,dc paperworks sent with the\n pt\n" }, { "category": "Physician ", "chartdate": "2133-02-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 445141, "text": "TITLE:\n Chief Complaint: dyspnea, tachycardia\n HPI:\n Ms. is an 81 yo female with PMH of trached since \n stomach mass, trouble weaning. Much of the history is provided by her\n husband, who is her HCP, given her ventilatory status. She was\n initially intubated for resection of a gastric cardiac tumor, but had\n difficulty weaning from the vent with complications including pna. She\n spent 72 days at for this. She was discharged to\n Rehab on , where she was slowly weaned. She underwent\n bronchoscopy and endoscopy at roughly one week ago\n which showed healed resection sites. She was at Rehab today\n when she noticed sudden onset dyspnea and tachycardia.\n .\n In the ED, initial vs were: T 100.6 P 117 in afib BP 128/52 (decreased\n to 91/41 upon signout) R 36 O2 sat 95% on 100% FiO2. She had no\n leukocytosis, HCT was 34, trop was 0.03 but CK was 36. Lactate was\n 2.9. CXR showed mild CHF, small bilateral effusions, and a\n retrocardiac opacity. CTA showed PE in his LUL pulm artery, right lung\n pna, and LLL collapse. UA was positive for > 50 WBCs. Patient was\n given diltiazem, levofloxacin 750mg, vancomycin 1g, ceftriaxone 1g, and\n started on heparin. 2 18 gage PIVs were placed. UCx and BCx were\n sent.\n .\n On arrival to the ICU, she is intubated. She is resting and\n comfortable. Denies abd pain, chest pain. She reports continued SOB,\n though it is better than upon presentation to the ED.\n History obtained from Patient, Family / Medical records\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,650 units/hour\n Other ICU medications:\n Other medications:\n zofran 9mg \n KCl 20mEq \n spironolactone 25mg qday\n ambine 5mg qhs\n percocet 5/325 0.5 tab q 6 hrs prn pain\n tramadol 50mg q 6 hrs prn pain\n ativan 0.25mg PO prn anxiety\n reg insulin SSI\n lactobacillus\n lidocaine patch 5% TD qday\n losartan 75 qday\n metformin 500mg \n metoprolol tartrate 50mg TID\n mritazapine 7.5 mg qhs\n omeprazole 20mg \n albuterol/ipratropium 4 puffs qid\n amlodipine 5mg qday\n digoxine 0.25mg qday\n duloxetine 20mg \n lovenox 40mg qday (starting )\n fentanyl patch 50mcg q3 day\n ferrous sulfate 325mg \n lasix 40mg qday\n hydralazine 25mg qid\n Past medical history:\n Family history:\n Social History:\n - stomach/esophageal CA of cardia s/p resection \n - herpes zoster in \n - MI treated at in , s/p heart\n - catheterization in , unknown details\n - hepatitis in , ? medication induced\n - obesity\n - hypercholesterolemia\n - HTN\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: nonsmoker. no EtOH.\n Review of systems:\n Flowsheet Data as of 03:36 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 102 (102 - 112) bpm\n BP: 159/97(108) {147/68(85) - 159/97(108)} mmHg\n RR: 18 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,743 mL\n PO:\n TF:\n IVF:\n 43 mL\n Blood products:\n Total out:\n 0 mL\n 760 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 983 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (328 - 328) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 100%\n Ve: 8.4 L/min\n Physical Examination\n Vitals: T: 99.7 BP: 147/68 P:112 R:22 99% on 100% FiO2\n Vent: PSV 10/5 40% FiO2\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple. bounding carotid pulses. JVP not elevated, no LAD. TTP\n right neck. Fullness of right neck and supraclavicular area.\n Lungs: bronchial BS in left base. Rales in right base.\n CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM murmur at base. no\n rubs, gallops\n Abdomen: soft, non-distended, bowel sounds present. Diffuse TTP. no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: answers questions appropriately by nodding. CNs intact\n grossly.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Lactate:2.9\n .\n Trop-T: 0.03\n CK: 36 MB: Notdone\n .\n Chem 7:\n 134 93 12 128\n 4.1 33 0.5\n .\n Ca: 9.0 Mg: 1.5 P: 1.9\n .\n WBC: 9.7 N:63.7 L:28.9 M:5.5 E:1.4 Bas:0.4\n Plt: 333\n HCT: 34.0\n .\n PT: 12.6 PTT: 20.4 INR: 1.1\n Imaging: CTA :\n Preliminary Read:\n Pulmonary emboli at origin of left upper lobe pulmonary artery\n extending into segmental and subsegmental vessels. No other central PE\n identified though motion limits evaluation of segmental and\n subsegmental vessels. Diffuse right lung peribronchovascular opacity\n concerning for infection. Left lower lobe collapse with opacification\n of lower lobe bronchi, perhaps secretions.\n .\n CXR :\n IMPRESSION: Mild CHF with small bilateral pleural effusions and\n retrocardiac opacity which may represent atelectasis and/or pneumonia.\n Would recommend followup post-diuresis.\n ECG: EKG: sinus tach, rate 155. QTc 468. NA. ST depressions in I, II,\n V5, V6. STE aVR.\n .\n EKG in ICU: afib, rate 97. NI/NA. No STTW changes.\n Assessment and Plan\n Assessment and Plan: 81 yo female with PMH of ?, p/w acute onset\n dyspnea, hypoxia, and tachycardia found to have a left upper PE, right\n pna, uti, and afib with RVR.\n .\n # PE: Both her clinic presentation of sudden onset dyspnea,\n tachycardia, and hypoxia as well as her positive CTA are consistent\n with PE. She was started on heparin ggt in the ED. Risks for PE in\n her include living in rehab, possible CA.\n - cont heparin drip\n - transition to coumadin\n - LE dopplers\n .\n # PNA: Noted to have pna by CXR and CT, which could also contribute to\n her hypoxia. She received vanc/levo/ctx in the ED. Given chronic\n trach dependence and residence in a rehab/nursing home, consideration\n to pseudomonal/MDR coverage should be given. BP stable in 140s\n systolic upon arrival to the floor. BCx sent in ED. Appears euvolemic\n now.\n - sputum culture\n - prn fluids\n - broaden antibiotics to vanc/levo/zosyn for MDR and double pseudomonal\n coverage.\n - cont PSV at current settings, possible weaning tomorrow\n - f/u BCx\n - trend lactate\n .\n # Afib: no known history of afib. rate controlled with diltiazem in\n ED.\n - prn diltiazem\n - ROMI\n .\n # Right neck fullness: ? SVC syndrome with clot.\n - RUE and neck doppler\n .\n # vent dependence: difficulty weaning after intubation for stomach mass\n resection. Trached. On PSV 10/5.\n - wean vent in AM\n .\n # abdominal pain: diffuse, benign exam.\n - send LFTs, pancreatic labs\n - trend lactate\n - consider CT abd\n .\n # UTI: Positive UA in ED. Cx's sent. Got dose of levo and ceftriaxone\n in ED.\n - antibiotics as above\n - f/u cultures\n .\n # afib: improved with dilt. ? new/old.\n - rate control\n .\n # HTN: history of HTN on multiple antihypertensives at home. SBP\n ranging 100s to 140s in ICU.\n - hold antihypertensives for now given infections with possibility for\n SIRS, sepsis as well as for PE with risk for right heart failure.\n - restart PRN\n .\n # Hx of MI in : not on aspirin (allergy). No known stents. EKG\n showing NS STTW changes. First set of CEs negative.\n - ROMI\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: heparin gtt, H2 blocker\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Contacts: husband: . cell .\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nutrition", "chartdate": "2133-02-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 445244, "text": "Subjective\n Mouthing \"Hi\". Per pt\ns husband was taking liquids,\nchopped\n chicken/vegetables and Carnation Instant Breakfast shakes at rehab.\n When asked about pt\ns appetite/po intake, says\nI think it was the bad\n chef there\n. Reports TF have been off at least 7 days.\n Per rehab note, pt cleared by SLP for soft solids and thin liquids ,\n but pt has poor appetite, Remeron started. Variable intake of\n Carnation Instant breakfast shakes. TF on hold x5 days PTA with plan to\nrestart tube feeds given poor appetite, low albumin\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 94.6 kg\n 33.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59\n 160\n 68 kg\n Diagnosis: PNA\n PMH : stomach/esophageal CA of cardia, s/p resection of tumor, trach\n , s/p Jtube, hepatitis, herpes zoster, MI, obesity, high chol, HTN\n Food allergies and intolerances: NKFA\n Pertinent medications: HISS, Abx, Colace, Famotidine, Heparin SS IV,\n Magnesium Sulfate (4gm repleted)\n Labs:\n Value\n Date\n Glucose\n 116 mg/dL\n 03:40 AM\n Glucose Finger Stick\n 144\n 05:00 AM\n BUN\n 9 mg/dL\n 03:40 AM\n Creatinine\n 0.5 mg/dL\n 03:40 AM\n Sodium\n 139 mEq/L\n 03:40 AM\n Potassium\n 4.2 mEq/L\n 03:40 AM\n Chloride\n 97 mEq/L\n 03:40 AM\n TCO2\n 30 mEq/L\n 03:40 AM\n PO2 (arterial)\n 76. mm Hg\n 04:40 AM\n PCO2 (arterial)\n 55 mm Hg\n 04:40 AM\n pH (arterial)\n 7.44 units\n 04:40 AM\n CO2 (Calc) arterial\n 39 mEq/L\n 04:40 AM\n Albumin\n 2.4 g/dL\n 03:40 AM\n Calcium non-ionized\n 7.7 mg/dL\n 03:40 AM\n Phosphorus\n 2.3 mg/dL\n 03:40 AM\n Magnesium\n 1.4 mg/dL\n 03:40 AM\n ALT\n 13 IU/L\n 03:40 AM\n Alkaline Phosphate\n 68 IU/L\n 03:40 AM\n AST\n 29 IU/L\n 03:40 AM\n Amylase\n 5 IU/L\n 03:40 AM\n Total Bilirubin\n 0.3 mg/dL\n 03:40 AM\n WBC\n 9.5 K/uL\n 03:40 AM\n Hgb\n 9.6 g/dL\n 03:40 AM\n Hematocrit\n 28.6 %\n 03:40 AM\n Current diet order / nutrition support: DIET: NPO\n GI: soft abdomen, (+) bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: Low po intake, NPO diet\n Estimated Nutritional Needs\n per adjusted body weight of 68kg\n Calories: 1360-1700 (BEE x or / 20-25 cal/kg)\n Protein: 68-82 (1-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: likely inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 81 y/o female s/p resection of gastric tumor c/b difficulty weaning\n vent, (+) PNA, spent 72 days at . Pt d/c\nd to\n rehab . s/p bronchoscopy and endoscopy one week ago which showed\n healed resection sites. Pt admitted from rehab w/ tachycardia and\n dyspnea. CXR showed mild CHF. CTA showed (+) PE, right lung PNA, LLL\n collapse. Also, U/A (+) for UTI. Consulted for TF recommendations.\n Would provide 100% of nutrition needs via TF at this time given pt NPO\n currently and noted poor intake per rehab report. Noted low Magnesium\n repleted this AM. Noted low phos. Also, low albumin\n likely\n multifactorial including poor nutrition PTA, long hospital/rehab stay,\n infection.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend S+S evaluation before initiating po diet\n Multivitamin / Mineral supplement: via TF\n Tube feeding recommendations: Fibersource HN @ 15ml/hr, advance as\n tolerated to goal of 55ml/hr = 1584 calories and 70g protein\n No residual checks w/ Jtube, monitor TF tolerance via abdominal exam,\n N/V\n Will adjust TF pending po advancement/tolerance\n Recommend replete Phos.\n Will follow\n page if ?s *\n" }, { "category": "Nursing", "chartdate": "2133-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445143, "text": "81 year old female admitted from Rehab with SOB,\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2133-02-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 445210, "text": "TITLE:\n Chief Complaint: dyspnea, tachycardia\n 24 Hour Events:\n - admitted with PE, pna\n - on heparin drip\n - antibiotics broadened to vanc/levo/zosyn\n - rhythm sinus interspersed with afeb/aflutter\n - 2 sets CEs negative\n - LE dopplers ordered\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:39 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.8\nC (98.2\n HR: 92 (84 - 112) bpm\n BP: 127/40(64) {98/40(54) - 159/97(108)} mmHg\n RR: 28 (18 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,932 mL\n PO:\n TF:\n IVF:\n 232 mL\n Blood products:\n Total out:\n 0 mL\n 1,060 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 872 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 312 (312 - 328) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 124\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.44/55/76./30/10\n Ve: 6.8 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 306 K/uL\n 9.6 g/dL\n 116 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n WBC\n 9.5\n Hct\n 28.6\n Plt\n 306\n Cr\n 0.5\n TropT\n 0.05\n TCO2\n 39\n Glucose\n 116\n Other labs: PT / PTT / INR:17.2/143.6/1.6, CK / CKMB /\n Troponin-T:40//0.05, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: 81 yo female with PMH of ?, p/w acute onset\n dyspnea, hypoxia, and tachycardia found to have a left upper PE, right\n pna, uti, and afib with RVR.\n .\n # PE: Both her clinic presentation of sudden onset dyspnea,\n tachycardia, and hypoxia as well as her positive CTA are consistent\n with PE. She was started on heparin ggt in the ED. Risks for PE in\n her include living in rehab, possible CA.\n - cont heparin drip\n - transition to coumadin\n .\n # PNA: Noted to have pna by CXR and CT, which could also contribute to\n her hypoxia. She received vanc/levo/ctx in the ED. Given chronic\n trach dependence and residence in a rehab/nursing home, consideration\n to pseudomonal/MDR coverage should be given. BP stable in 140s\n systolic upon arrival to the floor. BCx sent in ED. Appears euvolemic\n now.\n - sputum culture\n - prn fluids\n - broaden antibiotics to vanc/levo/zosyn for MDR and double pseudomonal\n coverage.\n - cont PSV at current settings, possible weaning tomorrow\n - f/u BCx\n - trend lactate\n .\n # Afib: no known history of afib. rate controlled with diltiazem in\n ED.\n - prn diltiazem\n - ROMI\n .\n # vent dependence: difficulty weaning after intubation for stomach mass\n resection. Trached. On PSV 10/5. hypercapnea.\n - wean vent in AM\n .\n # abdominal pain: diffuse, benign exam.\n - send LFTs, pancreatic labs\n - trend lactate\n - consider CT abd\n .\n # elevated bicarb:\n - compensation for resp hypercapnea\n .\n # UTI: Positive UA in ED. Cx's sent. Got dose of levo and ceftriaxone\n in ED.\n - antibiotics as above\n - f/u cultures\n .\n # afib/aflutter: improved with dilt. ? new/old.\n - rate control\n .\n # HTN: history of HTN on multiple antihypertensives at home. SBP\n ranging 100s to 140s in ICU.\n - hold antihypertensives for now given infections with possibility for\n SIRS, sepsis as well as for PE with risk for right heart failure.\n - restart PRN\n .\n # Hx of MI in : not on aspirin (allergy). No known stents. EKG\n showing NS STTW changes. First set of CEs negative.\n - ROMI\n .\n # DM: ISS\n .\n # FEN: No IVF, replete electrolytes, tube feeds nutrition consult\n .\n # Prophylaxis: heparin gtt, H2 blocker\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Contacts: husband: . cell .\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Nursing", "chartdate": "2133-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 445145, "text": "81 year old female admitted from Rehab with sudden onset\n dyspnea, tachycardia, hypoxia, trached, chronic vent s/p failure to\n wean; admit to MICU with PE, pna, UTI, trached, chronic vent\n Tachycardia, Other\n Assessment:\n Tachy to 150\ns in , ED afib, but pt has no history\n Action:\n Dilt 10 mg x1 in ED, EKG done\n Response:\n HR to 110\ns, HR 110\ns, now SR with PAC\n Plan:\n ROMI, CE\ns with am labs, next draw 11am\n Urinary tract infection (UTI)\n Assessment:\n +UA in ED\n Action:\n Rec\nd dose levaquin\n Response:\n None\n Plan:\n Cont abx\n Pulmonary Embolism (PE), Acute\n Assessment:\n Sudden onset dyspnea, tachycardia, and hypoxia\n Action:\n CTA in ED, started on heparin gtt @\n Response:\n PTT pending 6a draw\n Plan:\n LENI\ns, continue heparin gtt, transition to coumadin\n Pneumonia, other\n Assessment:\n +pna by CXR and CTA, thin, tan sputum\n Action:\n Vanc/levaquin/zosyn started, sputum culture sent\n Response:\n Afebrile, WBC\ns WNL, lactate slightly elevated, 2.9, next draw pending\n Plan:\n Continue abx, follow cultures\n Respiratory failure, chronic\n Assessment:\n Pt chronic vent, trached #7 Shiley, PS 40%/\n Action:\n Continue mechanical ventilation,\n Response:\n Satting 98-100%, RR 20\ns-teens, to 30\ns when anxious\n Plan:\n Continue mechanical vent, wean as tolerated\n" }, { "category": "Physician ", "chartdate": "2133-02-12 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 445146, "text": "Chief Complaint: Pulmonary embolism, respiratory distress, chronic\n respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 year old woman with chronic respiratory failure following\n gastrectomy for tumor, complicated by pneumonia. At Rehab where\n she developed respiratory distress. Sent to ED and was tachycardic and\n tachypneic with what appeared to be afib. CXR felt to show mild CHF\n with retrocardiac opacity. CTA showed LUL pulmonary embolism, LLL\n collapse and infiltrate. Was tachycardic. Given diltiazem. Heparin\n started along with antibiotics. Patient has been on lovanox for past\n two weeks; unclear why it was started.\n Transferred to ED. Continued dyspnea, but better than on presentation.\n Afebrile. BP has been in normal range. O2 sats 97% on 40% FIO2 on vent.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Trach\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,650 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Trach since following gastrectomy; chronic respiratory failure.\n Tissue type unknown\n Zoster\n s/p MI, cath in \n s/p hepatitis\n increased cholesterol\n hypertension\n DM on metformin\n Non contributory.\n Occupation:\n Drugs:\n Tobacco: negative\n Alcohol: negative\n Other: Lives with husband\n Review of systems:\n Flowsheet Data as of 04:23 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 102 (102 - 112) bpm\n BP: 159/97(108) {147/68(85) - 159/97(108)} mmHg\n RR: 18 (18 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,746 mL\n PO:\n TF:\n IVF:\n 46 mL\n Blood products:\n Total out:\n 0 mL\n 760 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 986 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 328 (328 - 328) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ////\n Ve: 8.4 L/min\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic, On vent, mild\n accessory muscle use\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Trach tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n Anterior and lateral, No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\n AutoPEEP=6\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese, PEG\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Not assessed\n Labs / Radiology\n 333\n 34\n 128\n 0.5\n 12\n 33\n 93\n 4.1\n 134\n 9.7\n [image002.jpg]\n Other labs: Lactic Acid:2.9, Ca++:9.0, Mg++:1.9, PO4:1.5\n Fluid analysis / Other labs: Troponin 0.03\n Imaging: CXR: obscuring of left hemi-diaphragm. Blunting of left CPA.\n Air bronchogram left mid zone.\n CTA: right upper lobe alveolar infiltrate and RLL ateletasis/infiltrate\n with air bronchograms. LLL atelectasis with air in segmental bronchi.\n By report, small LUL embolism.\n ECG: ECG: 19:34 - probable atrial flutter with ventricular rate changes consisstent with demand ischemia.\n 3:18: atrial fibrillation\n 4:03 NSR\n Assessment and Plan\n PULMONARY EMBOLISM\n RESPIRATORY DISTRESS\n PNEUMONIA\n CHRONIC RESPIRATORY FAILURE\n ATELECTASIS\n METABOLIC ALKALOSIS\n Patient with respiratory distress and atrial flutter/afib. Pulmonary\n embolism and infiltrate noted on CT scan. WBC not elevated. Pulmonary\n embolism likely etiology of her tachycardia. Troponin negative. Patient\n on heparin. No evidence of hypotension. Continue anticoagulation\n CT shows significant right lung infiltrate. Patient on broad spectrum\n antibiotics considering long hospitalization and hospital associated\n pneumonia. Awaiting gram stain and culture of sputum. Try to narrow\n antibiotics following culture results.\n Patient with chronic respiratory failure. Unclear if she has baseline\n of COPD. Elevated serum bicarbonate suggests possible chronic\n respiratory acidosis, although patient has also been on diuretic and\n may have metabolic alkalosis. Would obtain ABG to clarify acid-base\n status. Continue weaning from vent in AM.\n Aflutter/fibrillation probably from PE. Now back in NSR. Monitor off\n anti-arrythmics. Additional cardiac enzymes pending.\n LLL atelectasis present on CT. Doubt central plug on scan. have\n some compressive atelectasis with left effusion. Would consider\n recruitment maneuver later today.\n Pyuria noted. On antibiotics.\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 01:53 AM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-02-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 445225, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 81 y/o f with recent gastrectomy at NWH (?path), tx to Rehab on\n s/p trach and J tube, developed sudden tachycardia, SOB, low grade\n temp. Here found to be in afib. CTA showed LUL PE, RLL PNA, LLL\n collapse with effusion. U/A positive. Given diltiazem 10 mg IV which\n improved HR. Started levo/vanc/ctx. Placed on vent and 0.4.\n Unclear what vent settings she was on at Rehab.\n 24 Hour Events:\n Changed to vanco/zosyn/levoflox for VAP. CE neg X2. ABG 7.44/55/76 on\n 0.4. Lactate down from 2.9 to 1 with IVF.\n INVASIVE VENTILATION - START 01:37 AM\n EKG - At 03:40 AM\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:39 AM\n Infusions:\n Heparin Sodium - 1,275 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.7\nC (98.1\n HR: 89 (84 - 112) bpm\n BP: 114/54(70) {98/40(54) - 159/97(108)} mmHg\n RR: 24 (18 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,054 mL\n PO:\n TF:\n IVF:\n 354 mL\n Blood products:\n Total out:\n 0 mL\n 1,135 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 919 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 433 (312 - 433) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 124\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.44/55/76./30/10\n Ve: 12 L/min\n PaO2 / FiO2: 190\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.6 g/dL\n 306 K/uL\n 116 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n WBC\n 9.5\n Hct\n 28.6\n Plt\n 306\n Cr\n 0.5\n TropT\n 0.05\n TCO2\n 39\n Glucose\n 116\n Other labs: PT / PTT / INR:17.2/143.6/1.6, CK / CKMB /\n Troponin-T:40//0.05, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n URINARY TRACT INFECTION (UTI)\n PNEUMONIA, OTHER\n RESPIRATORY FAILURE, CHRONIC\n 81 y/o f with recent gastrectomy s/p trach and J tube, p/w VAp from\n rehab, possible LUL PE.\n 1. Resp failure: New VAP with multifocal infiltrate throughout R\n -vanco/levoflox/zosyn\n -f/u cx, suspect MRSA\n -get records from Rehab about prior vent settings\n -try , if she tolerates try TC\n 2. Possible PE:\n -f/u final PE\n -cont. heparin gtt\n -f/u LENIs\n 3. afib with RVR: Unclear if she has had this before\n -cont. home meds\n -check TTE\n 4. htn: Held BP meds\n -restart metoprolol if BP tolerates\n -restart dig\n 5. abd pain: Now resolved\n -LFTs normal\n 6. UTI:\n f/u UCx, cont. vanco/zosyn\n 7. CAD: Unclear history\n -complete rule out with CE\n -restart meds\n 8. DM2: SSI for now\n 9. FEN: restart TF\n 10. readdress code status\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2133-02-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 445234, "text": "TITLE:\n Chief Complaint: dyspnea, tachycardia\n 24 Hour Events:\n - admitted with PE, pna\n - on heparin drip\n - antibiotics broadened to vanc/levo/zosyn\n - rhythm sinus interspersed with afeb/aflutter\n - 2 sets CEs negative\n - LE dopplers ordered\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 03:39 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.8\nC (98.2\n HR: 92 (84 - 112) bpm\n BP: 127/40(64) {98/40(54) - 159/97(108)} mmHg\n RR: 28 (18 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,932 mL\n PO:\n TF:\n IVF:\n 232 mL\n Blood products:\n Total out:\n 0 mL\n 1,060 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 872 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 312 (312 - 328) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 124\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.44/55/76./30/10\n Ve: 6.8 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple. bounding carotid pulses. JVP not elevated, no LAD. TTP\n right neck. Fullness of right neck and supraclavicular area.\n Lungs: bronchial BS in left base. Rales in right base.\n CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM murmur at base. no\n rubs, gallops\n Abdomen: soft, non-distended, bowel sounds present. Diffuse TTP. no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Neuro: answers questions appropriately by nodding. CNs intact\n grossly.\n Labs / Radiology\n 306 K/uL\n 9.6 g/dL\n 116 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.6 %\n 9.5 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n WBC\n 9.5\n Hct\n 28.6\n Plt\n 306\n Cr\n 0.5\n TropT\n 0.05\n TCO2\n 39\n Glucose\n 116\n Other labs: PT / PTT / INR:17.2/143.6/1.6, CK / CKMB /\n Troponin-T:40//0.05, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:7.7 mg/dL, Mg++:1.4 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n Assessment and Plan: 81 yo female with PMH of ?, p/w acute onset\n dyspnea, hypoxia, and tachycardia found to have a left upper PE, right\n pna, uti, and afib with RVR.\n .\n # PE: Both her clinic presentation of sudden onset dyspnea,\n tachycardia, and hypoxia as well as her positive CTA are consistent\n with PE. She was started on heparin ggt in the ED. Risks for PE in\n her include living in rehab, possible CA. RV strain by EKG.\n - cont heparin drip\n - f/u final read of CTA\n - f/u LE dopplers\n - transition to coumadin\n - TTE\n .\n # PNA: Noted to have pna by CXR and CT, which could also contribute to\n her hypoxia. She received vanc/levo/ctx in the ED. Given chronic\n trach dependence and residence in a rehab/nursing home, consideration\n to pseudomonal/MDR coverage should be given. BP stable in 140s\n systolic upon arrival to the floor. BCx sent in ED. Appears euvolemic\n now. Growing 4+ GPCs in sputum (good sample).\n - f/u sputum culture\n - prn fluids\n - cont broad spectrum antibiotics vanc/levo/zosyn for MDR and double\n pseudomonal coverage for now, taper as per speciation and\n sensitivities.\n - wean PSV as tolerated\n - f/u BCx\n - trend lactate\n .\n # Afib/aflutter: intermittent afib/aflutter, mostly in sinus with good\n rate control in ICU. no known history of afib, though on dig and\n metoprolol. rate controlled with diltiazem in ED.\n - prn diltiazem\n - digoxin level\n - restart dig\n - ROMI\n .\n # vent dependence: difficulty weaning after intubation for stomach mass\n resection. Trached. On PSV 10/5. Compensated hypercapnea on ABG with\n elevated bicarb on chemistries. Has LLL collapse and small pleural\n effusion in addition to pna and PE to complicate weaning. No mucous\n plugging per CT.\n - wean vent as tolerated. today\n .\n # abdominal pain: diffuse TTP with benign exam o/n. Not apparent on\n exam this am. Lactate improved.\n - LFTs, pancreatic labs wnl\n - trend lactate\n - follow clinically\n .\n # UTI: Positive UA in ED. Cx's sent.\n - antibiotics as above\n - f/u cultures\n .\n # HTN: history of HTN on multiple antihypertensives at home. SBP\n ranging 100s to 140s in ICU.\n - restart digoxin as above\n - hold other antihypertensives for now given infections with\n possibility for SIRS, sepsis as well as for PE with risk for right\n heart failure.\n - restart PRN\n .\n # Hx of MI in : not on aspirin (allergy). No known stents. EKG\n showing NS STTW changes. First 2 set of CEs negative. Aspirin allergy\n reported as duodenal ulcer. Could likely benefit from low dose ASA\n with ulcer prophylaxis.\n - ROMI one more set\n - asa 81mg\n - H2 blocker\n .\n # DM: ISS, holding metformin while in ICU\n .\n # FEN: No IVF, replete electrolytes, tube feeds, appreciate nutrition\n consult\n .\n # Prophylaxis: heparin gtt, H2 blocker\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Contacts: husband: . cell .\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n" }, { "category": "Respiratory ", "chartdate": "2133-02-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 445360, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Shiley\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=88\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Pt had some episodes of anxiety accompanied by an increase in RR (>35)\n and HR (150), pressure support was titrated as needed.\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 445412, "text": "Chief Complaint:\n 24 Hour Events:\n - Digoxin resumed (Dig level=0.9)\n - LENI's negative\n - TTE showed dilated RV\n - PE confirmed on final chest CT report\n - Started Coumadin 2.5 mg qHS\n - NWH records obtained\n - Episode of tachycardia to 150's overnight, resolved with Lopressor 5\n mg IV\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:52 PM\n Piperacillin/Tazobactam (Zosyn) - 04:37 AM\n Infusions:\n Heparin Sodium - 1,425 units/hour\n Other ICU medications:\n Metoprolol - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 107 (74 - 131) bpm\n BP: 126/54(72) {92/43(55) - 130/71(114)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 66 Inch\n Total In:\n 3,323 mL\n 524 mL\n PO:\n TF:\n 129 mL\n 237 mL\n IVF:\n 1,364 mL\n 288 mL\n Blood products:\n Total out:\n 1,785 mL\n 440 mL\n Urine:\n 725 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 345 (138 - 345) mL\n PS : 8 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 13 cmH2O\n SpO2: 99%\n ABG: ///35/\n Ve: 5.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 267 K/uL\n 9.6 g/dL\n 142 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.4 %\n 7.0 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n 11:28 AM\n 05:15 AM\n WBC\n 9.5\n 7.0\n Hct\n 28.6\n 29.4\n 28.4\n Plt\n 306\n 267\n Cr\n 0.5\n 0.4\n TropT\n 0.05\n 0.03\n TCO2\n 39\n Glucose\n 116\n 142\n Other labs: PT / PTT / INR:15.6/62.5/1.4, CK / CKMB /\n Troponin-T:30//0.03, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n TACHYCARDIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n URINARY TRACT INFECTION (UTI)\n PNEUMONIA, OTHER\n RESPIRATORY FAILURE, CHRONIC\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:53 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2133-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 445413, "text": "Chief Complaint:\n 24 Hour Events:\n - Digoxin resumed (Dig level=0.9)\n - LENI's negative\n - TTE showed dilated RV\n - PE confirmed on final chest CT report\n - Started Coumadin 2.5 mg qHS\n - NWH records obtained\n - Episode of tachycardia to 150's overnight, resolved with Lopressor 5\n mg IV\n Allergies:\n Aspirin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 09:52 PM\n Piperacillin/Tazobactam (Zosyn) - 04:37 AM\n Infusions:\n Heparin Sodium - 1,425 units/hour\n Other ICU medications:\n Metoprolol - 03:12 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 107 (74 - 131) bpm\n BP: 126/54(72) {92/43(55) - 130/71(114)} mmHg\n RR: 24 (19 - 30) insp/min\n SpO2: 99%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 66 Inch\n Total In:\n 3,323 mL\n 524 mL\n PO:\n TF:\n 129 mL\n 237 mL\n IVF:\n 1,364 mL\n 288 mL\n Blood products:\n Total out:\n 1,785 mL\n 440 mL\n Urine:\n 725 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,538 mL\n 85 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 345 (138 - 345) mL\n PS : 8 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 13 cmH2O\n SpO2: 99%\n ABG: ///35/\n Ve: 5.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 267 K/uL\n 9.6 g/dL\n 142 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.8 mEq/L\n 9 mg/dL\n 98 mEq/L\n 138 mEq/L\n 28.4 %\n 7.0 K/uL\n [image002.jpg]\n 03:40 AM\n 04:40 AM\n 11:28 AM\n 05:15 AM\n WBC\n 9.5\n 7.0\n Hct\n 28.6\n 29.4\n 28.4\n Plt\n 306\n 267\n Cr\n 0.5\n 0.4\n TropT\n 0.05\n 0.03\n TCO2\n 39\n Glucose\n 116\n 142\n Other labs: PT / PTT / INR:15.6/62.5/1.4, CK / CKMB /\n Troponin-T:30//0.03, ALT / AST:13/29, Alk Phos / T Bili:68/0.3, Amylase\n / Lipase:, Differential-Neuts:72.0 %, Lymph:20.5 %, Mono:5.6 %,\n Eos:1.3 %, Lactic Acid:0.9 mmol/L, Albumin:2.4 g/dL, LDH:320 IU/L,\n Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 81 yo female with PMH of ?, p/w acute onset\n dyspnea, hypoxia, and tachycardia found to have a left upper PE, right\n pna, uti, and afib with RVR.\n .\n # PE: Both her clinic presentation of sudden onset dyspnea,\n tachycardia, and hypoxia as well as her positive CTA are consistent\n with PE. She was started on heparin ggt in the ED. Risks for PE in\n her include living in rehab, possible CA. RV strain by EKG.\n - cont heparin drip\n - f/u final read of CTA\n - f/u LE dopplers\n - transition to coumadin\n - TTE\n .\n # PNA: Noted to have pna by CXR and CT, which could also contribute to\n her hypoxia. She received vanc/levo/ctx in the ED. Given chronic\n trach dependence and residence in a rehab/nursing home, consideration\n to pseudomonal/MDR coverage should be given. BP stable in 140s\n systolic upon arrival to the floor. BCx sent in ED. Appears euvolemic\n now. Growing 4+ GPCs in sputum (good sample).\n - f/u sputum culture\n - prn fluids\n - cont broad spectrum antibiotics vanc/levo/zosyn for MDR and double\n pseudomonal coverage for now, taper as per speciation and\n sensitivities.\n - wean PSV as tolerated\n - f/u BCx\n - trend lactate\n .\n # Afib/aflutter: intermittent afib/aflutter, mostly in sinus with good\n rate control in ICU. no known history of afib, though on dig and\n metoprolol. rate controlled with diltiazem in ED.\n - prn diltiazem\n - digoxin level\n - restart dig\n - ROMI\n .\n # vent dependence: difficulty weaning after intubation for stomach mass\n resection. Trached. On PSV 10/5. Compensated hypercapnea on ABG with\n elevated bicarb on chemistries. Has LLL collapse and small pleural\n effusion in addition to pna and PE to complicate weaning. No mucous\n plugging per CT.\n - wean vent as tolerated. today\n .\n # abdominal pain: diffuse TTP with benign exam o/n. Not apparent on\n exam this am. Lactate improved.\n - LFTs, pancreatic labs wnl\n - trend lactate\n - follow clinically\n .\n # UTI: Positive UA in ED. Cx's sent.\n - antibiotics as above\n - f/u cultures\n .\n # HTN: history of HTN on multiple antihypertensives at home. SBP\n ranging 100s to 140s in ICU.\n - restart digoxin as above\n - hold other antihypertensives for now given infections with\n possibility for SIRS, sepsis as well as for PE with risk for right\n heart failure.\n - restart PRN\n .\n # Hx of MI in : not on aspirin (allergy). No known stents. EKG\n showing NS STTW changes. First 2 set of CEs negative. Aspirin allergy\n reported as duodenal ulcer. Could likely benefit from low dose ASA\n with ulcer prophylaxis.\n - ROMI one more set\n - asa 81mg\n - H2 blocker\n .\n # DM: ISS, holding metformin while in ICU\n .\n # FEN: No IVF, replete electrolytes, tube feeds, appreciate nutrition\n consult\n .\n # Prophylaxis: heparin gtt, H2 blocker\n .\n # Access: peripherals\n .\n # Code: presumed full\n .\n # Communication: Patient\n .\n # Contacts: husband: . cell .\n .\n # Disposition: ICU\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 03:53 PM 35 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 01:53 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Echo", "chartdate": "2133-02-12 00:00:00.000", "description": "Report", "row_id": 89609, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Pulmonary embolus.\nHeight: (in) 66\nWeight (lb): 208\nBSA (m2): 2.04 m2\nBP (mm Hg): 121/54\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated aortic sinus. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor apical views. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The right ventricular cavity is mildly dilated with mild\nglobal free wall hypokinesis. The aortic root is mildly dilated at the sinus\nlevel. There is no aortic valve stenosis. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion. There is an anterior\nspace which most likely represents a fat pad.\n\nIMPRESSION: Mild right ventricular systolic dysfunction. Preserved global left\nventricular systolic function. No significant valvular disease seen. No\npericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1066328, "text": " 3:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman on trach now with PNA and pulmonary embolism.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and pulmonary embolism, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there are persistent low lung\n volumes in this patient with a tracheostomy tube in place. Opacification at\n the left base is consistent with pleural fluid and atelectasis, though\n superimposed pneumonia cannot be excluded in the absence of a lateral view.\n The pulmonary vasculature is essentially within normal limits. The cardiac\n silhouette is somewhat prominent, though much of this may reflect the poor\n inspiration. Opacification at the right base medially could reflect crowding\n of vessels or a possible consolidation in this area as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-02-12 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1066115, "text": " 8:17 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: assess for LE DVT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PE.\n REASON FOR THIS EXAMINATION:\n assess for LE DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:02 PM\n PFI: No evidence of deep vein thrombosis in either leg.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with PE, assess for lower extremity DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: scale, color and Doppler son of bilateral common\n femoral, superficial femoral, popliteal and tibial veins were performed.\n There is normal flow, compression and augmentation seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2133-02-11 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1066059, "text": " 8:45 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval pe\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with sudden onset tachycardia and dyspnea\n REASON FOR THIS EXAMINATION:\n eval pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb WED 11:48 PM\n Pulmonary emboli at origin of left upper lobe pulmonary artery extending into\n segmental and subsegmental vessels. No other central PE identified though\n motion limits evaluation of segmental and subsegmental vessels. Diffuse right\n lung peribronchovascular opacity concerning for infection. Left lower lobe\n collapse with opacification of lower lobe bronchi, perhaps secretions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with sudden onset of tachycardia and dyspnea.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast and contrast-enhanced axial images of the chest are\n obtained according to the CTA protocol. Multiplanar reformatted images are\n also submitted for review.\n\n CTA CHEST: Pulmonary artery filling defects, consistent with acute thrombus,\n begin at the origin of the right upper lobe pulmonary artery extending into\n segmental and subsegmental right upper lobe branches. Focal acute pulmonary\n embolism is noted in the right interlobar pulmonary aretery as well. Other\n pulmonary artery filling defects appear peripherally located within the\n vessel, perhaps representing recannulated arteries in the setting of chronic\n embolism (i.e. branches to the superior segment of the left lower lobe). .\n Breathing artifact obscures evaluation of subsegmental levels, particularly to\n the right lower lobe. No left sided pulmonary emboli are identified. There is\n no overt evidence of right- sided heart strain. Atherosclerotic calcifications\n involve the thoracic aorta and its branches including the coronary arteries.\n There is no evidence of pericardial effusion. Small scattered mediastinal\n lymph nodes are identified though they do not appear to meet CT criteria for\n pathologic enlargement. An tracheostomy tube appears appropriately\n positioned. Heterogeneous appearance of the thyroid with rim- calcified left\n thyroid nodules are partially imaged.\n\n Lung windows reveal extensive right lung peribronchovascular opacity\n throughout the upper, middle, and lower lobes. More consolidative changes at\n the right base are also noted. There is a small left pleural effusion with\n consolidation of the left lower lobe consistent with collapse. Secretions are\n noted in the left main stem bronchus extending into left lower lobe bronchi.\n\n Although this exam is not tailored to evaluate abdominal organs, limited\n evaluation of the upper abdomen is unremarkable.\n\n (Over)\n\n 8:45 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval pe\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There are no bone findings of malignancy. Fracture deformity of the left\n seventh rib is old. Multilevel thoracolumbar bridging anterior osteophytosis\n is noted.\n\n IMPRESSION:\n 1. Pulmonary emboli including those beginning at the origin of the right\n upper lobe pulmonary artery extending into segmental and subsegmental vessels\n and another in the right interlobar artery.\n\n 2. Focal right basilar consolidation and diffuse right lung\n peribronchovascular opacity is most concerning for infection or aspiration,\n though the sequela of chronic emboli is in the differential.\n\n 3. Left lower lobe collapse with opacification of lower lobe bronchi, perhaps\n reflecting mucus impaction. Associated small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2133-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1066049, "text": " 7:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with fever, tachycardia and sob\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: None.\n\n CLINICAL HISTORY: 81-year-old woman with fever and tachycardia, shortness of\n breath. Evaluate for pneumonia.\n\n FINDINGS: Single AP upright portable chest radiograph is obtained.\n Tracheostomy tube is noted. Evaluation is quite limited given the low lung\n volumes. Bilateral pleural effusions are noted, slightly greater on the left\n side. There is retrocardiac density which may in part reflect pleural\n effusion though left lower lobe atelectasis and/or pneumonia cannot be\n excluded. There is prominence of the central pulmonary hilar structures with\n mild interstitial congestion. Heart size cannot be accurately assessed.\n Mediastinal contour is grossly unremarkable. There is no pneumothorax.\n Osseous structures appear intact.\n\n IMPRESSION: Mild CHF with small bilateral pleural effusions and retrocardiac\n opacity which may represent atelectasis and/or pneumonia. Would recommend\n followup post-diuresis.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2133-02-12 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1066116, "text": ", W. MED MICU-7 8:17 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: assess for LE DVT\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PE.\n REASON FOR THIS EXAMINATION:\n assess for LE DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "ECG", "chartdate": "2133-02-11 00:00:00.000", "description": "Report", "row_id": 242921, "text": "Artifact is present. Regular supraventricular tachycardia which is probably\nsinus. Diffuse ST-T wave changes. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2141-12-20 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 355255, "text": "Chief Complaint: Angioedema\n HPI:\n 24 year old female with ESRD on HD, SLE, malignant HTN, history of SVC\n syndrome transferring from floor team due to evidence of angioedema by\n ENT and increasing difficulty with blood pressure control. The patient\n reports she feels her face is more swollen which is confirmed by her\n mother on the floor. The patient was give lasix IV as she has been\n unable to have any negative filtration with HD. The patient was\n started on decadron 10mg q8hr *3, famotidine, diphenhydramine for the\n edema. Her tekturna was discontinued it is a renin blocker and while\n she has been tolerating this medication well she has a history of ACE-i\n angioedema.\n She denies difficulty with her breathing at this time, but is very\n somnulent. Of note she received benadryl 25 mg iv, dilaudid 4mg po and\n klonapin 0.5 mg PO for pain and concern for angio edema prior to\n arrival in MICU. On arrival to the MICU her vitas were stable and\n satting 100% on face mask.\n Allergies:\n Penicillins Rash;\n Percocet itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 02:05 PM\n Other medications:\n Medications at Home:\n Aliskiren 150 mg \n Clonidine 0.3mg / 24 hr patch weekly qwednesday\n Hydralazine 100mg PO q8H\n Labetalol 800mg PO TID\n Hydromorphone 4mg PO q4H PRN\n Nifedipine ER 90mg PO qday\n Prednisone 4mg PO qday\n Lorazepam 0.5mg PO qHS\n Clonazepam 0.5 mg \n Celexa 20mg PO qday\n Gabapentin 300 mg \n Acetaminophen 325 mg q6H PRN\n Ergocalciferol (Vitamin D2) 50,000 unit PO once a month\n Warfarin held on discharge due to supratherap INR\n .\n Medications on Floor:\n HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain\n Heparin IV per Weight-Based Dosing\n Acetaminophen 325 mg PO Q6H:PRN\n HydrALAzine 100 mg PO Q8H\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Labetalol 800 mg PO TID\n Citalopram 20 mg PO DAILY\n Lorazepam 0.5 mg PO HS\n Clonazepam 0.5 mg PO BID\n NIFEdipine CR 90 mg PO DAILY\n Clonidine Patch 0.3 mg/24 hr 1 QWED\n Dexamethasone 4 mg IV Q8H\n Ondansetron 4 mg IV Q8H:PRN\n DiphenhydrAMINE 25 mg IV Q6H:PRN\n Senna 1 TAB PO BID\n Docusate Sodium 100 mg PO BID\n Famotidine 20 mg IV Q24H\n Gabapentin 300 mg PO Q48H\n Past medical history:\n Family history:\n Social History:\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting , Straight\n CPAP/ Pressure setting 7\n .\n PSHx:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n 5. S/P Ex-lap for free air in abdomen, ex-lap normal \n Negative for autoimmune diseases including sle, thrombophilic\n disorders. Maternal grandfather with HTN, MI, stroke in 70s.\n Occupation: on disability\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: lives with mother and brother\n Review of systems:\n Neurologic: somnulent\n Pain: Minimal\n Pain location: abdominal\n Flowsheet Data as of 03:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 93 (91 - 103) bpm\n BP: 162/121(130) {146/82(100) - 197/125(137)} mmHg\n RR: 13 (13 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 741 mL\n 60 mL\n PO:\n 500 mL\n TF:\n IVF:\n 241 mL\n 60 mL\n Blood products:\n Total out:\n 450 mL\n 675 mL\n Urine:\n 450 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 291 mL\n -615 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: 7.36/42/158//-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, periorbital, perioral edema,\n facial swelling, no stridor, but son voice\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, PD catheter\n in place\n Extremities: Edema- Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Oriented (to): self, place, date, reason for admission, Movement:\n Purposeful, Tone: Normal, somnulent\n Labs / Radiology\n 191 K/uL\n 8.7 g/dL\n 104 mg/dL\n 6.2 mg/dL\n 40 mg/dL\n 23 mEq/L\n 103 mEq/L\n 5.0 mEq/L\n 136 mEq/L\n 26.7 %\n 3.8 K/uL\n [image002.jpg]\n \n 2:33 A12/9/ 06:45 AM\n \n 10:20 P12/9/ 01:40 PM\n \n 1:20 P12/10/ 12:09 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 3.8\n Hct\n 26.7\n Plt\n 191\n Cr\n 5.8\n 6.2\n TC02\n 25\n Glucose\n 90\n 104\n Other labs: PT / PTT / INR:14.9/64.9/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Imaging: CT abdomen/pelvis with contrast :\n 1. Moderate amount of free fluid in the pelvis is compatible with the\n patient's known peritoneal dialysis. Unchanged peritoneal enhancement.\n 2. Stable liver hemangioma.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n # Facial Swelling/Angioedema: med rxn (Aliskiren can cause this 1% of\n time and can have rxn at any time) vs fluid overload (unable to take\n fluid off at HD due to hypotension) vs SVC syndrome (has hx and INR\n suptherapeutic on admission). Got prednisone 60mg, then started on\n decadron out of concern for angio edema\n - Appreciate END scope demonstrating no stridor, just son and \n occlusion. Patient with known OSA.\n - HD today via temp HD line\n - MRV w/o contrast to eval for SVC\n - Heparin drip for goal PTT 60-80\n - Stopped potentially offending medication AND on decadron, H2\n blockers, and benadryl.\n - Nasal trumpet in place for airway protection\n - CPAP for sleep\n # Somulence: Patient rousable and oriented. Likely med effect. ABG w/o\n hypercarbia\n - monitor closely\n - decrease dilaudid\n # Hypertension: initially 235/170 in ED, but improved with nicardipine\n drip which was discontinued during first unit stay. No clear\n precipitating event. No hx of recent drug use. On admit to the floor\n BPs are stable and the patient is aysmptomatic. Nephrology following.\n Plan to continue PO anti-hypertensives.\n - STOP Aliskiren\n -continue labetalol, hydralazine, nifedipine, clonidine at current\n doses. Have room to increase nifedipine if needed.\n -dialysis T, Thrs, Sat, plan for replacement of HD catheter on Thurs\n with temp line\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. No evidence of blood or urine\n infection by culture that may have led to an acute flare. Pneumonia\n unlikely at this point as patient does not have fever or leukocytosis.\n Echo does not suggest worsening pericarditis.\n -hold prednisone at 4 mg PO q day while patient on decadron.\n #Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter.\n -PD catheter to be removed on Thursday.\n -Decrease dilaudid dose given somnulence this am\n #ESRD: HD today and scheduled for Thurs as well. Renal following.\n -follow lytes, replete as indicated\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, hold clonazepam\n # OSA: CPAP for sleep with 7 pressure.\n ICU Care\n Nutrition:\n Comments: PO diet\n Glycemic Control: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: not intubated\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key points:\n SLE, ESRD, on HD but with prior PD, chronic severe HTN\n SVC syndrome, on heparin\n Question of angioedema\nplan to evaluate by MRI/MRV to\n minimize dye load and nephrotoxicity\n Somnolence\nlikely med effect. Resolved. No hypercapnia\n during somnolent period.\n Critically ill with threatened airway compromise requiring nasal\n trumpet\n Time: 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 17:51 ------\n" }, { "category": "Physician ", "chartdate": "2141-12-20 00:00:00.000", "description": "Attending Note", "row_id": 355257, "text": "TITLE: MICU Attending Note\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. Unclear historian and\n no records here.\n Briefly, 80 yo man with h/o DM, HTN, atrial fib, who is on coumadin as\n outpt, presents with 2d h/o melena. Has had falls in the past few days.\n ROS sig for lightheadedness, weakness. NG lavage in ED with BRB, clots,\n cleared. In MICU NG lavage repeated with small amt blood, also cleared.\n SBP as low as 80-90, responded to IV fluids. Received vit K, FFP, PPI\n gtt.\n No resp distress. C/O fatigue but denies any abdominal pain, vomiting.\n Now 127/30, HR 80s in afib, 100% on RA. No melena since arrival in\n hospital.\n Hgb/Hct 9.4/27.5\n 7.9/22.7 after 2L NS + 2U FFP.\n INR on arrival 1.8, now 1.6.\n Check dig level.\n LFTs.\n CIWA- drinks bottle of wine daily.\n DNR/DNI.\n Critically ill\n 40 minutes\n" }, { "category": "Nursing", "chartdate": "2141-12-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 355259, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. This a.m. she presented with angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following, scoped nose this a.m.\n Airway obstruction, Central / Upper\n Assessment:\n Received pt. this a.m. with son sounds. No stridor noted,\n however obvious occlusive process noted in upper airways. Initially\n resp\ns were tachy and labored, with increased WOB. At this time, pt.\n was somnolent. Generalized facial swelling noted, especially\n periorbital and soft tissue of neck. Pt. complained of neck swelling\n and discomfort with breathing. Pt. also due for dialysis.\n Action:\n Nasal trumpet placed right nare. Close airway monitoring. Pt. given\n decadron and lasix given as noted. Anesthesia aware of case. ABG done\n due to continued somnolence. Pt. presently being dialyzed. Heparin\n gtt restarted this eve due to history of SVC syndrome (turned off by\n floor due to possible IR procedure.)\n Response:\n ABG stable without hypercarbia. Initially no change in snoring noted\n with trumpet in place. Some diuresis noted. Over the course of the\n day, resp. assessment has waxed and waned as evidenced by intermittent\n improvement of snoring/occlusion and pattern/overall wob. Since\n approximately 1600, resp\ns have been unlabored with minimal to no\n snoring. She continues to have an irregular breathing pattern\n intermittently. No stridor, no distress, no hypoxia noted.\n Plan:\n Continue close monitoring of airway and facial swelling. Pt. to\n receive 2 more doses of decadron. Cont. optimal positioning. ENT here\n at present to re-scope.\n Problem\n Decreased LOC\n Assessment:\n Pt. markedly lethargic/somnolent throughout day. At times, pt. will\n only open eyes to trapezius squeeze/deep pain. Pt. was partially\n incontinent of urine this afternoon.\n Action:\n Neuro checks done. Pt. given narcan this a.m. as she received 4mg\n dilaudid this a.m. ABG drawn.\n Response:\n No results from narcan noted. ABG normal. Pt. wide awake for approx.\n 45-60mins. After trumpet placed, the back to somnolent state. LOC\n waxes and wanes, but for the majority of the day she has remained\n somnolent.\n Plan:\n Ongoing reassessments. Continue attempts to stimulate pt. as\n appropriate.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n BP as high as 190\ns/110\n Action:\n IV hydralazine given x 2.\n Response:\n BP down to 160\ns/. With HD, BP down further to 140-150\n Plan:\n Continue to monitor and treat as indicated. Give antihypertensives\n when HD complete.\n" }, { "category": "General", "chartdate": "2141-12-22 00:00:00.000", "description": "ICU Event Note", "row_id": 355518, "text": "Clinician: Attending\n Critical Care\n Transferred back to MICU after developing hypertensive urgency on floor\n in setting of abd pain and agitation. We have given her usual meds,\n rest and min stimulation and BP has responded - now down to 108/57.\n Plan is to continue meds, HD tomorrow, pain control. No evidence CHF,\n no HA.\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354989, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354917, "text": " MD H+P:\n 24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n .\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her Po dose of Labetalol(800mg) but\n hydralazine po dose held secondary SBP 110-120. Team aware, ? if pt is\n taking meds at home. Pt has repeat ECHO today to eval for pericardial\n effusion seen on ECHO from . Renal into see pt plan for HD Tues\n and removal of PD cath prior to discharge. Pt has been difficult to\n arouse today secondary to lethargy, sleeping throughout day w/ CPAP\n on.\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-12-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 354887, "text": "Chief Complaint: Hypertensive urgency\n HPI: 24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n .\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n .\n On arrival to the MICU her vitas were T 96.4 HR 99 BP 175/120 RR 15\n 100%RA. Patient was comfortable.\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Aliskiren 150 mg \n Clonidine 0.3mg / 24 hr patch weekly qwednesday\n Hydralazine 100mg PO q8H\n Labetalol 800mg PO TID\n Hydromorphone 4mg PO q4H PRN\n Nifedipine ER 90mg PO qday\n Prednisone 4mg PO qday\n Lorazepam 0.5mg PO qHS\n Clonazepam 0.5 mg \n Celexa 20mg PO qday\n Gabapentin 300 mg \n Acetaminophen 325 mg q6H PRN\n Ergocalciferol (Vitamin D2) 50,000 unit PO once a month\n Warfarin held on discharge due to supratherap INR\n Past medical history:\n Family history:\n Social History:\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting , Straight\n CPAP/ Pressure setting 7\n Noncontributory\n Single and lives with her mother and a brother. She graduated\n from high school. The patient is on disability. No smoking, alcohol,\n drug use.\n Review of systems:\n Flowsheet Data as of 11:59 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 92 (92 - 109) bpm\n BP: 140/68(87) {129/67(83) - 177/124(137)} mmHg\n RR: 17 (11 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 446 mL\n PO:\n 360 mL\n TF:\n IVF:\n 86 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 196 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n T 96.4 HR 99 BP 175/120 RR 15 100%RA\n Gen: well-appearing african-american woman, sleeping comfortably,\n easily awoken by verbal stimuli\n HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM\n Heart: S1S2 RRR, III/VI SEM throughout the precordium\n Pulm: CTA b/l\n Abd: normal bowel sounds, midline scar well-healed, soft, nontender. PD\n catheter in LLQ.\n Ext: no edema, no clubbing, WWP. R femoral HD in place\n Neuro: following commands, answers appropriately, motor strength,\n sensation is intact.\n Labs / Radiology\n [image002.jpg]\n ECG: NSR at 110 bpm, normal axis, left atrial enlargement,\n mildly prominent Twaves compared to .\n .\n TTE :\n The left atrium is moderately dilated. The estimated right atrial\n pressure is 0-5 mmHg. There is severe symmetric left ventricular\n hypertrophy. The left ventricular cavity is unusually small. Regional\n left ventricular wall motion is normal. Left ventricular systolic\n function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). There is a\n mild resting left ventricular outflow tract obstruction. A mid-cavitary\n gradient is identified with cavity obliteration during systole. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic stenosis. Mild (1+) aortic regurgitation is\n seen. The mitral valve leaflets are structurally normal. There is no\n mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\n tricuspid valve leaflets are mildly thickened. There is moderate\n pulmonary artery systolic hypertension. Significant pulmonic\n regurgitation is seen. The end-diastolic pulmonic regurgitation\n velocity is increased suggesting pulmonary artery diastolic\n hypertension. There is a small to moderate sized pericardial effusion.\n The effusion appears circumferential. There are no echocardiographic\n signs of tamponade. Echocardiographic signs of tamponade may be absent\n in the presence of elevated right sided pressures.\n Compared with the prior study (images reviewed) of , the\n pericardial effusion has increased in size with the most accumulation\n posterior to the LV.\n .\n CT abdomen/pelvis with contrast :\n 1. Moderate amount of free fluid in the pelvis is compatible with the\n patient's known peritoneal dialysis. Unchanged peritoneal\n enhancement.\n 2. Stable liver hemangioma.\n Assessment and Plan\n 24 year old lady with SLE, ESRD on HD and malignant hypertension\n presents with abdominal pain and headache consistent with her usual\n hypertensive urgency and was found to be in hypertensive urgency in\n ED.\n .\n 1. Hypertensive Urgency: BP elevated on arrival to 253/170 in ED. No\n significant improvement to 10 IV hydral and max dose of labetolol drip\n per ED signout. Currently on nicardipine drip. Patient has known\n malignant hypertension of unclear etiology. Has known ESRD/HD due to\n SLE. Patient underwent hemodialysis yesterday. Hisory and exam not\n consistent with infection or ischemia. Likely has an anxiety component\n precipitating hypertension.\n - will cont nicardipine gtt for BP goal of < 180/100\n - continue PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine\n 90mg PO qday, Clonidine\n - will consult nephrology in AM\n - verify aliskiren with nephrology team in AM\n - follow up BCx sent from ED\n - will send for UA/Cx\n .\n 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT\n scan which did not show source of abdominal pain. Lipase near recent\n baseline of low 70s.\n - transplant surgery was suppose to remove the PD line on Thursday\n - cont PO dilaudid prn home dose\n .\n 3. ESRD: HD yesterday. On T/Th/Sat schedule. Pt currently undergoing HD\n however still has PD line.\n - consult renal team in AM\n .\n 4. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last\n admission for supratherapeutic INR. Admitted on subtherpeutic INR of\n 1.2\n - consider heparin gtt bridge to therapeutic INR if her BP normalizes\n - will start Coumadin 2mg PO qday\n .\n 5. Anxiety: Likely contributing to medical problems. Pt recently saw\n psychiatrist who started her on Celexa.\n - continue Celexa 20mg PO qday\n - continue home lorazepam and clonazepam\n .\n 6. Anemia: currently at baseline. Likely related to ESRD.\n - continue to monitor\n .\n 7. SLE:\n - continue Prednisone 4mg PO qday\n .\n 8. Pericardial effusion:\n - noted in TTE in the past.\n .\n 9. HOCM:\n - will need to careful not to reduce too much after load\n - will attemp to rate control\n .\n 10. FEN: renal diet, replete lytes PRN\n .\n 11. Prophylaxis: Heparin sc till INR is therapeutic, PPI\n .\n 12. Code Status: FULL\n .\n 13. Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 05:00 AM\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354964, "text": " MD H+P:\n 24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n .\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her Po dose of Labetalol(800mg) but\n hydralazine po dose held secondary SBP 110-120. Team aware, ? if pt is\n taking meds at home. Pt has repeat ECHO today to eval for pericardial\n effusion seen on ECHO from . Renal into see pt plan for HD Tues\n and removal of PD cath prior to discharge. Pt has been difficult to\n arouse today secondary to lethargy, sleeping throughout day w/ CPAP\n on.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has newly DX sleep apnea. Pt very lethargic this am, difficult to\n arouse. Pt falling asleep while talking to team. Pt snoring loudly\n Action:\n Pt placed on nasal Cpap throughout day\n Response:\n Sat\ns have been 96-99%\n Plan:\n Continue to place pt on CPAP whwn asleep\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt has been normatensive thru day.\n Action:\n Pt given 1 dose of labetaolol and hydralazine dose held in am but pm\n dose given\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-12-20 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 355199, "text": "Chief Complaint: ?Angioedmea and labile BP\n HPI:\n 24 year old woman with SLE, ESRD on HD, history of SVC syndrome\n original admitted for hypertensive crisis transferred for facial\n swelling and concern for angioedema. Getting Decadron, Benadryl.\n Currently on renin inhibitor, history of angioedmea to ACE.\n Patient admitted from: \n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n SLE - on prednisone 4mg at baseline\n SVC Syndrome - On coumadin at baseline, subtherapeutic at presentation.\n Neg cardiolipn, B2 and lupus anticoagulant\n HOCM - noted on Echo \n OSA - Home CPAP\n As per resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: As per resident note\n Review of systems:\n Flowsheet Data as of 10:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 102 (95 - 103) bpm\n BP: 161/100(114) {119/65(80) - 161/100(114)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 741 mL\n PO:\n 500 mL\n TF:\n IVF:\n 241 mL\n Blood products:\n Total out:\n 450 mL\n 0 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 291 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191 K/uL\n 26.7 %\n 8.7 g/dL\n 104 mg/dL\n 6.2 mg/dL\n 40 mg/dL\n 23 mEq/L\n 103 mEq/L\n 5.0 mEq/L\n 136 mEq/L\n 3.8 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n WBC\n 3.8\n Hct\n 26.7\n Plt\n 191\n Cr\n 5.8\n 6.2\n Glucose\n 90\n 104\n Other labs: PT / PTT / INR:15.3/88.0/1.4, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ##Agioedema -\n ? secondary to med effect. Last dose of aliskiren at 8am. Currenty on\n Decadron + Bendaryl+ famotidine. Monitoring airway.\n ##Airway\n Risk for unstable airway.\n Baseline OSA vs contribution from Angioedema. Narcan now to asses how\n much of upper airway obstruction is OSA vs new angioedema. did get\n dilaudid on the floor prior to transfer\n ##SVC syndrome -\n Subtherapeutic INR at presentation. On Heparin drip now\n ##Renal Failure\n Needs HD. Going to IR for temp HD line with anesthsia then to get HD.\n ##SLE\n Baseline prednisone 4mg. On Decadron now.\n Further plans as per resident note.\n ICU Care\n Nutrition:\n Comments: NPO now somnolence.\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:01 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2141-12-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355385, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. On floor she developed angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt. received on 1.5mcg/kg/min Nitro gtt. BP was 150\ns to 180\n systolic.\n Action:\n Pt. given PO antihypertensive regimen which was held yesterday HD\n and somnolence. Nifedepine dose increased to 120 daily.\n Response:\n Nitro gtt able to be weaned off. BP currently 100\ns to 110\ns systolic.\n Plan:\n Cont regular PO BP med regimen. Monitor BP and hemodynamics.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. received on Heparin gtt at 400units/hr. PTT this am was 104.\n Action:\n Heparin gtt held for OR and increased PTT. Restarted at 300units/hr.\n Response:\n PTT sent at 1500.\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355386, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. On floor she developed angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt. received on 1.5mcg/kg/min Nitro gtt. BP was 150\ns to 180\n systolic.\n Action:\n Pt. given PO antihypertensive regimen which was held yesterday HD\n and somnolence. Nifedepine dose increased to 120 daily.\n Response:\n Nitro gtt able to be weaned off. BP currently 100\ns to 110\ns systolic.\n Plan:\n Cont regular PO BP med regimen. Monitor BP and hemodynamics.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. received on Heparin gtt at 400units/hr. PTT this am was 104.\n Action:\n Heparin gtt held for OR. Restarted at 300units/hr for increased PTT..\n Response:\n PTT sent at 1500 was 99. Heparin gtt left\n Plan:\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2141-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355076, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:08 AM\n -per transplant PD cath to come out Thurs\n needs pre-op labs, stop\n heparin on wed night, NPO after midnight\n -HD today\n -Echo: ? ASD septum secundum, LVH - > nl function, mild aortic regurg,\n small circumferential pericardial effusion, no tamponade, mild\n pulmonary systolic hypertension\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 87 (75 - 109) bpm\n BP: 162/81(100) {122/67(80) - 172/116(131)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 803 mL\n 313 mL\n PO:\n 460 mL\n 200 mL\n TF:\n IVF:\n 343 mL\n 113 mL\n Blood products:\n Total out:\n 750 mL\n 250 mL\n Urine:\n 750 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191\n 8.7\n 90\n 5.8\n 22\n 4.8\n 38\n 106\n 139\n 26.7\n 3.8\n [image002.jpg]\n Other labs: PT / PTT / INR:15.6/105.1/1.4\n Rheum labs: dsDNA: pends, CRP: 4.5, C3: 68, C4: 19, Sed: 21\n Assessment and Plan\n 24 year old lady with SLE, ESRD on HD and malignant hypertension\n presents with abdominal pain and headache consistent with her usual\n hypertensive urgency and was found to be in hypertensive urgency in\n ED.\n .\n 1. Hypertensive Urgency: BP elevated on arrival to 253/170 in ED. No\n significant improvement to 10 IV hydral and max dose of labetolol drip\n per ED signout. Currently on nicardipine drip. Patient has known\n malignant hypertension of unclear etiology. Has known ESRD/HD due to\n SLE. Patient underwent hemodialysis yesterday. History and exam not\n consistent with infection or ischemia. Likely has an anxiety component\n precipitating hypertension.\n - will cont nicardipine gtt for BP goal of < 180/100\n - continue PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine\n 90mg PO qday, Clonidine\n - nephrology consulted\n HD on Tuesday, cont BP meds, unlikely that pt\n is fluid overloaded\n - aliskiren dose verified\n - BCx with no growth as of \n - will send for UA/Cx\n epi\ns with bacteria, neg WBC, LE and Nitr\n .\n 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT\n scan which did not show source of abdominal pain. Lipase near recent\n baseline of low 70s.\n - transplant surgery to remove PD cath Thrusday \n - cont PO dilaudid prn home dose\n - pt states abd pain at baseline \n .\n 3. ESRD: HD yesterday. On T/Th/Sat schedule. Pt currently undergoing HD\n however still has PD line.\n - dialyzed \n .\n 4. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last\n admission for supratherapeutic INR. Admitted on subtherpeutic INR of\n 1.2\n - heparin gtt\n - started Coumadin 2mg PO qday\n d/c\nd in prep for OR Thursday,\n will stop heparin drip midnight before OR Thursday\n .\n 5. Anxiety: Likely contributing to medical problems. Pt recently saw\n psychiatrist who started her on Celexa.\n - continue Celexa 20mg PO qday\n - continue home lorazepam and clonazepam\n .\n 6. Anemia: currently at baseline. Likely related to ESRD.\n - continue to monitor\n .\n 7. SLE:\n - continue Prednisone 4mg PO qday\n .\n 8. Pericardial effusion:\n - noted in TTE in the past.\n .\n 9. HOCM:\n - will need to careful not to reduce too much after load\n - will attemp to rate control\n .\n 10. FEN: renal diet, replete lytes PRN\n .\n 11. Prophylaxis: Heparin sc till INR is therapeutic, PPI\n .\n 12. Code Status: FULL\n .\n 13. Dispo: ICU\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 05:00 AM\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355077, "text": "24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her PO dose of Labetalol (800mg) but\n hydralazine PO dose held secondary SBP 110-120. MICU team aware, ? if\n pt is taking meds at home. Pt had repeat ECHO to eval for\n pericardial effusion seen on ECHO from . Renal into see pt. HD\n today (Tues ) and plan for removal of PD cath prior to discharge.\n Pt was difficult to arouse yesterday secondary to lethargy, today pt\n sleeping intermittently w/ CPAP when asleep.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt normotensive today today, NBPs 110s-120s systolic, MAPs 70s-80s. Pt\n denies HA today.\n Action:\n Admin PO BP meds: labetolol, hydralazine, nicardipine. No indication\n for IV BP medication.\n Response:\n Pt remains free from hypertensive crisis and subsequent s/s.\n Plan:\n Cont to monitor closely, admin meds, encourage cont complaince\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n BUN 40, Cre 6.2 at at 1340 today. HD cath to R groin intact. PD cath\n in place at L abdomen. Pt voided 200 ml today before going for HD.\n Action:\n Pt receiving HD now. PD on hold until condition further stabilized.\n Response:\n Pt would like to cont PD in the future as opposed to HD.\n Plan:\n Remove present PD cath on , pt will be NPO at MN , hold\n coumadin starting today. Cont w/ HD for now.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o intermittent abdominal pain today in general area of PD cath\n placement, consistent w/ previous complaints.\n Action:\n Dilaudid 4 mg x 1 given.\n Response:\n Pt stated relief from abd pain.\n Plan:\n Cont to assess. Remove PD cath on Thurs.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Hx of coagulapathic state d/t chronic SLE. Heparin gtt 850 units/hr.\n Action:\n PTT therapeutic today: 90.8 and 88.\n Response:\n No change in heparin dose.\n Plan:\n Cont to monitor.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 47.7 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions: No Additional Precautions\n PMH: Anemia, HEMO or PD, Renal Failure\n CV-PMH: Hypertension\n Additional history: OSA, systemic lupus erythematous diagnosed ,\n ESRD/CKD diagnosed refusing HD as of and PD catheter\n placement , malignant hypertension, hypertensive crisis with\n seizures, thrombocytopenia, SVC thrombosis, staph bacteremia and HD\n line infection and , s/p ex-lap\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:132\n D:65\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Bipap mask\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 739 mL\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 01:40 PM\n Potassium:\n 5.0 mEq/L\n 01:40 PM\n Chloride:\n 103 mEq/L\n 01:40 PM\n CO2:\n 23 mEq/L\n 01:40 PM\n BUN:\n 40 mg/dL\n 01:40 PM\n Creatinine:\n 6.2 mg/dL\n 01:40 PM\n Glucose:\n 104 mg/dL\n 01:40 PM\n Hematocrit:\n 26.7 %\n 06:45 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: cell phone, purse\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 712\n Date & time of Transfer: 1530\n" }, { "category": "Physician ", "chartdate": "2141-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355078, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:08 AM\n -per transplant PD cath to come out Thurs\n needs pre-op labs, stop\n heparin on wed night, NPO after midnight\n -HD today\n -Echo: ? ASD septum secundum, LVH - > nl function, mild aortic regurg,\n small circumferential pericardial effusion, no tamponade, mild\n pulmonary systolic hypertension\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 87 (75 - 109) bpm\n BP: 162/81(100) {122/67(80) - 172/116(131)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 803 mL\n 313 mL\n PO:\n 460 mL\n 200 mL\n TF:\n IVF:\n 343 mL\n 113 mL\n Blood products:\n Total out:\n 750 mL\n 250 mL\n Urine:\n 750 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191\n 8.7\n 90\n 5.8\n 22\n 4.8\n 38\n 106\n 139\n 26.7\n 3.8\n [image002.jpg]\n Other labs: PT / PTT / INR:15.6/105.1/1.4\n Rheum labs: dsDNA: pends, CRP: 4.5, C3: 68, C4: 19, Sed: 21\n Assessment and Plan\n 24 year old lady with SLE, ESRD on HD and malignant hypertension\n presents with abdominal pain and headache consistent with her usual\n hypertensive urgency and was found to be in hypertensive urgency in\n ED.\n .\n 1. Hypertensive Urgency: BP elevated on arrival to 253/170 in ED. No\n significant improvement to 10 IV hydral and max dose of labetolol drip\n per ED signout. Currently on nicardipine drip. Patient has known\n malignant hypertension of unclear etiology. Has known ESRD/HD due to\n SLE. Patient underwent hemodialysis yesterday. History and exam not\n consistent with infection or ischemia. Likely has an anxiety component\n precipitating hypertension.\n - will cont nicardipine gtt for BP goal of < 180/100\n - continue PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine\n 90mg PO qday, Clonidine\n - nephrology consulted\n HD on Tuesday, cont BP meds, unlikely that pt\n is fluid overloaded\n - aliskiren dose verified\n will continue\n - BCx with no growth as of \n - will send for UA/Cx\n epi\ns with bacteria, neg WBC, LE and Nitr\n .\n 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT\n scan which did not show source of abdominal pain. Lipase near recent\n baseline of low 70s.\n - transplant surgery to remove PD cath Thrusday \n - cont PO dilaudid prn home dose\n - pt states abd pain at baseline \n .\n 3. ESRD: HD yesterday. On T/Th/Sat schedule. Pt currently undergoing HD\n however still has PD line.\n - dialyzed \n .\n 4. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last\n admission for supratherapeutic INR. Admitted on subtherpeutic INR of\n 1.2\n - heparin gtt\n - started Coumadin 2mg PO qday\n d/c\nd in prep for OR Thursday,\n will stop heparin drip midnight before OR Thursday\n .\n 5. Anxiety: Likely contributing to medical problems. Pt recently saw\n psychiatrist who started her on Celexa.\n - continue Celexa 20mg PO qday\n - continue home lorazepam and clonazepam\n .\n 6. Anemia: currently at baseline. Likely related to ESRD.\n - continue to monitor\n .\n 7. SLE:\n - continue Prednisone 4mg PO qday\n .\n 8. Pericardial effusion:\n - noted in TTE in the past.\n .\n 9. HOCM:\n - will be careful not to reduce too much after load\n - will attemp to rate control\n .\n 10. FEN: renal diet, replete lytes PRN\n .\n 11. Prophylaxis: Heparin sc till INR is therapeutic, PPI\n .\n 12. Code Status: FULL\n .\n 13. Dispo: ICU\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 05:00 AM\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2141-12-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 355281, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. This a.m. she presented with angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following, scoped nose this a.m.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt hypertensive to 200s/100s. after missing afternoon labetolol and\n hydralazine during HD. HD removed 1L.\n Action:\n Pt was unable to take PM PO BP meds as she was too somulent after\n receiving 4mg IV Ativan during MRI. Pt then received 20mg IV\n Hydralazine x5 without effect. Nitro gtt was then started at 1.0mcg/kg\n and weaned to 0.5mcg/kg.\n Response:\n BP now down to 150s/90s, pt now easily arousable and able to take PO\n meds.\n Plan:\n Cont regular PO BP meds, wean nitro gtt as tolerated.\n Problem\n \n Assessment:\n Pt very lethargic, only arousable to sternal rub and unable to stay\n awake to participate in conversation. This lasting about 3hrs after\n MRI.\n Action:\n Pt had received 4mg IV Ativan.\n Response:\n Pt now easily arousable to voice, and able to take POs. Pt does not\n remember being so sedated.\n Plan:\n Minimize sedating meds for emergency only.\n Airway obstruction, Central / Upper\n Assessment:\n Angio edema and facial swelling resolving. LS CTA, no wheezes. No\n difficulty breathing or swallowing.\n Action:\n Pt received Decadron, x2 doses and will get one more. Pt had MRI of\n head and neck to look for source of event.\n Response:\n Swelling improving. MRI negative.\n Plan:\n Cont last dose of Decadron.\n" }, { "category": "Physician ", "chartdate": "2141-12-22 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 355530, "text": "Chief Complaint: hypertensive urgency\n HPI:\n Ms. is a 24 year old woman with ESRD on HD, SLE, malignant HTN\n readmitted to the MICU for hypertension to 240s/120s today after taking\n usual PO BP meds. Please see the prior MICU admission notes and\n transfer note from primary medical team for full details. Briefly, the\n patient was originally admitted with hypertensive urgency on ;\n this was treated with a nicardipine drip and she was transitioned to\n her usual home medications and transferred to the medical floor on\n . She then had a question of angioedema on in setting of\n hypertension. MRV was performed which did not show any progression of\n clot. She was evaluated by the Rheumatology consult team due to ? of\n recurrent thrombotic events. Her PD catheter was removed on by\n the Transplant Surgery team. Her prior femoral catheter was\n malpositioned, so this was removed and a temporary femoral line was\n placed. She was maintained on a heparin gtt for her SVC syndrome.\n .\n This morning, the patient was noted to have BP up to 247/120 at 0800.\n Hypertension persisted throughout the morning with BPs 210s-240s\n systolic. HR during this time was in the 90s. She received a total of\n 60 mg IV hydralazine over the course of the morning as well as 0.1 mg\n PO clonidine. Due to persistent hypertension, she is now transferred to\n the ICU for further care.\n .\n On arrival to the ICU, the patient reports severe abdominal pain over\n the site of recently removed PD catheter. She denies any headache,\n nausea, vomiting, diarrhea, constipation, or lower extremity swelling.\n She reports bilateral calf cramping but no leg swelling. She denies any\n difficulty breathing or chest pain. She took her AM BP meds without\n difficulty. After my leaving the room, she fell asleep and did not\n require any pain medication or additional blood pressure medications.\n Her blood pressure decreased to 130s-140s/60s without further\n intervention. She was then called back out to the floor.\n .\n ROS: Denies headache, visual changes (left eye prosthesis),\n nausea/vomiting. Has some urine output. No dysuria. No\n numbness/tingling of arms or legs.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 700 units/hour\n Other ICU medications:\n Heparin Sodium - 06:16 PM\n Other medications:\n MEDICATIONS on transfer:\n Heparin IV Sliding Scale\n HydrALAzine 100 mg PO Q8H\n aliskerin 150 \n Labetalol 800 mg PO TID\n Acetaminophen 325 mg PO Q6H:PRN pain\n NIFEdipine CR 120 mg PO DAILY\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Citalopram Hydrobromide 20 mg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN\n Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED (0.1 mg/24hr patch added\n for total 0.4 mg/24hr)\n Pantoprazole 40 mg PO Q24H\n Clonazepam 0.5 mg PO BID\n PredniSONE 4 mg PO DAILY\n Docusate Sodium 100 mg PO BID\n Senna 1 TAB PO BID\n Gabapentin 300 mg PO Q48H\n * patient had not received pain medications this morning other than PO\n dilaudid\n Past medical history:\n Family history:\n Social History:\n (per OMR)\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting , Straight\n CPAP/ Pressure setting 7\n Noncontributory\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Constipation\n Genitourinary: No(t) Dysuria\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Daytime somnolence\n Flowsheet Data as of 10:54 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 85 (83 - 103) bpm\n BP: 123/71(83) {108/52(69) - 235/149(172)} mmHg\n RR: 15 (11 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,554 mL\n 36 mL\n PO:\n 1,200 mL\n TF:\n IVF:\n 354 mL\n 36 mL\n Blood products:\n Total out:\n 600 mL\n 0 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 954 mL\n 36 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n T: 98.7 BP: 235/140 HR: 103 RR: 14 02 sat:100% RA\n Gen: tearful, clutching abdomen, infrequently opening eyes, falls\n asleep after I leave the room\n HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM\n Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3\n Pulm: CTA b/l\n Abd: normal bowel sounds, midline scar well-healed, soft, nontender,\n prior PD site with dry dressing, patient with tenderness to palpation\n over prior PD cath site, no guarding/rebound\n Ext: no edema, no clubbing, WWP. R femoral HD in place\n Neuro: following commands, answers appropriately, motor strength,\n sensation is intact.\n Labs / Radiology\n 132 K/uL\n 8.3 g/dL\n 139 mg/dL\n 4.9 mg/dL\n 29 mg/dL\n 26 mEq/L\n 101 mEq/L\n 4.9 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n \n 2:33 A12/9/ 06:45 AM\n \n 10:20 P12/9/ 01:40 PM\n \n 1:20 P12/10/ 11:03 AM\n \n 11:50 P12/10/ 12:09 PM\n \n 1:20 A12/10/ 03:50 PM\n \n 7:20 P12/11/ 06:28 AM\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n 4.9\n TC02\n 25\n Glucose\n 90\n 104\n 100\n 119\n 139\n Other labs: PT / PTT / INR:14.5/36.8/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.8 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Imaging: MRV : Right subclavian vein and right brachiocephalic\n veins are patent. Right IJ not visualized in the neck, consistent with\n occlusion. Again seen is a large right external jugular vein which\n provides the major venous drainage of the neck. Left subclavian vein is\n patent and drains into numerous venous collaterals in the mediastinum\n due to left brachiocephalic vein occlusion. Left IJ is patent, but\n diminuitive.\n .\n CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild\n pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis,\n although developing pneumonia cannot be excluded. 3. No evidence of\n free intraperitoneal air.\n .\n TTE : The left atrium is moderately dilated. The estimated\n right atrial pressure is 0-5 mmHg. There is severe symmetric left\n ventricular hypertrophy. The left ventricular cavity is unusually\n small. Regional left ventricular wall motion is normal. Left\n ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler\n imaging suggests an increased left ventricular filling pressure\n (PCWP>18mmHg). There is a mild resting left ventricular outflow tract\n obstruction. A mid-cavitary gradient is identified with cavity\n obliteration during systole. Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion and no aortic stenosis.\n Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\n structurally normal. There is no mitral valve prolapse. Mild (1+)\n mitral regurgitation is seen. The tricuspid valve leaflets are mildly\n thickened. There is moderate pulmonary artery systolic hypertension.\n Significant pulmonic regurgitation is seen. The end-diastolic pulmonic\n regurgitation velocity is increased suggesting pulmonary artery\n diastolic hypertension. There is a small to moderate sized pericardial\n effusion. The effusion appears circumferential. There are no\n echocardiographic signs of tamponade. Echocardiographic signs of\n tamponade may be absent in the presence of elevated right sided\n pressures.\n Compared with the prior study (images reviewed) of , the\n pericardial effusion has increased in size with the most accumulation\n posterior to the LV.\n .\n CT abdomen/pelvis with contrast : 1. Moderate amount of free\n fluid in the pelvis is compatible with the patient's known peritoneal\n dialysis. Unchanged peritoneal enhancement. 2. Stable liver\n hemangioma.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD originally admitted with\n hypertensive urgency s/p transfer back to ICU with hypertensive\n urgency.\n .\n # Hypertension: Pt with extensive history of hypertension. On\n readmission to the MICU, the patient's hypertension resolved with\n letting her rest to 140s/60s without further intervention. She had\n received 60 mg IV hydralazine over the course of the morning but had\n not improved immediately after.\n -continue nifedipine, aliskerin, labetalol, hydralazine, and clonidine\n at current doses.\n - Appreciate renal recs\n - Plan for HD tomorrow\n .\n # Facial Swelling/Angioedema: Resolved. Likely patient developed\n functional SVC with fluid overload in the setting of known venous\n clots. However, can not r/o Aliskiren, but unlikely and renal agrees.\n No evidence acute SVC syndrome by MRV. Pt got prednisone 60mg, then\n decadron out of concern for angio edema in the MICU. Continue 4mg\n prednisone.\n - Heparin drip for goal PTT 60-80\n - cont to monitor\n - cont prednisone 4mg which her home dose\n .\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. Echo does not suggest worsening\n pericarditis.\n - restart prednisone at 4 mg PO daily\n .\n # Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter. PD was removed yesterday. I alerted transplant\n surgery about patient's abdominal pain but no peritoneal signs at\n present. In fact, though patient complained of pain, she fell asleep\n before any pain meds were given. She agreed to try toradol for pain\n this evening. Attempting to decrease opiates given and only use IV\n opiates if necessary.\n - toradol prn\n - can reinitiate PO dilaudid prn as patient requires\n .\n #ESRD: Renal following, plan for HD tomorrow. Pt will need new tunneled\n cath line which is planned for Monday at this time.\n - follow lytes, replete as indicated\n - Will discuss with renal regarding placement of HD line\n .\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n .\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -cont heparin heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n .\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, restart clonazepam 0.5mg \n .\n # OSA: CPAP for sleep with 7 pressure.\n -continue as inpatient\n .\n # FEN: replete lytes prn / regular diet\n .\n # PPX: PPI, heparin drip, bowel regimen\n .\n # ACCESS: PIV/ temp dialysis cath R fem\n .\n # CODE: FULL\n .\n # CONTACT: (mother) \n .\n # DISPO: back to floor given rapid improvement in blood pressures\n ICU Care\n Nutrition:\n Comments: regular diet once awake\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 01:30 PM\n Dialysis Catheter - 05:47 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2141-12-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355531, "text": "Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355532, "text": "24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355534, "text": "24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n H/O mulitple ICU admissions for hypertensive crisis, presented to ED\n with vomiting & abdominal pain similar to prior episodes. No response\n to labetalol, Nitro paste & iv Hydral. Labetalol drip changed to\n Nicardipine. Admitted to MICU for hypertensive urgency.\n ***Pt. readmitted to MICU (to floor 12/09pm) for angioedema. ENT\n examined pt. on floor prior to transfer - plan to w/u etiology -\n medication SE vs. SVC syndrome vs. other?\n ****Pt tranferred back to CC7 on eve of and transferred back to\n MICU 6 on for hypertension. On arrival to MICU, pt crying\n stating pain in abdomen and legs. Pt able to be calmed. Once she\n fell asleep, BP down to 130's without intervention\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Patient sleeping, SBP 110-120\n Action:\n Regular po antihypertensive given, patient states that as her BPis 110\n and she was concern to take her all po meds, MD talked to her\n and took all meds.\n Response:\n SBP 120/67\n Plan:\n Continue close monitoring of BP\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o pain abdominal pain\n Action:\n Iv ketorolac 30mg given for pain\n Response:\n Patient is comfortable and sleeping\n Plan:\n Continue to monitor for pain and no pain meds with sedation\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 47.7 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions: No Additional Precautions\n PMH: Anemia, HEMO or PD, Renal Failure, Seizures\n CV-PMH: Hypertension\n Additional history: OSA, systemic lupus erythematous diagnosed ,\n ESRD/CKD diagnosed refusing HD as of and PD catheter\n placement , malignant hypertension, hypertensive crisis with\n seizures, thrombocytopenia, SVC thrombosis, staph bacteremia and HD\n line infection and , s/p ex-lap\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:123\n D:71\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 38 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:28 AM\n Potassium:\n 4.9 mEq/L\n 06:28 AM\n Chloride:\n 101 mEq/L\n 06:28 AM\n CO2:\n 26 mEq/L\n 06:28 AM\n BUN:\n 29 mg/dL\n 06:28 AM\n Creatinine:\n 4.9 mg/dL\n 06:28 AM\n Glucose:\n 139 mg/dL\n 06:28 AM\n Hematocrit:\n 25.2 %\n 06:28 AM\n Finger Stick Glucose:\n 120\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC709\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355072, "text": "24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her PO dose of Labetalol (800mg) but\n hydralazine PO dose held secondary SBP 110-120. MICU team aware, ? if\n pt is taking meds at home. Pt had repeat ECHO to eval for\n pericardial effusion seen on ECHO from . Renal into see pt. HD\n today (Tues ) and plan for removal of PD cath prior to discharge.\n Pt was difficult to arouse yesterday secondary to lethargy, today pt\n sleeping intermittently w/ CPAP when asleep.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355073, "text": "24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her PO dose of Labetalol (800mg) but\n hydralazine PO dose held secondary SBP 110-120. MICU team aware, ? if\n pt is taking meds at home. Pt had repeat ECHO to eval for\n pericardial effusion seen on ECHO from . Renal into see pt. HD\n today (Tues ) and plan for removal of PD cath prior to discharge.\n Pt was difficult to arouse yesterday secondary to lethargy, today pt\n sleeping intermittently w/ CPAP when asleep.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt normotensive today today, NBPs 110s-120s systolic, MAPs 70s-80s. Pt\n denies HA today.\n Action:\n Admin PO BP meds: labetolol, hydralazine, nicardipine. No indication\n for IV BP medication.\n Response:\n Pt remains free from hypertensive crisis and subsequent s/s.\n Plan:\n Cont to monitor closely, admin meds, encourage cont complaince\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n BUN 40, Cre 6.2 at at 1340 today. HD cath to R groin intact. PD cath\n in place at L abdomen. Pt voided 200 ml today before going for HD.\n Action:\n Pt receiving HD now. PD on hold.\n Response:\n Pt would like to cont PD in the future as opposed to HD.\n Plan:\n Re\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2141-12-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 355267, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. This a.m. she presented with angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following, scoped nose this a.m.\n Airway obstruction, Central / Upper\n Assessment:\n Received pt. this a.m. with son sounds. No stridor noted,\n however obvious occlusive process noted in upper airways. Initially\n resp\ns were tachy and labored, with increased WOB. At this time, pt.\n was somnolent. Generalized facial swelling noted, especially\n periorbital and soft tissue of neck. Pt. complained of neck swelling\n and discomfort with breathing. Pt. also due for dialysis.\n Action:\n Nasal trumpet placed right nare. Close airway monitoring. Pt. given\n decadron and lasix given as noted. Anesthesia aware of case. ABG done\n due to continued somnolence. Pt. presently being dialyzed. Heparin\n gtt restarted this eve due to history of SVC syndrome (turned off by\n floor due to possible IR procedure.)\n Response:\n ABG stable without hypercarbia. Initially no change in snoring noted\n with trumpet in place. Some diuresis noted. Over the course of the\n day, resp. assessment has waxed and waned as evidenced by intermittent\n improvement of snoring/occlusion and pattern/overall wob. Since\n approximately 1600, resp\ns have been unlabored with minimal to no\n snoring. She continues to have an irregular breathing pattern\n intermittently. No stridor, no distress, no hypoxia noted.\n Plan:\n Continue close monitoring of airway and facial swelling. Pt. to\n receive 2 more doses of decadron. Cont. optimal positioning. ENT here\n at present to re-scope.\n Problem\n Decreased LOC\n Assessment:\n Pt. markedly lethargic/somnolent throughout day. At times, pt. will\n only open eyes to trapezius squeeze/deep pain. Pt. was partially\n incontinent of urine this afternoon.\n Action:\n Neuro checks done. Pt. given narcan this a.m. as she received 4mg\n dilaudid this a.m. ABG drawn.\n Response:\n No results from narcan noted. ABG normal. Pt. wide awake for approx.\n 45-60mins. After trumpet placed, the back to somnolent state. LOC\n waxes and wanes, but for the majority of the day she has remained\n somnolent.\n Plan:\n Ongoing reassessments. Continue attempts to stimulate pt. as\n appropriate.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n BP as high as 190\ns/110\n Action:\n IV hydralazine given x 2.\n Response:\n BP down to 160\ns/. With HD, BP down further to 140-150\n Plan:\n Continue to monitor and treat as indicated. Give antihypertensives\n when HD complete.\n ------ Protected Section ------\n Addendum to above plan\n pt. to have MRI tonight as early as to\n evaluate for SVC thrombus. If thrombus noted, plan to transport pt. to\n IR urgently.\n Pt. is presently awake since approx. 1840 and emotional/upset due to\n being NPO. Only fulls ordered for now. Pt. threatening to sign out\n AMA despite nursing and MD (re)education.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:55 ------\n" }, { "category": "General", "chartdate": "2141-12-21 00:00:00.000", "description": "Generic Note", "row_id": 355274, "text": "TITLE: Pt remains on cpap of 7 cmH20. Pt takes off mask every now and\n then. Has increased snoring when off.\n" }, { "category": "Physician ", "chartdate": "2141-12-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 355069, "text": "Chief Complaint: Hypertensive urgency\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 11:08 AM\n CALLED OUT\n History obtained from Medical records\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Neurologic: No(t) Headache, Sleeping much of day\n Signs or concerns for abuse : No\n Flowsheet Data as of 02:10 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.5\nC (97.7\n HR: 95 (75 - 99) bpm\n BP: 132/65(83) {114/51(67) - 172/116(131)} mmHg\n RR: 15 (11 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 803 mL\n 724 mL\n PO:\n 460 mL\n 500 mL\n TF:\n IVF:\n 343 mL\n 224 mL\n Blood products:\n Total out:\n 750 mL\n 450 mL\n Urine:\n 750 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 274 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 98%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: enucleated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (Murmur: Systolic), II/VI SEM\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, PD catheter\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 191 K/uL\n 90 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 4.8 mEq/L\n 38 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.7 %\n 3.8 K/uL\n [image002.jpg]\n 06:45 AM\n WBC\n 3.8\n Hct\n 26.7\n Plt\n 191\n Cr\n 5.8\n Glucose\n 90\n Other labs: PT / PTT / INR:15.4/90.8/1.4, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n BP has come down almost excessively on usual meds. She remains labile\n but I suspect she has had trouble complying with her regime at home\n given the ease with which we have achieved control. I do worry we may\n overdose her if we escalate her regime. Seen by Rheum w/o no clear\n recommendations as they think SLE is inactive. Plan for PD catheter\n removal on Thurs.\n ICU Care\n Nutrition:\n Comments: full diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 05:00 AM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354996, "text": "24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n .\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her Po dose of Labetalol(800mg) but\n hydralazine po dose held secondary SBP 110-120. Team aware, ? if pt is\n taking meds at home. Pt has repeat ECHO today to eval for pericardial\n effusion seen on ECHO from . Renal into see pt plan for HD Tues\n and removal of PD cath prior to discharge. Pt has been difficult to\n arouse today secondary to lethargy, sleeping throughout day w/ CPAP\n on.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Hypertensive with maps in 110-120 when close to next dosing of\n medication. No c/o headache, dizziness or vision difficulties.\n Action:\n Cont. prescribed medication, monitor q 30 min\n Response:\n Maps current 110, pt asleep tol. Po meds well\n Plan:\n Cont. medication regime\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Hd cath right groin intact. Urine output 450 this shift.\n Action:\n Cont. to follow urine out. Plan to move out of unit today. Follow up\n HD per plan\n Response:\n Pt would like to return doing PD at home soon. Understands reasoning\n for need for HD\n Plan:\n HD as scheduled\n Nausea / vomiting\n Assessment:\n Woke with c/o nausea . little appetite, ate soda crackers and peanut\n butter. No distress, falls asleep easily. Pt with candy and assorted\n foods to snack on at bedside\n Action:\n Order obtained for zofran. given\n Response:\n Pt wakes 3 hrs later with no c/o nausea, asking for but ate\n little, asked for crackers/pb.\n Plan:\n Follow food intake, encourage pt. to snack on low sodium foods, small\n amts freq.\n Pain control (acute pain, chronic pain)\n Assessment:\n Somnolent, sleeping most of night. Woke with c/o pain in abd. NO\n Distress noted. Did not appear in pain , vs show no changes, pain\n non-specific. Asleep and snoring within 5 min of request specifically\n for Dilaudid IV.\n Action:\n No pain meds given. discussed with pt. her response to pain request.\n Response:\n Pt. accepts decision to hold on meds while somnolent and sleeping\n easily. Asked to reeval pain and attempt to change position and take\n snack . fell back to sleep\n Plan:\n Obstructive sleep apnea (OSA)\n Assessment:\n Snoring with sats at 100%, no apnea noted. Pt. reluctant and deferred\n wearing nasal bipap although she knows of her need.\n Action:\n Upright at 30 degrees and turned to side.\n Response:\n No noted apnea or drop of sats. Slept for 3-4 hrs before wakening.\n Falls asleep easily\n Plan:\n Cont. to offer nasal bipap and educate on need to use reinforcedment\n needed.\n" }, { "category": "Nursing", "chartdate": "2141-12-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 355001, "text": "24 year old lady with ESRD on HD, SLE, malignant HTN presents with\n headache and abdominal pain beginning this morning. Patient had her\n hemodialysis day before yesterday. She has had multiple admissions to\n with hypertensive urgency with symptoms of headache and abdominal\n pain. Has had extensive work-up for abdominal pain including ex-lap on\n which was negative. Patient states that her headache and\n abdominal pain are similar in characteristics to her previous\n admission. Patient denies any fever, chills, nightsweats, chest pain,\n shortness of breath, abdominal pain, nausea, vomitting, diarrhea,\n constipation, blood in stool, dysuria, hematuria, change in vision,\n hearing, weakness or numbness.\n .\n In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was\n initially given 10mg IV Labetalol once and then started on drip at\n 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch\n nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea.\n Her BP elevated as high as 270/174 and his labetolol was switched to\n nicardipine 1mg/kg/min.\n Nicardipine gtt was D/C\nd at 6:55am and pt was given PO dose of\n narcardipine XL. Pt was given her Po dose of Labetalol(800mg) but\n hydralazine po dose held secondary SBP 110-120. Team aware, ? if pt is\n taking meds at home. Pt has repeat ECHO today to eval for pericardial\n effusion seen on ECHO from . Renal into see pt plan for HD Tues\n and removal of PD cath prior to discharge. Pt has been difficult to\n arouse today secondary to lethargy, sleeping throughout day w/ CPAP\n on.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Hypertensive with maps in 110-120 when close to next dosing of\n medication. No c/o headache, dizziness or vision difficulties.\n Action:\n Cont. prescribed medication, monitor q 30 min\n Response:\n Maps current 110, pt asleep tol. Po meds well\n Plan:\n Cont. medication regime\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Hd cath right groin intact. Urine output 450 this shift.\n Action:\n Cont. to follow urine out. Plan to move out of unit today. Follow up\n HD per plan\n Response:\n Pt would like to return doing PD at home soon. Understands reasoning\n for need for HD\n Plan:\n HD as scheduled\n Nausea / vomiting\n Assessment:\n Woke with c/o nausea . little appetite, ate soda crackers and peanut\n butter. No distress, falls asleep easily. Pt with candy and assorted\n foods to snack on at bedside\n Action:\n Order obtained for zofran. given\n Response:\n Pt wakes 3 hrs later with no c/o nausea, asking for but ate\n little, asked for crackers/pb.\n Plan:\n Follow food intake, encourage pt. to snack on low sodium foods, small\n amts freq.\n Pain control (acute pain, chronic pain)\n Assessment:\n Somnolent, sleeping most of night. Woke with c/o pain in abd. NO\n Distress noted. Did not appear in pain , vs show no changes, pain\n non-specific. Asleep and snoring within 5 min of request specifically\n for Dilaudid IV.\n Action:\n pain meds given. discussed with pt. her response to pain request. One\n time po dose\n Response:\n Pt. accepts decision to hold on meds while somnolent and sleeping\n easily. Asked to reeval pain and attempt to change position and take\n snack . fell back to sleep. Early am requested dilaudid for abd\n pain. No distress noted, had just eaten, no change in VS\n Plan:\n Reeval pain medication used and dc if possible\n Obstructive sleep apnea (OSA)\n Assessment:\n Snoring with sats at 100%, no apnea noted. Pt. reluctant and deferred\n wearing nasal bipap although she knows of her need.\n Action:\n Upright at 30 degrees and turned to side.\n Response:\n No noted apnea or drop of sats. Slept for 3-4 hrs before wakening.\n Falls asleep easily\n Plan:\n Cont. to offer nasal bipap and educate on need to use reinforcedment\n needed.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n On heparin gtt at 1000units hr ., no other sites of bleeding\n Action:\n Ptt q 6 hr.\n Response:\n Adjusted 850 units\n Plan:\n Repeat labs at 0600 adjust heparin gtt according to protocol ordered,\n transition to coumadin asap, monitor for signs of bleeding.\n" }, { "category": "Physician ", "chartdate": "2141-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355006, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:08 AM\n PD cath to come out Th per transplant\n -HD tomorrow\n -Echo: ? ASD septum secundum\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 87 (75 - 109) bpm\n BP: 162/81(100) {122/67(80) - 172/116(131)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 803 mL\n 313 mL\n PO:\n 460 mL\n 200 mL\n TF:\n IVF:\n 343 mL\n 113 mL\n Blood products:\n Total out:\n 750 mL\n 250 mL\n Urine:\n 750 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:15.6/105.1/1.4\n Assessment and Plan\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 05:00 AM\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-12-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355008, "text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:08 AM\n PD cath to come out Th per transplant\n -HD tomorrow\n -Echo: ? ASD septum secundum\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.4\nC (97.6\n HR: 87 (75 - 109) bpm\n BP: 162/81(100) {122/67(80) - 172/116(131)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 803 mL\n 313 mL\n PO:\n 460 mL\n 200 mL\n TF:\n IVF:\n 343 mL\n 113 mL\n Blood products:\n Total out:\n 750 mL\n 250 mL\n Urine:\n 750 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: PT / PTT / INR:15.6/105.1/1.4\n Assessment and Plan\n 24 year old lady with SLE, ESRD on HD and malignant hypertension\n presents with abdominal pain and headache consistent with her usual\n hypertensive urgency and was found to be in hypertensive urgency in\n ED.\n .\n 1. Hypertensive Urgency: BP elevated on arrival to 253/170 in ED. No\n significant improvement to 10 IV hydral and max dose of labetolol drip\n per ED signout. Currently on nicardipine drip. Patient has known\n malignant hypertension of unclear etiology. Has known ESRD/HD due to\n SLE. Patient underwent hemodialysis yesterday. Hisory and exam not\n consistent with infection or ischemia. Likely has an anxiety component\n precipitating hypertension.\n - will cont nicardipine gtt for BP goal of < 180/100\n - continue PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine\n 90mg PO qday, Clonidine\n - will consult nephrology in AM\n - verify aliskiren with nephrology team in AM\n - follow up BCx sent from ED\n - will send for UA/Cx\n .\n 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT\n scan which did not show source of abdominal pain. Lipase near recent\n baseline of low 70s.\n - transplant surgery was suppose to remove the PD line on Thursday\n - cont PO dilaudid prn home dose\n .\n 3. ESRD: HD yesterday. On T/Th/Sat schedule. Pt currently undergoing HD\n however still has PD line.\n - consult renal team in AM\n .\n 4. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last\n admission for supratherapeutic INR. Admitted on subtherpeutic INR of\n 1.2\n - consider heparin gtt bridge to therapeutic INR if her BP normalizes\n - will start Coumadin 2mg PO qday\n .\n 5. Anxiety: Likely contributing to medical problems. Pt recently saw\n psychiatrist who started her on Celexa.\n - continue Celexa 20mg PO qday\n - continue home lorazepam and clonazepam\n .\n 6. Anemia: currently at baseline. Likely related to ESRD.\n - continue to monitor\n .\n 7. SLE:\n - continue Prednisone 4mg PO qday\n .\n 8. Pericardial effusion:\n - noted in TTE in the past.\n .\n 9. HOCM:\n - will need to careful not to reduce too much after load\n - will attemp to rate control\n .\n 10. FEN: renal diet, replete lytes PRN\n .\n 11. Prophylaxis: Heparin sc till INR is therapeutic, PPI\n .\n 12. Code Status: FULL\n .\n 13. Dispo: ICU\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 05:00 AM\n 20 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355332, "text": "Chief Complaint: facial swelling\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:00 AM\n DIALYSIS CATHETER - START 10:00 AM\n PD cath noted left abd.\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n MRI of head and neck\n Very upset pre-MRV that was not getting fed, bargained PBJ vs\n leaving AMA\n Required ativan for MRV x2 2mg doses, then was sleepy but breathing\n comfortably thereafter\n MRV done overnight: per fellow, no signs of new obstruction, R EJ is\n main venous drainage as it has been, collaterals and blockages remain\n essentially similar to \n NPO p MN for peritoneal dialysis catheter removal per transplant\n surgery\n D/c decadron\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 400 units/hour\n Nitroglycerin - 1.5 mcg/Kg/min\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 03:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 99 (88 - 107) bpm\n BP: 178/117(130) {146/82(100) - 220/139(157)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 320 mL\n 302 mL\n PO:\n 240 mL\n 240 mL\n TF:\n IVF:\n 80 mL\n 62 mL\n Blood products:\n Total out:\n 2,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -98 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: 7.36/42/158/22/-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, slightly more\n by PD catheter\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): *3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 132 K/uL\n 8.3 g/dL\n 119 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 5.9 mEq/L\n 34 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n 11:03 AM\n 12:09 PM\n 03:50 PM\n 06:28 AM\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n TCO2\n 25\n Glucose\n 90\n 104\n 100\n 119\n Other labs: PT / PTT / INR:14.9/43.0/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL\n Imaging: \n SVC is patent.\n Right subclavian vein and right brachiocephalic veins are patent. Right\n IJ not visualized in the neck, consistent with occlusion. Again seen is\n a large right external jugular vein which provides the major venous\n drainage of the neck.\n Left subclavian vein is patent and drains into numerous venous\n collaterals in the mediastinum due to left brachiocephalic vein\n occlusion. Left IJ is patent, but diminuitive.\n Assessment and Plan\n AIRWAY OBSTRUCTION, CENTRAL / UPPER\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)\n ANEMIA, CHRONIC\n SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n NAUSEA / VOMITING\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control: Comments: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments: not intubated\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355335, "text": "Chief Complaint: facial swelling\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:00 AM\n DIALYSIS CATHETER - START 10:00 AM\n PD cath noted left abd.\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n MRI of head and neck\n Very upset pre-MRV that was not getting fed, bargained PBJ vs\n leaving AMA\n Required ativan for MRV x2 2mg doses, then was sleepy but breathing\n comfortably thereafter\n MRV done overnight: per fellow, no signs of new obstruction, R EJ is\n main venous drainage as it has been, collaterals and blockages remain\n essentially similar to \n NPO p MN for peritoneal dialysis catheter removal per transplant\n surgery\n D/c decadron\n D/c nasal trumpet\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 400 units/hour\n Nitroglycerin - 1.5 mcg/Kg/min\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 03:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 99 (88 - 107) bpm\n BP: 178/117(130) {146/82(100) - 220/139(157)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 320 mL\n 302 mL\n PO:\n 240 mL\n 240 mL\n TF:\n IVF:\n 80 mL\n 62 mL\n Blood products:\n Total out:\n 2,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -98 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: 7.36/42/158/22/-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, slightly more\n by PD catheter\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): *3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 132 K/uL\n 8.3 g/dL\n 119 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 5.9 mEq/L\n 34 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n 11:03 AM\n 12:09 PM\n 03:50 PM\n 06:28 AM\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n TCO2\n 25\n Glucose\n 90\n 104\n 100\n 119\n Other labs: PT / PTT / INR:14.9/43.0/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL\n Imaging: \n SVC is patent.\n Right subclavian vein and right brachiocephalic veins are patent. Right\n IJ not visualized in the neck, consistent with occlusion. Again seen is\n a large right external jugular vein which provides the major venous\n drainage of the neck.\n Left subclavian vein is patent and drains into numerous venous\n collaterals in the mediastinum due to left brachiocephalic vein\n occlusion. Left IJ is patent, but diminuitive.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n # Facial Swelling/Angioedema: Resolved. Perhaps given patient\ns known\n venous blockages in neck patient develops functional SVC with fluid\n overload. Do no feel was med rxn to Aliskiren and no evidence acute SVC\n syndrome by MRV. On admission to MICU got prednisone 60mg, then started\n on decadron out of concern for angio edema. Patient\n - Stop decadron, restart prednisone 4mg which her home dose\n - Heparin drip for goal PTT 60-80\n - Stop benadryl and H2 blocker\n - D/C Nasal trumpet\n - CPAP for sleep\n # Somulence: Patient rousable and oriented. Likely med effect. ABG w/o\n hypercarbia\n - monitor closely\n - cont at decreased Dilaudid dose\n # Hypertension: initially 235/170 in ED, but improved with nicardipine\n drip which was discontinued during first unit stay. No clear\n precipitating event. No hx of recent drug use. On admit to the floor\n BPs are stable and the patient is aysmptomatic. Nephrology following.\n Plan to continue PO anti-hypertensives.\n - Consider restarting Aliskiren in consultation with renal\n -continue labetalol, hydralazine, nifedipine, clonidine at current\n doses. Have room to increase nifedipine if needed.\n -dialysis T, Thrs, Sat, plan for replacement of HD catheter on Thurs\n with temp line\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. No evidence of blood or urine\n infection by culture that may have led to an acute flare. Pneumonia\n unlikely at this point as patient does not have fever or leukocytosis.\n Echo does not suggest worsening pericarditis.\n - restart prednisone at 4 mg PO daily\n #Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter.\n -PD catheter to be removed on TODAY.\n -cont to treat pain\n #ESRD: HD today and scheduled for Thurs as well. Renal following.\n -follow lytes, replete as indicated\n - schedule NEW tunneled HD line, patient currently has temp\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, hold clonazepam\n # OSA: CPAP for sleep with 7 pressure.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: Comments: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n change to PPI\n VAP:\n Comments: not intubated\n Communication: discussed in interdisciplinary rounds, patient, mother\n status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 355337, "text": "Chief Complaint: Angioedmea and labile BP\n HPI:\n 24 year old woman with SLE, ESRD on HD, history of SVC syndrome\n original admitted for hypertensive crisis transferred for facial\n swelling and concern for angioedema. Getting Decadron, Benadryl.\n Currently on renin inhibitor, history of angioedmea to ACE.\n Patient admitted from: \n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n SLE - on prednisone 4mg at baseline\n SVC Syndrome - On coumadin at baseline, subtherapeutic at presentation.\n Neg cardiolipn, B2 and lupus anticoagulant\n HOCM - noted on Echo \n OSA - Home CPAP\n As per resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: As per resident note\n Review of systems:\n Flowsheet Data as of 10:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 102 (95 - 103) bpm\n BP: 161/100(114) {119/65(80) - 161/100(114)} mmHg\n RR: 23 (15 - 23) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n Total In:\n 741 mL\n PO:\n 500 mL\n TF:\n IVF:\n 241 mL\n Blood products:\n Total out:\n 450 mL\n 0 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 291 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 191 K/uL\n 26.7 %\n 8.7 g/dL\n 104 mg/dL\n 6.2 mg/dL\n 40 mg/dL\n 23 mEq/L\n 103 mEq/L\n 5.0 mEq/L\n 136 mEq/L\n 3.8 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n WBC\n 3.8\n Hct\n 26.7\n Plt\n 191\n Cr\n 5.8\n 6.2\n Glucose\n 90\n 104\n Other labs: PT / PTT / INR:15.3/88.0/1.4, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n ##Agioedema -\n ? secondary to med effect. Last dose of aliskiren at 8am. Currenty on\n Decadron + Bendaryl+ famotidine. Monitoring airway.\n ##Airway\n Risk for unstable airway.\n Baseline OSA vs contribution from Angioedema. Narcan now to asses how\n much of upper airway obstruction is OSA vs new angioedema. did get\n dilaudid on the floor prior to transfer\n ##SVC syndrome -\n Subtherapeutic INR at presentation. On Heparin drip now\n ##Renal Failure\n Needs HD. Going to IR for temp HD line with anesthsia then to get HD.\n ##SLE\n Baseline prednisone 4mg. On Decadron now.\n Further plans as per resident note.\n ICU Care\n Nutrition:\n Comments: NPO now somnolence.\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 10:01 AM\n Comments:\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 355340, "text": "Chief Complaint: facial swelling\n HPI:\n admitted to MICU with facial swelling, ddx angioedema vs SVC syndrome.\n s/p MRV with no evidence of new SVC clot. Angioedema r/o. Remains in\n MICu to establish HD access (prior ESRD, HD line pulled out\n inadvertantly on the floor)\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:00 AM\n DIALYSIS CATHETER - START 10:00 AM\n PD cath noted left abd.\n MAGNETIC RESONANCE IMAGING - At 09:00 PM\n MRI of head and neck\n Old peritoneal Dialysis catheter removed.\n decadron Dc'd\n Dialyes via temp fem line\n Allergies:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 400 units/hour\n Nitroglycerin - 1.5 mcg/Kg/min\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 03:06 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 99 (88 - 107) bpm\n BP: 178/117(130) {146/82(100) - 220/139(157)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 320 mL\n 314 mL\n PO:\n 240 mL\n 240 mL\n TF:\n IVF:\n 80 mL\n 74 mL\n Blood products:\n Total out:\n 2,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -86 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: 7.36/42/158/22/-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: decreased facial edema\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Percussion: Resonant : ), (Breath Sounds: Clear :\n )\n Abdominal: Soft, Tender: mildly diffusely\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 132 K/uL\n 119 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 5.9 mEq/L\n 34 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n 11:03 AM\n 12:09 PM\n 03:50 PM\n 06:28 AM\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n TCO2\n 25\n Glucose\n 90\n 104\n 100\n 119\n Other labs: PT / PTT / INR:14.9/43.0/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL\n Assessment and Plan\n Facial Edema -\n Acute SVC syndrome now likely. Ddx fluid overload vs agioedema,\n though no really likely meds. Now off decadron, benadryl and H2\n blocker. No decision on restarting renin inhibitor.\n Will restart heaprin drip now that PD catheter removed.\n Htn -\n Given time course, angioedmea still a possibility. Will increase\n nifedipine today. DC nitro drip.\n somnolence/altered mental status - now resolved.\n Renal failure -\n Plans as per renal for placement of permanent HD access.\n Further plans as per resident notes.\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor when off nitro drip\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 355341, "text": "Chief Complaint: facial swelling\n 24 Hour Events:\n Temporary Femoral Dialysis Catheter inserted yesterday and Old\n tunnelled line that had cuff out was removed\n MRV neck/chest : no new obstructions, stable old clot\n Peritoneal dialysis catheter removed by transplant surgery\n D/c decadron\n D/c nasal trumpet\n Started nitro drip for hypertension, given patient off Aliskerin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 400 units/hour\n Nitroglycerin - 1.5 mcg/Kg/min\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 03:06 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 99 (88 - 107) bpm\n BP: 178/117(130) {146/82(100) - 220/139(157)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 320 mL\n 302 mL\n PO:\n 240 mL\n 240 mL\n TF:\n IVF:\n 80 mL\n 62 mL\n Blood products:\n Total out:\n 2,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -98 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: 7.36/42/158/22/-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, slightly more\n by PD catheter removal site\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): *3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 132 K/uL\n 8.3 g/dL\n 119 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 5.9 mEq/L\n 34 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n 11:03 AM\n 12:09 PM\n 03:50 PM\n 06:28 AM\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n TCO2\n 25\n Glucose\n 90\n 104\n 100\n 119\n Other labs: PT / PTT / INR:14.9/43.0/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL\n Imaging:\n MRV \n SVC is patent.\n Right subclavian vein and right brachiocephalic veins are patent. Right\n IJ not visualized in the neck, consistent with occlusion. Again seen is\n a large right external jugular vein which provides the major venous\n drainage of the neck.\n Left subclavian vein is patent and drains into numerous venous\n collaterals in the mediastinum due to left brachiocephalic vein\n occlusion. Left IJ is patent, but diminuitive.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n # Facial Swelling/Angioedema: Resolved. Perhaps given patient\ns known\n venous blockages in neck patient develops functional SVC with fluid\n overload. Can not r/o due to Aliskiren. No evidence acute SVC syndrome\n by MRV. On admission to MICU got prednisone 60mg, then started on\n decadron out of concern for angio edema. Patient\n - Stop decadron, restart prednisone 4mg which her home dose\n - Heparin drip for goal PTT 60-80\n - Stop benadryl and H2 blocker\n - D/C Nasal trumpet\n - CPAP for sleep\n # Somulence: Patient rousable and oriented. Likely med effect. ABG w/o\n hypercarbia. Avoid benadryl\n - monitor closely\n - cont at decreased Dilaudid dose\n # Hypertension: initially 235/170 in ED, but improved with nicardipine\n drip which was discontinued during first unit stay. No clear\n precipitating event. No hx of recent drug use. On admit to the floor\n BPs are stable and the patient is aysmptomatic. Nephrology following.\n Plan to continue PO anti-hypertensives.\n - Concerned about restarting Aliskiren\n - Increase nifedipine for better blood pressure control\n - D/C nitro drip if SBP <160\n -continue labetalol, hydralazine, clonidine at current doses.\n -dialysis T, Thrs, Sat, plan for replacement of HD catheter on Thurs\n with temp line\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. No evidence of blood or urine\n infection by culture that may have led to an acute flare. Pneumonia\n unlikely at this point as patient does not have fever or leukocytosis.\n Echo does not suggest worsening pericarditis.\n - restart prednisone at 4 mg PO daily\n #Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter.\n -PD catheter to be removed on TODAY.\n -cont to treat pain\n #ESRD: HD today and scheduled for Thurs as well. Renal following.\n -follow lytes, replete as indicated\n - schedule NEW tunneled HD line, patient currently has temp per renal\n -speak with renal about repeat dialysis today vs treating hyperkalemia\n with lasix\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -restart heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, restart clonazepam 0.5mg \n # OSA: CPAP for sleep with 7 pressure.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: Comments: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: Heparin Drip\n Stress ulcer: Stop H2, no indication PPI\n VAP:\n Comments: not intubated\n Communication: discussed in interdisciplinary rounds, patient, mother\n status: Full code\n Disposition:Transfer to floor once BPs stable off nitro drip\n" }, { "category": "Physician ", "chartdate": "2141-12-20 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 355226, "text": "Chief Complaint: Angioedema\n HPI:\n 24 year old female with ESRD on HD, SLE, malignant HTN, history of SVC\n syndrome transferring from floor team due to evidence of angioedema by\n ENT and increasing difficulty with blood pressure control. The patient\n reports she feels her face is more swollen which is confirmed by her\n mother on the floor. The patient was give lasix IV as she has been\n unable to have any negative filtration with HD. The patient was\n started on decadron 10mg q8hr *3, famotidine, diphenhydramine for the\n edema. Her tekturna was discontinued it is a renin blocker and while\n she has been tolerating this medication well she has a history of ACE-i\n angioedema.\n She denies difficulty with her breathing at this time, but is very\n somnulent. Of note she received benadryl 25 mg iv, dilaudid 4mg po and\n klonapin 0.5 mg PO for pain and concern for angio edema prior to\n arrival in MICU. On arrival to the MICU her vitas were stable and\n satting 100% on face mask.\n Allergies:\n Penicillins Rash;\n Percocet itching;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 02:05 PM\n Other medications:\n Medications at Home:\n Aliskiren 150 mg \n Clonidine 0.3mg / 24 hr patch weekly qwednesday\n Hydralazine 100mg PO q8H\n Labetalol 800mg PO TID\n Hydromorphone 4mg PO q4H PRN\n Nifedipine ER 90mg PO qday\n Prednisone 4mg PO qday\n Lorazepam 0.5mg PO qHS\n Clonazepam 0.5 mg \n Celexa 20mg PO qday\n Gabapentin 300 mg \n Acetaminophen 325 mg q6H PRN\n Ergocalciferol (Vitamin D2) 50,000 unit PO once a month\n Warfarin held on discharge due to supratherap INR\n .\n Medications on Floor:\n HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain\n Heparin IV per Weight-Based Dosing\n Acetaminophen 325 mg PO Q6H:PRN\n HydrALAzine 100 mg PO Q8H\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Labetalol 800 mg PO TID\n Citalopram 20 mg PO DAILY\n Lorazepam 0.5 mg PO HS\n Clonazepam 0.5 mg PO BID\n NIFEdipine CR 90 mg PO DAILY\n Clonidine Patch 0.3 mg/24 hr 1 QWED\n Dexamethasone 4 mg IV Q8H\n Ondansetron 4 mg IV Q8H:PRN\n DiphenhydrAMINE 25 mg IV Q6H:PRN\n Senna 1 TAB PO BID\n Docusate Sodium 100 mg PO BID\n Famotidine 20 mg IV Q24H\n Gabapentin 300 mg PO Q48H\n Past medical history:\n Family history:\n Social History:\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting , Straight\n CPAP/ Pressure setting 7\n .\n PSHx:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n 5. S/P Ex-lap for free air in abdomen, ex-lap normal \n Negative for autoimmune diseases including sle, thrombophilic\n disorders. Maternal grandfather with HTN, MI, stroke in 70s.\n Occupation: on disability\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: lives with mother and brother\n Review of systems:\n Neurologic: somnulent\n Pain: Minimal\n Pain location: abdominal\n Flowsheet Data as of 03:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 93 (91 - 103) bpm\n BP: 162/121(130) {146/82(100) - 197/125(137)} mmHg\n RR: 13 (13 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 741 mL\n 60 mL\n PO:\n 500 mL\n TF:\n IVF:\n 241 mL\n 60 mL\n Blood products:\n Total out:\n 450 mL\n 675 mL\n Urine:\n 450 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 291 mL\n -615 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: 7.36/42/158//-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, periorbital, perioral edema,\n facial swelling, no stridor, but son voice\n Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, No(t) Rub\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, PD catheter\n in place\n Extremities: Edema- Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Oriented (to): self, place, date, reason for admission, Movement:\n Purposeful, Tone: Normal, somnulent\n Labs / Radiology\n 191 K/uL\n 8.7 g/dL\n 104 mg/dL\n 6.2 mg/dL\n 40 mg/dL\n 23 mEq/L\n 103 mEq/L\n 5.0 mEq/L\n 136 mEq/L\n 26.7 %\n 3.8 K/uL\n [image002.jpg]\n \n 2:33 A12/9/ 06:45 AM\n \n 10:20 P12/9/ 01:40 PM\n \n 1:20 P12/10/ 12:09 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 3.8\n Hct\n 26.7\n Plt\n 191\n Cr\n 5.8\n 6.2\n TC02\n 25\n Glucose\n 90\n 104\n Other labs: PT / PTT / INR:14.9/64.9/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.1 mg/dL\n Imaging: CT abdomen/pelvis with contrast :\n 1. Moderate amount of free fluid in the pelvis is compatible with the\n patient's known peritoneal dialysis. Unchanged peritoneal enhancement.\n 2. Stable liver hemangioma.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n # Facial Swelling/Angioedema: med rxn (Aliskiren can cause this 1% of\n time and can have rxn at any time) vs fluid overload (unable to take\n fluid off at HD due to hypotension) vs SVC syndrome (has hx and INR\n suptherapeutic on admission). Got prednisone 60mg, then started on\n decadron out of concern for angio edema\n - Appreciate END scope demonstrating no stridor, just son and \n occlusion. Patient with known OSA.\n - HD today via temp HD line\n - MRV w/o contrast to eval for SVC\n - Heparin drip for goal PTT 60-80\n - Stopped potentially offending medication AND on decadron, H2\n blockers, and benadryl.\n - Nasal trumpet in place for airway protection\n - CPAP for sleep\n # Somulence: Patient rousable and oriented. Likely med effect. ABG w/o\n hypercarbia\n - monitor closely\n - decrease dilaudid\n # Hypertension: initially 235/170 in ED, but improved with nicardipine\n drip which was discontinued during first unit stay. No clear\n precipitating event. No hx of recent drug use. On admit to the floor\n BPs are stable and the patient is aysmptomatic. Nephrology following.\n Plan to continue PO anti-hypertensives.\n - STOP Aliskiren\n -continue labetalol, hydralazine, nifedipine, clonidine at current\n doses. Have room to increase nifedipine if needed.\n -dialysis T, Thrs, Sat, plan for replacement of HD catheter on Thurs\n with temp line\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. No evidence of blood or urine\n infection by culture that may have led to an acute flare. Pneumonia\n unlikely at this point as patient does not have fever or leukocytosis.\n Echo does not suggest worsening pericarditis.\n -hold prednisone at 4 mg PO q day while patient on decadron.\n #Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter.\n -PD catheter to be removed on Thursday.\n -Decrease dilaudid dose given somnulence this am\n #ESRD: HD today and scheduled for Thurs as well. Renal following.\n -follow lytes, replete as indicated\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, hold clonazepam\n # OSA: CPAP for sleep with 7 pressure.\n ICU Care\n Nutrition:\n Comments: PO diet\n Glycemic Control: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: H2 blocker\n VAP: not intubated\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2141-12-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355388, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. On floor she developed angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following.\n Pt. to OR today PD cath removal. Received local anesthesia and\n conscious sedation. Site is CDI.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt. received on 1.5mcg/kg/min Nitro gtt. BP was 150\ns to 180\n systolic.\n Action:\n Pt. given PO antihypertensive regimen which was held yesterday HD\n and somnolence. Nifedepine dose increased to 120 daily.\n Response:\n Nitro gtt able to be weaned off. BP currently 100\ns to 110\ns systolic.\n Plan:\n Cont regular PO BP med regimen. Monitor BP and hemodynamics.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. received on Heparin gtt at 400units/hr. PTT this am was 104.\n Action:\n Heparin gtt held for OR. Restarted at 300units/hr for increased PTT..\n Response:\n PTT sent at 1500 was 99. Heparin gtt left at 300units/hr, goal for PTT\n is 60-100.\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. complaining of abdominal pain.\n Action:\n Receiving Dilaudid 2mg PO q4hrs PRN.\n Response:\n Pt. still complaining of pain, given additional 1 time dose of 2mg\n Dilaudid PO.\n Plan:\n Continue to monitor for pain and medicate as needed.\n" }, { "category": "Nursing", "chartdate": "2141-12-21 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 355389, "text": "Pt. is a 24y.o. female known to service with history of lupus, ESRD,\n and hyptertention. Pt. was admitted with hypertensive crisis earlier\n this week, was stabilized and transferred to the medical floor\n yesterday. On floor she developed angioedema/generalized facial\n swelling and was transferred back to MICU for airway monitoring.\n Etiology of swelling unclear at this time\n 2 possibilities inclused\n antihypertensive medication side effect or (re)development of SCV\n syndrome. ENT following.\n Pt. to OR today PD cath removal. Received local anesthesia and\n conscious sedation. Site is CDI.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt. received on 1.5mcg/kg/min Nitro gtt. BP was 150\ns to 180\n systolic.\n Action:\n Pt. given PO antihypertensive regimen which was held yesterday HD\n and somnolence. Nifedepine dose increased to 120 daily.\n Response:\n Nitro gtt able to be weaned off. BP currently 100\ns to 110\ns systolic.\n Plan:\n Cont regular PO BP med regimen. Monitor BP and hemodynamics.\n .H/O deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. received on Heparin gtt at 400units/hr. PTT this am was 104.\n Action:\n Heparin gtt held for OR. Restarted at 300units/hr for increased PTT..\n Response:\n PTT sent at 1500 was 99. Heparin gtt left at 300units/hr, goal for PTT\n is 60-100.\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. complaining of abdominal pain.\n Action:\n Receiving Dilaudid 2mg PO q4hrs PRN.\n Response:\n Pt. still complaining of pain, given additional 1 time dose of 2mg\n Dilaudid PO.\n Plan:\n Continue to monitor for pain and medicate as needed.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERTENSION\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 47.7 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Precautions: No Additional Precautions\n PMH: Anemia, HEMO or PD, Renal Failure, Seizures\n CV-PMH: Hypertension\n Additional history: OSA, systemic lupus erythematous diagnosed ,\n ESRD/CKD diagnosed refusing HD as of and PD catheter\n placement , malignant hypertension, hypertensive crisis with\n seizures, thrombocytopenia, SVC thrombosis, staph bacteremia and HD\n line infection and , s/p ex-lap\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:124\n D:72\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,550 mL\n 24h total out:\n 600 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:28 AM\n Potassium:\n 4.9 mEq/L\n 06:28 AM\n Chloride:\n 101 mEq/L\n 06:28 AM\n CO2:\n 26 mEq/L\n 06:28 AM\n BUN:\n 29 mg/dL\n 06:28 AM\n Creatinine:\n 4.9 mg/dL\n 06:28 AM\n Glucose:\n 139 mg/dL\n 06:28 AM\n Hematocrit:\n 25.2 %\n 06:28 AM\n Finger Stick Glucose:\n 120\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: transferred with patient.\n Wallet / Money: Wallet with credit cards transferred with patient\n deferred locking up with security.\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: CC 7\n Transferred to: MICU 7\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2141-12-21 00:00:00.000", "description": "Physician Resident/attending Progress Note - MICU", "row_id": 355406, "text": "Chief Complaint: facial swelling\n 24 Hour Events:\n Temporary Femoral Dialysis Catheter inserted yesterday and Old\n tunnelled line that had cuff out was removed\n MRV neck/chest : no new obstructions, stable old clot\n Peritoneal dialysis catheter removed by transplant surgery\n D/c decadron\n D/c nasal trumpet\n Started nitro drip for hypertension, given patient off Aliskerin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Rash;\n Percocet (Oral) (Oxycodone Hcl/Acetaminophen)\n itching;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 400 units/hour\n Nitroglycerin - 1.5 mcg/Kg/min\n Other ICU medications:\n Naloxone (Narcan) - 11:24 AM\n Furosemide (Lasix) - 11:45 AM\n Hydralazine - 03:06 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: No(t) Dyspnea\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.4\nC (97.6\n HR: 99 (88 - 107) bpm\n BP: 178/117(130) {146/82(100) - 220/139(157)} mmHg\n RR: 15 (8 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 320 mL\n 302 mL\n PO:\n 240 mL\n 240 mL\n TF:\n IVF:\n 80 mL\n 62 mL\n Blood products:\n Total out:\n 2,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,230 mL\n -98 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 100%\n ABG: 7.36/42/158/22/-1\n PaO2 / FiO2: 451\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: diffusely, slightly more\n by PD catheter removal site\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): *3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 132 K/uL\n 8.3 g/dL\n 119 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 5.9 mEq/L\n 34 mg/dL\n 104 mEq/L\n 136 mEq/L\n 25.2 %\n 3.6 K/uL\n [image002.jpg]\n 06:45 AM\n 01:40 PM\n 11:03 AM\n 12:09 PM\n 03:50 PM\n 06:28 AM\n WBC\n 3.8\n 3.6\n Hct\n 26.7\n 25.2\n Plt\n 191\n 132\n Cr\n 5.8\n 6.2\n 5.5\n 5.8\n TCO2\n 25\n Glucose\n 90\n 104\n 100\n 119\n Other labs: PT / PTT / INR:14.9/43.0/1.3, Lactic Acid:0.9 mmol/L,\n Ca++:9.2 mg/dL, Mg++:1.7 mg/dL, PO4:5.5 mg/dL\n Imaging:\n MRV \n SVC is patent.\n Right subclavian vein and right brachiocephalic veins are patent. Right\n IJ not visualized in the neck, consistent with occlusion. Again seen is\n a large right external jugular vein which provides the major venous\n drainage of the neck.\n Left subclavian vein is patent and drains into numerous venous\n collaterals in the mediastinum due to left brachiocephalic vein\n occlusion. Left IJ is patent, but diminuitive.\n Assessment and Plan\n 24 yo woman with hx of SLE, ERSD on HD who presented with hypertensive\n urgency, HA and abd pain now transferred to the unit for angioedema.\n # Facial Swelling/Angioedema: Resolved. Perhaps given patient\ns known\n venous blockages in neck patient develops functional SVC with fluid\n overload. Can not r/o due to Aliskiren. No evidence acute SVC syndrome\n by MRV. On admission to MICU got prednisone 60mg, then started on\n decadron out of concern for angio edema. Patient\n - Stop decadron, restart prednisone 4mg which her home dose\n - Heparin drip for goal PTT 60-80\n - Stop benadryl and H2 blocker\n - D/C Nasal trumpet\n - CPAP for sleep\n # Somulence: Patient rousable and oriented. Likely med effect. ABG w/o\n hypercarbia. Avoid benadryl\n - monitor closely\n - cont at decreased Dilaudid dose\n # Hypertension: initially 235/170 in ED, but improved with nicardipine\n drip which was discontinued during first unit stay. No clear\n precipitating event. No hx of recent drug use. On admit to the floor\n BPs are stable and the patient is aysmptomatic. Nephrology following.\n Plan to continue PO anti-hypertensives.\n - Concerned about restarting Aliskiren\n - Increase nifedipine for better blood pressure control\n - D/C nitro drip if SBP <160\n -continue labetalol, hydralazine, clonidine at current doses.\n -dialysis T, Thrs, Sat, plan for replacement of HD catheter on Thurs\n with temp line\n # SLE: Rheum following and does not suspect acute flare and dsDNA, C3,\n C4 nl, ESR and CRP slightly elevated. No evidence of blood or urine\n infection by culture that may have led to an acute flare. Pneumonia\n unlikely at this point as patient does not have fever or leukocytosis.\n Echo does not suggest worsening pericarditis.\n - restart prednisone at 4 mg PO daily\n #Abd pain: No clear etiology however previous workup is without\n significant findings, may be secondary to inflammation around the site\n of the PD catheter.\n -PD catheter to be removed on TODAY.\n -cont to treat pain\n #ESRD: HD today and scheduled for Thurs as well. Renal following.\n -follow lytes, replete as indicated\n - schedule NEW tunneled HD line, patient currently has temp per renal\n -speak with renal about repeat dialysis today vs treating hyperkalemia\n with lasix\n # Anemia: baseline 26. AOCD and in setting of renal failure\n -monitor HCT\n #Coagulopathy: patient on lifetime anticoagulation for hx of multiple\n thrombotic events\n -hold warfarin now for replacement of dialysis catheter\n -restart heparin bridge\n -will restart warfarin for INR of after replacement of HD cath.\n # HOCM: evidence of myocardial hypertrophy on Echo. Currently not\n symptomatic. Echo without evidence of worsening pericardial effusion.\n -Continue bblocker\n # Depression/anxiety. Continue Celexa, restart clonazepam 0.5mg \n # OSA: CPAP for sleep with 7 pressure.\n ICU Care\n Nutrition: PO diet\n Glycemic Control: Comments: not needed\n Lines:\n Dialysis Catheter - 10:00 AM\n 22 Gauge - 10:01 AM\n Prophylaxis:\n DVT: Heparin Drip\n Stress ulcer: Stop H2, no indication PPI\n VAP:\n Comments: not intubated\n Communication: discussed in interdisciplinary rounds, patient, mother\n status: Full code\n Disposition:Transfer to floor once BPs stable off nitro drip\n ------ Protected Section ------\n ATTENDING ADDENDUM:\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above and below.\n Key Points:\n Facial swelling/angioedema. Resolved. Acute SVC syndrome\n unlikely. Ddx fluid overload vs agioedema, though no high risk meds.\n Now off decadron, benadryl and H2 blocker. No decision on restarting\n renin inhibitor.\n Will restart heparin drip now that PD catheter removed.\n Htn - Will increase nifedipine today. DC nitro drip.\n Somnolence/altered mental status - now resolved. Likely\n medication effect.\n Renal failure - Plans as per renal for placement of\n permanent HD access.\n HOCM- on beta blocker\n Further plans as per resident notes.\n Safe for transfer to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:18 ------\n" }, { "category": "Nursing", "chartdate": "2141-12-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 355491, "text": "24 year old female with mulitple ICU admissions for hypertensive\n crisis, presented to ED with vomiting & abdominal pain similar to prior\n episodes. No response to labetalol, Nitro paste & iv Hydral. Labatalol\n drip changed to Nicardipine. Admitted to MICU for hypertensive urgency.\n ***Pt. readmitted to MICU (to floor 12/09pm) for angioedema. ENT\n examined pt. on floor prior to transfer - plan to w/u etiology -\n medication SE vs. SVC syndrome vs. other?\n ****Pt tranferred back to CC7 on eve of and transferred back to\n MICU 6 on for hypertension. On arrival to MICU, pt crying\n stating pain in abdomen and legs. Pt able to be calmed. Once she\n fell asleep, BP down to 130's without intervention.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Pt with initial BP of 245/140, crying in pain. Pt had become\n hypertensive on the floor despite having rec\nd her regular morning meds\n on CC7. She rec\nd mult meds in an attempt to bring BP down, but\n ineffective, so transferred back to MICU 6. Pt was able to be calmed\n on arrival and fell asleep.\n Action:\n No pharmaceutical intervention given\n Response:\n BP down to 130\ns-150\n Plan:\n Cont to monitor VS\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal pain and calf cramping, crying in pain.\n Action:\n Pt able to fall asleep without intervention.\n Response:\n Pt appears more comfortable and is able to rest.\n Plan:\n Cont to monitor pain level and medicate as ordered.\n" }, { "category": "Nursing", "chartdate": "2141-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354833, "text": "TITLE:\n Ms is a 24 year old woman with a history of CKD V (on HD)\n from lupus nephritis, chronic intermittent abdominal pain, and\n multiple prior ICU admissions for hypertensive urgency who\n presented to the ED complaining of abdominal pain,\n nausea. She also has had diffuse\n abdominal pain consistent with her prior flares of pain as well\n as her typical diffuse headache. The headache in particular was\n worsening and, for her, this is a sign of poorly-controlled\n hypertension so she came to the ED. Upon arrival to the\n ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room\n air. She was given 4 mg of IV ondansetron, inch intropaste,\n Past Medical History:\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera\n injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n .\n PSHx:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n 5. S/P Ex-lap for free air in abdomen, ex-lap normal \n Social History:\n Single and lives with her mother and a brother. She graduated\n from high school. The patient is on disability. The patient does\n not drink alcohol or smoke, and has never used recreational\n drugs.\n Family History:\n Negative for autoimmune diseases including sle, thrombophilic\n disorders. Maternal grandfather with HTN, MI, stroke in 70s.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient on Arrival to MICU was fast asleep & snoring, when awoken, she\n complained of abd pain of 6 & headache of 7. She would immediately\n fall asleep with severe snoring, she was given 4 mg IV Morphine in the\n ED.\n Action:\n Dilaudid 4 mgs po given at 0630 hrs.\n Response:\n Patient is sleeping. NO nausea / vomiting since admission to MICU.\n Plan:\n Will continue to monitor pain, will be cautious with meds as last\n admission she had episodes of resp depression with hypoxia\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with diagnosos of OSA.\n Action:\n Patient on RA , spo2 100 &. LS Clear, RT will start Patient on Cpap.\n Response:\n Not on cpap yet.\n Plan:\n Will Follow up.\n Hypertension, malignant (hypertensive crisis, hypertensive emergency)\n Assessment:\n Received on Nicardipine drip at 0.5 mic/kg/min. SBP 160\ns to 170\n Action:\n Nicardipine drip weaned off . Tab NIcardipine 90 mgs CR given at 0630\n am.\n Response:\n Current BP 170/90\n Plan:\n Goal BP 180/100.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt had HD yesterday. She has a HD cath at the rt groin & peritoneal\n dialysis cath on her abdomen.\n Action:\n Patient voided 250 mls cleay yellow.\n Response:\n None.\n Plan:\n To send Culture next time she voids. ? DC peritoneal cath. Follow up\n on next dialysis.\n" }, { "category": "General", "chartdate": "2141-12-18 00:00:00.000", "description": "ICU Event Note", "row_id": 354855, "text": "Clinician: Attending\n Critical Care\n Unfortunate 24 yo woman with SLE, ESRD, recurrent thrombosis, anxiety\n and multiple episodes of hypertensive urgency. Readm overnight with\n hypertensive urgency. C/o chronic abd pain - no chest pain or SOB but\n PaO2 50's. BP responding to nicardipine after no response to\n labetolol. We are consulting renal, rheumatology. She has a\n pericardial effusion of echo last mo and a L pleural effusion - raises\n ? of whether this is SLE or need for more aggressive dialysis. Need to\n obtain records from dialysis last several weeks to know how BP has been\n running. Will wean iv meds and plan for HD today per renal.\n Total time spent: 50 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2141-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 354831, "text": "TITLE:\n Ms is a 24 year old woman with a history of CKD V (on HD)\n from lupus nephritis, chronic intermittent abdominal pain, and\n multiple prior ICU admissions for hypertensive urgency who\n presented to the ED complaining of two days' of abdominal pain,\n nausea. She also has had diffuse\n abdominal pain consistent with her prior flares of pain as well\n as her typical diffuse headache. The headache in particular was\n worsening and, for her, this is a sign of poorly-controlled\n hypertension so she came to the ED. Upon arrival to the\n ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room\n air. She was given 4 mg of IV ondansetron, inch intropaste,\n Past Medical History:\n 1. Systemic lupus erythematosus:\n - Diagnosed (16 years old) when she had swollen fingers,\n arm rash and arthralgias\n - Previous treatment with cytoxan, cellcept; currently on\n prednisone\n - Complicated by uveitis () and ESRD ()\n 2. CKD/ESRD:\n - Diagosed \n - Initiated dialysis but refused it as of , has\n survived despite this\n - PD catheter placement \n 3. Malignant hypertension\n - Baseline BPs 180's - 120's\n - History of hypertensive crisis with seizures\n - History of two intraparenchymal hemorrhages that were thought\n due to the posterior reversible leukoencephalopathy syndrome,\n associated with LE paresis in that resolved\n 4. Thrombocytopenia:\n - TTP (got plasmapheresisis) versus malignant HTN\n 5. Thrombotic events:\n - SVC thrombosis (); related to a catheter\n - Negative lupus anticoagulant (, , )\n - Negative anticardiolipin antibodies IgG and IgM x4 (-)\n - Negative Beta-2 glycoprotein antibody (, )\n 6. HOCM: Last noted on echo \n 7. Anemia\n 8. History of left eye enucleation for fungal infection\n 9. History of vaginal bleeding lasting 2 months s/p\n DepoProvera\n injection requiring transfusion\n 10. History of Coag negative Staph bacteremia and HD line\n infection - and \n 11. Thrombotic microangiopathy: may be etiology of episodes of\n worse hypertension given appears quite labile\n .\n PSHx:\n 1. Placement of multiple catheters including dialysis.\n 2. Tonsillectomy.\n 3. Left eye enucleation in .\n 4. PD catheter placement in .\n 5. S/P Ex-lap for free air in abdomen, ex-lap normal \n Social History:\n Single and lives with her mother and a brother. She graduated\n from high school. The patient is on disability. The patient does\n not drink alcohol or smoke, and has never used recreational\n drugs.\n Family History:\n Negative for autoimmune diseases including sle, thrombophilic\n disorders. Maternal grandfather with HTN, MI, stroke in 70s.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient on Arrival to MICU was fast asleep & snoring, when awoken, she\n complained of abd pain of 6 & headache of 7. She would immediately\n fall asleep with severe snoring, she was given 4 mg IV Morphine in the\n ED.\n Action:\n Dilaudid 4 mgs po given at 0630 hrs.\n Response:\n Patient is sleeping.\n Plan:\n Will continue to monitor pain, will be cautious with meds as last\n admission she had episodes of resp depression with hypoxia\n Obstructive sleep apnea (OSA)\n Assessment:\n Patient with diagnosos of OSA.\n Action:\n Patient on RA , spo2 100 &. LS Clear, RT will start Patient on Cpap.\n Response:\n Not on cpap yet.\n Plan:\n Will Follow up.\n" }, { "category": "Echo", "chartdate": "2141-12-18 00:00:00.000", "description": "Report", "row_id": 72704, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Hypertensive cardiomyopathy. Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 108\nBSA (m2): 1.44 m2\nBP (mm Hg): 133/89\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 11:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\nLVOT gradient increases with Valsalva.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. A possible\nsecundum type atrial septal defect is seen by color Doppler (clip ) There is\nsevere symmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function. There is no significant resting LVOT\ngradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is mild\npulmonary artery systolic hypertension. There is a small circumferential\npericardial effusion without echocardiographic signs of tamponade.\n\nIMPRESSION: Marked symmetric left ventricular hypertrophy with normal\nregional/global systolic function and mild inducible LVOT gradient. Mild\naortic regurgitation. Mild pulmonary artery systolic hypertension. Possible\nsecundum type atrial septal defect.\nCompared with the prior study (images reviewed) of , a possible\nsecundum type atrial septal defect is now suggested.\nIf clinically indicated, a follow-up study with saline contrast and/or a TEE\nwould be better able to characterize the possible atrial septal defect.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Radiology", "chartdate": "2141-12-20 00:00:00.000", "description": "MRV CHEST W/O CONTRAST", "row_id": 1050440, "text": " 9:21 PM\n MRV CHEST W/O CONTRAST Clip # \n Reason: eval ?SVC/venous obstruction\n Admitting Diagnosis: HYPERTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with known past SVC, recent increase in facial edema,\n swelling\n REASON FOR THIS EXAMINATION:\n eval ?SVC/venous obstruction\n CONTRAINDICATIONS for IV CONTRAST:\n renal disease\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: CLxc WED 11:30 PM\n\n\n SVC is patent.\n\n Right subclavian vein and right brachiocephalic veins are patent. Right IJ not\n visualized in the neck, consistent with occlusion. Again seen is a large right\n external jugular vein which provides the major venous drainage of the neck.\n\n Left subclavian vein is patent and drains into numerous venous collaterals in\n the mediastinum due to left brachiocephalic vein occlusion. Left IJ is patent,\n but diminuitive.\n\n These findings are unchanged since the prior MRV chest study dated and\n were discussed with Dr. at 11:15 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 24-year-old woman with lupus, history of right internal jugular and\n left brachiocephalic vein occlusions. Recent increase in facial edema,\n question SVC/venous obstruction.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5 T\n magnet without contrast. Comparison is made to a prior MRV of the chest dated\n .\n\n FINDINGS: There has been no significant interval change since the prior exam\n dated .\n\n The SVC is patent.\n\n The right subclavian and brachiocephalic veins are patent. The right IJ is\n not visualized, consistent with the known occlusion. There is a prominent\n right external jugular vein which provides the major venous drainage of the\n neck.\n\n The left subclavian vein drains into numerous mediastinal venous collaterals\n due to the known left brachiocephalic vein occlusion. The left internal\n jugular vein is diminutive, but is patent.\n (Over)\n\n 9:21 PM\n MRV CHEST W/O CONTRAST Clip # \n Reason: eval ?SVC/venous obstruction\n Admitting Diagnosis: HYPERTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n No appreciable change since the MRV chest exam dated . SVC is\n patent. Again seen is occlusion of the right internal jugular and left\n brachiocephalic veins. Right external jugular vein is provides the major\n venous drainage from the neck.\n\n These findings were discussed with Dr. at 11:15 p.m. on , .\n\n\n" }, { "category": "Radiology", "chartdate": "2141-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1049849, "text": " 1:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: perf?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with severe abd pain, nausea, Renal failure on HD\n REASON FOR THIS EXAMINATION:\n perf?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 24-year-old female with severe abdominal pain, nausea and renal\n failure on hemodialysis.\n\n COMPARISON: CTA chest , chest radiographs .\n\n FINDINGS: Previously noted right PICC line has been removed. Study is\n limited by mild leftward rotation. Linear opacities in a retrocardiac\n location are again noted and likely represent atelectasis as before. However,\n underlying developing consolidation cannot be excluded. Linear opacity along\n the medial right hemidiaphragm also likely reflects atelectasis with minimal\n interstitial prominence suggesting mild pulmonary edema. No pneumothorax is\n identified. There is no evidence of free intraperitoneal air.\n\n IMPRESSION:\n\n 1. Cardiomegaly with findings suggestive of mild pulmonary edema.\n\n 2. Bibasilar linear opacities suggesting atelectasis, although developing\n pneumonia cannot be excluded.\n\n 3. No evidence of free intraperitoneal air.\n\n\n" }, { "category": "ECG", "chartdate": "2141-12-18 00:00:00.000", "description": "Report", "row_id": 169951, "text": "Sinus tachycardia. Probable left ventricular hypertrophy. Compared to the\nprevious tracing of the rate has increased.\n\n" } ]

[ { "category": "Echo", "chartdate": "2199-10-02 00:00:00.000", "description": "Report", "row_id": 88365, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 66\nWeight (lb): 206\nBSA (m2): 2.03 m2\nBP (mm Hg): 118/68\nHR (bpm): 111\nStatus: Outpatient\nDate/Time: at 11:13\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal mitral valve\nsupporting structures. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic\nfunction, and a normal left ventricular filling pressure (PCWP<12mmHg). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Normal\ndiastolic function. Mild mitral regurgitation in a structurally-normal valve.\n\n\n" }, { "category": "ECG", "chartdate": "2199-10-15 00:00:00.000", "description": "Report", "row_id": 235935, "text": "Sinus rhythm at upper limits of normal rate. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1100457, "text": " 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please do abd/pelvic CT with PO and PR contrast to eval for\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL ADDENDUM\n On additional review of the images, in addition to rarefaction, there are\n small locules of gas within the left posterior iliac bone.\n\n\n 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please do abd/pelvic CT with PO and PR contrast to eval for\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman 11d post-partum (episiotomy) with sepsis of unclear ,\n ARF, liver failure with WBC=48\n REASON FOR THIS EXAMINATION:\n please do abd/pelvic CT with PO and PR contrast to eval for abscess,\n ?appendicitis (with possible perferation) or colitis, or other intraabdominal\n or pelvic pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 5:00 PM\n Gas within the left iliacus and piriformis and minimal phlegmon adjacent to\n the left sacroiliac joint with rarefaction of the left iliac bone, highly\n concerning for septic arthritis. Bilateral pleural effusions with associated\n atelectasis, but pneumonia cannot be excluded. Diffuse edema and small amount\n of free fluid in the pelvis. No evidence of appendicitis or colitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female 11 days postpartum with episiotomy presents\n with sepsis of unclear etiology, acute renal failure, liver failure, and white\n blood cell count of 48. Evaluate for abscess, appendicitis, colitis, or other\n intra-abdominal abnormality.\n\n COMPARISON: Abdominal and pelvic ultrasounds performed the same day.\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to\n the pubic symphysis without IV contrast due to the acute renal failure. Oral\n contrast was administered. Coronal and sagittal reformats were displayed and\n essential in delineating the anatomy and pathology.\n\n CT ABDOMEN WITHOUT IV CONTRAST: There are bilateral pleural effusions, right\n greater than left, with associated atelectasis. However, underlying infection\n cannot be excluded.\n\n The liver demonstrates diffuse low attenuation without focal mass lesion.\n There is no intra- or extra-hepatic biliary ductal dilatation. The\n gallbladder demonstrates a thickened wall, similar to ultrasound performed\n earlier the same day. In addition, there is low attenuation material in the\n gallbladder, likely sludge. The pancreas and right adrenal gland are\n unremarkable. There are two tiny calcifications within the left adrenal gland\n without associated mass lesion. The spleen is enlarged measuring up to 16.4\n cm. Two 1.5-cm splenules are noted in the splenic hilum. The kidneys are\n symmetric without evidence of hydronephrosis or stones. The opacified stomach\n and intra-abdominal loops of small bowel are unremarkable. Oral contrast does\n not make it to the large bowel, however, the intra-abdominal loops of large\n bowel are unremarkable. The appendix is not definitely visualized, but there\n are no secondary signs of appendicitis.\n\n (Over)\n\n 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please do abd/pelvic CT with PO and PR contrast to eval for\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is mild diffuse stranding in the subcutaneous fat and mesentery and a\n small amount of fluid in the right paracolic gutter consistent with\n generalized edema. There is no mesenteric or retroperitoneal lymphadenopathy\n meeting CT criteria for pathologic enlargement.\n\n CT PELVIS WITHOUT IV CONTRAST: There is a 4 cm pocket of gas within or\n adjacent to the left iliacus muscle and smaller locules of gas tracking into\n the sacroiliac joint, left S1 neural foramen and left piriformis and gluteus\n minimus muscles. The left piriformis muscle is slightly larger than the right\n and there is miminal phlegmonous material adjacent to the piriformis muscle.\n There is associated rarefaction of the posterior left iliac bone with apparent\n erosion of the medial cortex (2:72).\n\n The uterus is bulky, but consistent with postpartum state. There is a small\n amount of free fluid in the pelvis, measuring simple fluid attenuation. There\n are a few small locules of gas within the urinary bladder, presumably related\n to the in situ Foley catheter. The adnexa, sigmoid colon, and rectum are\n unremarkable. There is no pelvic or inguinal lymphadenopathy meeting CT\n criteria for pathologic enlargement.\n\n BONE WINDOWS: Aside from the left iliac bone findings described above, there\n is no suspicious lytic or sclerotic osseous lesion.\n\n IMPRESSION:\n\n 1. Small phlegmonous density anterior to the left sacroiliac joint and\n possibly continuous with the joint space, with pockets of gas within the left\n iliacus, piriformis and gluteus minimus muscles with associated rarefaction of\n the posterior left iliac bone, highly suspicious for septic arthritis of the\n left sacroiliac joint and associated osteomyelitis.\n\n 2. Small bilateral pleural effusions with associated atelectasis. Underlying\n pneumonia cannot be excluded.\n\n 3. Low attenuation of the liver is likely related to acute hepatitis or\n generalized edema.\n\n 4. Gallbladder sludge not seen on ultrasound, but may be related to fasting\n state. Gallbladder wall thickening is likely related to diffuse edema rather\n than acute cholecystitis.\n\n 5. Splenomegaly.\n\n 6. Small amount of free fluid within the pelvis.\n\n Findings were discussed at the time of interpretation via telephone with Dr.\n \n\n 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please do abd/pelvic CT with PO and PR contrast to eval for\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n and in person with Drs. and on\n .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1102214, "text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with self-extubation\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n WET READ: SPfc MON 9:03 PM\n ETT has been removed. NGT and right IJ line are unchanged. Bilateral pleural\n effusions are increased. Extensive bilateral parenchymal opacities are\n redemonstrated.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:11 P.M. \n\n HISTORY: 19-year-old patient self-extubated.\n\n IMPRESSION: AP chest compared to , 5:22 a.m.:\n\n No endotracheal tube is seen below C6, the upper margin of this film.\n Nasogastric tube ends in the upper stomach. Right jugular line tip projects\n over the low SVC. Lung volumes are lower and there is greater opacification\n generally particularly in the right lung. This could be little changed, could\n be due primarily to the loss of positive pressure ventilator support, but is\n also concerning for progression of underlying abnormality, presumably edema,\n cardiogenic or otherwise. Small right pleural effusion is presumed. There is\n no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101361, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: New infiltrate?\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with septic shock\n REASON FOR THIS EXAMINATION:\n New infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with septic shock.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is just above the level of the clavicular heads approximately\n 5 cm above the carina. The right internal jugular line tip is at the level of\n low SVC. There is interval extensive progression of the parenchymal opacities\n currently involving the entire lungs with bibasilar dense consolidations.\n Thus, the bilateral pleural effusion cannot be excluded. Within the\n limitations of this study, the cardiomediastinal silhouette appears to be\n unchanged.\n\n The above-described changes might represent significant rapid progression of\n infection or superimposed pulmonary edema on the pre-existing abnormalities\n within the lungs. ARDS would be another possibility and should be correlated\n with clinical findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "P PELVIS U.S., TRANSVAGINAL PORT", "row_id": 1100408, "text": " 7:54 AM\n PELVIS U.S., TRANSVAGINAL PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n PELVIS, NON-OBSTETRIC; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please eval for retained products, ovarian pathology\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman 11 days post partum, sepsis, severe crampy pelvic pain\n REASON FOR THIS EXAMINATION:\n please eval for retained products, ovarian pathology\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 11:07 AM\n Fluid and echogenic debris within the endometrial cavity without vascularity\n may represent blood but devascularized retained products of conception cannot\n be excluded. Normal left ovary. Right ovary not visualized. Small amount of\n free fluid within the pelvis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female 11 days postpartum with sepsis and severe\n crampy pelvic pain. Evaluate for retained products or ovarian pathology.\n\n COMPARISON: No prior study available for comparison.\n\n FINDINGS: Transabdominal and transvaginal ultrasound were performed, the\n latter for better evaluation of the endometrium and ovaries. The uterus\n measures 12.7 x 6.8 x 9.3 cm. The endometrial cavity contains a small amount\n of fluid and echogenic debris. There is no vascularity within the debris. The\n left ovary is normal. The right ovary was not visualized. There is a small\n amount of free fluid within the pelvis.\n\n IMPRESSION:\n\n 1. Fluid and echogenic debris within the endometrial cavity without\n vascularity may represent blood, but devascularized retained products of\n conception cannot be excluded.\n\n 2. Small amount of free fluid within the pelvis.\n\n 3. Normal left ovary. Right ovary not visualized.\n\n Findings were discussed with Dr. at the time of interpretation on\n .\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "P PELVIS U.S., TRANSVAGINAL PORT", "row_id": 1100409, "text": ", M. MED 7:54 AM\n PELVIS U.S., TRANSVAGINAL PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n PELVIS, NON-OBSTETRIC; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please eval for retained products, ovarian pathology\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman 11 days post partum, sepsis, severe crampy pelvic pain\n REASON FOR THIS EXAMINATION:\n please eval for retained products, ovarian pathology\n ______________________________________________________________________________\n PFI REPORT\n Fluid and echogenic debris within the endometrial cavity without vascularity\n may represent blood but devascularized retained products of conception cannot\n be excluded. Normal left ovary. Right ovary not visualized. Small amount of\n free fluid within the pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100863, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with septic shock, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:04 A.M., .\n\n HISTORY: 19-year-old woman with septic shock.\n\n IMPRESSION: AP chest compared to through :\n\n Pulmonary edema developed between at 12:30 a.m. and 10:45 p.m.,\n accompanied by increasing mild cardiomegaly. There is some improvement at\n least radiographically over the next seven hours, but since 5:40 a.m. on\n , diffuse pulmonary opacification has worsened again, accompanied by\n small right pleural effusion. Mild cardiomegaly has improved, suggesting a\n component of cardiac decompensation, but now there could be noncardiogenic\n edema. ET tube and nasogastric tube are in standard placements, and a right\n internal jugular line ends just above the superior cavoatrial junction. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1101465, "text": " 2:43 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ?line placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman s/p Right IJ line changed over wire\n REASON FOR THIS EXAMINATION:\n ?line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: Study of earlier the same date.\n\n INDICATION: Line change.\n\n FINDINGS: A right internal jugular catheter tip projects just below the\n expected junction of the superior vena cava and right atrium. However,\n relatively low lung volumes may cause this to appear at a slightly lower\n position. Widespread bilateral pulmonary opacities appear minimally improved\n in the interval. Examination is otherwise unchanged since the recent study.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-17 00:00:00.000", "description": "P PELVIS (AP ONLY) PORT", "row_id": 1102680, "text": " 8:33 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman s/p pelvis infection/I+D\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PLAIN FILM OF ABDOMEN:\n\n INDICATION: Patient with I and D of the pelvic collection, for evaluation.\n\n TECHNIQUE: Frontal radiograph only was obtained.\n\n COMPARISON: CT dated .\n\n REPORT: A ring is projected over the superior aspect of the symphysis pubis\n with a tubular lucency here also seen, barely appreciated. Coils and clips\n are projected over the left quadrant. There are multiple rounded radiopaque\n bodies projected over the left iliac bone, which probably represents\n antibiotic impregnated beads. The bowel gas pattern appears grossly\n unremarkable.\n\n CONCLUSION:\n\n Status post antibiotic bead placement. Normal-appearing bones and soft\n tissues.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-09 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1101385, "text": " 8:41 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ? acalculus cholecystitis\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with spiking temps despite broad abx coverage.\n REASON FOR THIS EXAMINATION:\n ? acalculus cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fevers. Question acalculous cholecystitis.\n\n COMPARISON: .\n\n FINDINGS: The gallbladder has a similar appearance with no change in the\n luminal volume. Again there is gallbladder wall thickening which is entirely\n nonspecific and could be related to the known hypoalbuminemia. A trace amount\n of pericholecystic fluid is noted. No gallstones are seen. Patient is\n intubated and therefore we cannot evaluate for son sign. The\n visualized liver demonstrates normal echotexture and size. There is normal\n hepatopetal flow in the main portal vein. There is a right pleural effusion.\n\n IMPRESSION:\n\n Stable appearance of nonspecific gallbladder wall thickening which is likely\n to be related to third spacing. The appearance is not suggestive of acute\n cholecystitis, and furthermore the stability of gallbladder volume would also\n argue against acute cholecystitis.\n\n" }, { "category": "Physician ", "chartdate": "2199-10-06 00:00:00.000", "description": "Intensivist Note", "row_id": 489181, "text": "SICU\n HPI:\n 19F presents with septic shock following birth/episiotomy, s/p septic\n joint washout\n Chief complaint:\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Bisacodyl\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Cisatracurium Besylate\n Famotidine\n Fentanyl Citrate\n Furosemide\n Heparin\n Insulin\n Magnesium Sulfate Replacement\n Midazolam\n Ondansetron\n Piperacillin-Tazobactam\n Potassium Chloride\n Potassium Phosphate\n Senna\n Vancomycin\n 24 Hour Events:\n cont resp distress, paralyzed\n started lasix drip\n Post operative day:\n POD#3 - I & D Lt ileum and Sacroiliac joint debridement\n POD#2 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Clindamycin - 06:16 AM\n Vancomycin - 12:00 PM\n Piperacillin - 07:00 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl - 450 mcg/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Furosemide (Lasix) - 02:50 PM\n Cisatracurium - 03:45 PM\n Other medications:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.8\nC (100.1\n HR: 107 (92 - 121) bpm\n BP: 95/63(75) {82/44(58) - 118/85(95)} mmHg\n RR: 19 (0 - 36) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 21 (11 - 357) mmHg\n CO/CI (Thermodilution): (9.3 L/min) / (4.5 L/min/m2)\n SVR: -2,305 dynes*sec/cm5\n SV: 92 mL\n SVI: 45 mL/m2\n Total In:\n 2,465 mL\n 247 mL\n PO:\n Tube feeding:\n 137 mL\n IV Fluid:\n 1,427 mL\n 247 mL\n Blood products:\n 902 mL\n Total out:\n 2,063 mL\n 295 mL\n Urine:\n 1,783 mL\n 295 mL\n NG:\n 280 mL\n Stool:\n Drains:\n Balance:\n 402 mL\n -48 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n PIP: 45 cmH2O\n Plateau: 42 cmH2O\n Compliance: 14.6 cmH2O/mL\n SPO2: 94%\n ABG: 7.32/43/82./21/-3\n Ve: 9.7 L/min\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : b/l)\n Abdominal: Soft, Non-distended, Non-tender, No(t) Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 44 K/uL\n 10.3 g/dL\n 80 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 44 mg/dL\n 109 mEq/L\n 140 mEq/L\n 29.3 %\n 11.0 K/uL\n [image002.jpg]\n 02:16 PM\n 03:14 PM\n 05:48 PM\n 07:45 PM\n 10:04 PM\n 10:14 PM\n 10:31 PM\n 12:29 AM\n 02:12 AM\n 02:20 AM\n WBC\n 12.2\n 11.0\n Hct\n 30.4\n 29.3\n Plt\n 48\n 44\n Creatinine\n 3.1\n 3.1\n TCO2\n 23\n 22\n 23\n 20\n 24\n 23\n 21\n 23\n Glucose\n 93\n 100\n 80\n Other labs: PT / PTT / INR:17.0/29.5/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:28/23, Alk-Phos / T bili:137/5.8, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:417 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Septic shock and MSOF\n Neurologic: Neuro checks Q: 1 hr, Restraints, midaz/ fentanyl for\n sedation/analgesia. Paralyzed with cisatricurium for disynchrony.\n Cardiovascular: Levophed; monitoring in right Ax a line. High CI\n with low SVR and hypovolemia. High extra vascular lung water..\n Pulmonary: Cont ETT, ARDS protocol, f/u CXR\n Gastrointestinal / Abdomen: Restart TF\n Nutrition: Tube feeding,\n Renal: Foley, lasix drip. Continue albumin for colloid pressure\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, cont abx vanc /zosyn for GNR in\n wound\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: drain in place\n Imaging: CXR today\n Fluids: KVO, lasix drip\n Consults: Ortho, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic)\n ICU Care\n Nutrition: TF on hold\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489294, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received this am on Levo gtt for goal MAP 65-70\n SBP decreased over noc with Levo off\n SVR in 500-700 range CO/CI 7.01-9.31/2.9-4.8\n Lasix gtt at 5cc/hr U/O ~ 60cc/hr\n T-max 100.9\n Fent/versed for sedation/pain\n Platelets holding at 45\n Crit stable\n Action:\n Pan CX per ID\n Zosyn d/c\nd and meropenem added for more Gram\n coverage\n Levo titrate down as tolerated\n Vanco held level >20\n Lasix increased to 7\n Response:\n Tolerating low dose levo\n CO/CI elevating CO averaging around 9 and SVR cont to be\n below 800 range\n MD aware Cont to maintain MAP >70\n Remains with adequate u/o pt becoming more tachy in late pm\n lasix back down to 5 creatinine bumped to 3.3\n Temp 98.3\n Plan:\n Cont to monitor hemodynamics closely\n F/U BC\n Recheck Vanco level in am\n Respiratory failure, acute (ARDS/)\n Assessment:\n Pt received on .50% FI02 TV 28X350 18 PEEP\n ABG this am pt acidotic with -5 BE\n ELWI 13 up from 10\n Lungs throughout\n Pt paralyzed with 3-4 twitches\n PIP\ns >40\n Action:\n Paralytic increased by .5\n Midaz/Fent cont\n Pt placed in Swimmers position\n Response:\n Pt tolerating swimmers on Right Pa02 88 sats 90- in swimmers with RL down LS very\n \n Pt did not tolerate swimmers on left. Pa02 dropped to 61\n with sats 86-89\n Pt placed supine and back in rotation with improving Pa02 to\n 110 Ph 7.30\n No vent changed made only pulmonary hygiene\n Pt did tolerate CPT when in Swimmers on Right side\n Rotation time on left decreased to 10 min because pt sating\n at 88-89 when on Left side\n Sxn for yellow thich secretions\n PIP\ns remain >40\n Plan:\n Cont with pulmonary hygiene\n Rotation and swimmers as tolerated\n Supportive care to pt and family\n" }, { "category": "Physician ", "chartdate": "2199-10-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488497, "text": "TITLE:\n [NOTE ACURATE AS OF . PLEASE SEE ADDENDUM FOR ADDITIONAL\n INFORMATION]\n Chief Complaint:\n HPI:\n For full admission note please refer to initial H&P. Briefly this\n is a 19 y.o. post-partum G1P1 Female who initially presented to an OSH\n with hypotension to 70s.\n .\n On review of initial H&P it appears she recently had a vaginal delivery\n 11 days ago following a uncomplicated delivery. The vaginal delivery\n lasted 3.5hrs and included an episiotomy, she never experienced any\n hypotension at that time and received no spinal anaesthesia or spinal\n block. When she came home she noted some fatigue, intermittent loose\n stool. Over the next 5 days she noted progressive watery, non-bloody\n diarrhea, orthostatic symptoms, as well as one episode of vision \n upon standing. She denied any sick contact, new or uncooked foods or\n cheeses, drugs, ETOH, ingestion, exposures. She does not believe she\n has ever had an STD and did not require antibiotics during delivery as\n far as she knows (did not know her group B strep status).\n .\n At the OSH her initial BP was 89/36 but she dropped to SBPs 70s(per\n report). Her HCT was 28, her creatinine was 3.1, albumin 1.8. She was\n given 6.5L of NS, Zosyn and started on dopamine and med-flighted to\n ED.\n .\n In the ED, initial vs were: T:99.2 P126 BP98/57 R20 O2 95 sat.\n Central line was placed. Patient was started on levo and neo given\n Vanco and 2.5L fluids. OB was consulted and did a bedside ultrasound\n that did not show evidence of retained placenta. On labs, patient noted\n to have stable HCT 28, WBC of 7.7 and PLT of 22. Her AST/ALT and T.\n Bili were elevated. Her creatinine was 2.9 and K was 2.4, bicarb 13.\n INR was 1.3 and fibrinogen was 479. Urine and serum tox were negative.\n On transfer to the floor T:98.0, HR 112, BP 102/53, RR: 30, 02 sats\n 100on2L and VBG showed ph 7.25, pco2:25 p02 of 66. Per the patient's\n parents the patient was mentating well this entire time.\n .\n She was transferred to the where she was noted to be tachypneic on\n arrival. She developed crampy pelvic pain similar to her menstrual pain\n but more severe in nature and she complained of worsening left buttock\n pain without radiation. She intially required 3 pressors to keep her\n MAPs>65 and was bolused with LR. she was given a total of 13L of fluid\n total and was able to wean off from 3 pressors to just Vasopressin. She\n was noted to be thrombocytopenic from 22 to 50s-60s. Heme-Onc were\n consulted and her smear showed no schistocytes or blasts. Hemolysis\n labs were also negative. Given her pelvic pain a CT abd/pelvis was\n obtained which showed a prelim read concerning for gas within the left\n iliacus and piriformis and minimal phlegmon adjacent to the left\n sacroiliac joint with rarefaction of the left iliac bone, highly\n concerning for septic arthritis. Diffuse edema and a small amount of\n free fluid was noted in the pelvis along with bilateral pleural\n effusions with associated atelectasis. Orthopaedics were consulted and\n recommended debridement for possible nec fasc. Pt was then transferred\n from service to MICU Team.\n .\n Of note, the team called the OSH regarding culture data, pt had\n 4/4 bottles positive for Gram Negative Bacili.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Metronidazole - 08:48 AM\n Piperacillin - 08:48 AM\n Vancomycin - 09:48 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:57 PM\n Sodium Bicarbonate 8.4% (Amp) - 10:52 PM\n Home medications:\n None\n Past medical history:\n Family history:\n Social History:\n no medical or surgical history\n G1P1 s/p vaginal delivery with episiotomy 11 days PTA. Pregnancy\n otherwise uncomplicated.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 103 (87 - 136) bpm\n BP: 85/52(63) {31/20(-7) - 140/92(356)} mmHg\n RR: 28 (19 - 45) insp/min\n SpO2: 99%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 66 Inch\n CVP: 318 (5 - 332)mmHg\n Total In:\n 20,216 mL\n 10,878 mL\n PO:\n 900 mL\n TF:\n IVF:\n 9,792 mL\n 7,030 mL\n Blood products:\n 174 mL\n 3,848 mL\n Total out:\n 2,454 mL\n 1,098 mL\n Urine:\n 949 mL\n 438 mL\n NG:\n 675 mL\n Stool:\n Drains:\n 10 mL\n Balance:\n 17,762 mL\n 9,780 mL\n Respiratory\n Physical Examination\n General: Caucasian Female laying down in bed, tachypneic.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Crackles noted bilaterally.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 44 K/uL\n 7.8 g/dL\n 225 mg/dL\n 2.4 mg/dL\n 36 mg/dL\n 21 mEq/L\n 110 mEq/L\n 3.6 mEq/L\n 141 mEq/L\n 22.3 %\n 15.6 K/uL\n [image002.jpg]\n \n 2:33 A10/1/ 01:28 AM\n \n 10:20 P10/1/ 02:16 AM\n \n 1:20 P10/1/ 02:22 AM\n \n 11:50 P10/1/ 03:04 AM\n \n 1:20 A10/1/ 03:17 AM\n \n 7:20 P10/1/ 04:55 AM\n 1//11/006\n 1:23 P10/1/ 05:06 AM\n \n 1:20 P10/1/ 06:54 AM\n \n 11:20 P10/1/ 07:06 AM\n \n 4:20 P10/1/ 09:44 AM\n WBC\n 30.6\n 30.5\n 15.6\n Hct\n 24\n 13.8\n 12.7\n 12\n 30\n 22.3\n Plt\n 83\n 62\n 74\n 44\n Cr\n 2.5\n 2.4\n TC02\n 15\n 16\n 16\n 18\n 19\n 22\n Glucose\n 126\n 149\n 149\n 138\n 225\n Other labs: PT / PTT / INR:16.1/31.0/1.4, CK / CKMB / Troponin-T:374//,\n ALT / AST:62/152, Alk Phos / T Bili:152/1.3, Amylase / Lipase:/10,\n Differential-Neuts:90.0 %, Band:2.0 %, Lymph:6.0 %, Mono:2.0 %, Eos:0.0\n %, Fibrinogen:286 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:1.6 g/dL,\n LDH:326 IU/L, Ca++:7.4 mg/dL, Mg++:1.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 19 year old female 11 days post partum who presented to OSH with\n non-bloody diarrhea, found to be hypotensive with , admitted to ICU\n in septic shock and found to have ?nec fasc in pelvis, transferred to\n for OR debridement.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n .\n ##. Septic Shock: Pt currently in septic shock with leukocytosis,\n vasopressor requirement with suspected source pelvic flora given recent\n vaginal delivery. CT scan notable for gas within the left iliacus and\n piriformis and minimal phlegmon adjacent to the left sacroiliac joint\n with rarefaction of the left iliac bone. Pt received fluid\n resiscitation and has now been weaned down to Vasopressin. Currently on\n narrowed spectrum of Zosyn/Flagyl given 4/4 bottles of GN bacilli at\n OSH. Pt currently awaiting OR debridement tonight versus tomorrow\n - will continue to fluid resuscitate for goal MAP >65\n - will attempt to wean of pressors\n - will continue on Zosyn/Flagyl given GN Bacilli results at OSH\n - will f/u labs from hospital\n - will discuss with Ortho regarding debridement this evening, will also\n touch base with surgery as it is unclear where the collection\n originated from, may involve bowel\n - will place art line\n .\n #Thrombocytopenia: Pt noted to be thrombocytopenic with an initial plt\n of 22 which was trending up to 60s and now trending down to 40. Given\n that she will undergo surgery will give plts prior to surgery. Heme/Onc\n consulted regarding thrombocytopenia and recommend several titer tests\n to determine origin. Suspect thrombocytopenia may be from sepsis.\n - trend Plt counts q4hrs\n - will transfuse plts prior to surgery\n - will f/u infectious titers\n .\n #Acute Renal Failure: Most likely pre-renal versus ATN given pt's\n septic shock. Will continue to trend Creatinine and monitor urine\n output for a goal >30cc/hr\n - monitor UOP\n - trend Creatinine\n - consider renal consult in the AM\n .\n #LFT abnormalitis: Mild Transaminitis with rising direct bilirubinemia.\n Given low platelets, low albumin, increasing INR, possible that there\n is an underlying liver abnormality however, most likely hypotension\n but AFLP or cholestasis of pregnancy or cholangitis possible (though no\n pain). -trend LFTs\n -call for patient's OSH records for any prior medication exposures,\n underlying liver dz and most recent labs.\n .\n #Metabolic Acidosis: Both gap and non-gap acidosis with respiratory\n compensation. Likely gap due to sepsis/lactate and non-gap from renal\n failure and diarrhea. Given pt's last ABG showing hypoxia as well as\n upcoming surgery and tachypnea will electively intubate pt.\n -Serial ABGs for monitoring\n - will give HCO3 with fluids as mentioned above\n - will electively intubate\n .\n FEN: Will continue IVF fluid with NaHCO3 3 amps in 1L D5W, replete\n electrolytes, NPO.\n .\n Prophylaxis: Subutaneous heparin\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient, will touch base with surgical teams. Met with\n pt's mother and father regarding her treatment course.\n .\n Disposition: pending clinical improvement\n ------ Protected Section ------\n A-line was attempted to be placed several times by MICU team and\n Anaesthesia but was not successful. Pt underwent elective intubation\n which was complicated due to pt\ns anatomy. During intubation process pt\n was noted to be hypoxic down to 60%s, BP was also noted to drop down\n and was at one point not measurable by non-invasive BP. Whilst pt was\n noted to be trending down pt was given several litre boluses of LR,\n Neosynephrine gtt and bolus were also given. Pt\ns BP was noted to\n increase with bolus therapy and vasopressors. Following intubation pt\n BP was noted to improve with LR bolus, NaHCO3 MIVF and Neosynephrine\n was weaned down from 4 to 1.5. Dr. was called to assess pt\n given her decrease in BP and intubation difficulty. Radial art line and\n Femoral art line was attempted but not successful. Pt was then noted to\n drop her BPs with her legs appearing very mottled. Neo was increased\n and pt was given more boluses, given continued mottled appearance of\n lower extremity Levophed was start and Ortho/Surgery consulted stat for\n assessment for possible emergency debridement. Pt was noted to lose her\n pulse at the carotids and femoral. Code Blue was initiated and\n compressions were started, however with initial compression pt was\n noted to be agitated. Carotids and Femoral pulses were rechecked and\n were found, however after several minutes her pulses became thready and\n weak. Ortho was notified and recommended having surgery evaluate her.\n Surgery then came to bedside and assessed patient. Given her acute\n decompensation as well as increased pressor requirements emergency\n surgery was warranted and Ortho were called in to perform emergency\n washout and debridement. Surgery attempted A-line placement but were\n not successful in the radial and femoral arteries. CBC, INR,\n Electrolytes were rechecked, pt was given K+ 80Meq due to her HCO3\n load, pt was ordered for plts as well as FFPs. Family were notified of\n pt\ns change in status and need for emergency surgery. Talked to \n (pt\ns mother) who stated she would immediately come to the hospital\n with her family. At approximately 11pm pt was taken down to the OR. Met\n with family with Dr. and Dr. present to given update on\n change of status. As pt will be going down to OR for surgical\n debridement for possible nec fasc pt will transfer to Surgical ICU\n service when she returns.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:59 ------\n" }, { "category": "Physician ", "chartdate": "2199-10-04 00:00:00.000", "description": "Intensivist Note", "row_id": 488736, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At patient evaluated by OB gyn and a Vaginal US was\n performed which did not show retained products. Refused bimanual\n exam. Pt now on three pressors, increasing renal failure,\n increased WBC in 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n septic shock\n PMHx:\n PMHx: G1P1\n .\n PShx: Tonsillectomy, episotomy\n .\n : None\n .\n All: NKDA\n .\n SHx: NC\n .\n Fhx: NC\n .\n Current medications:\n Albumin 5% (25g / 500mL) 2. Bisacodyl 3. Calcium Gluconate 4. Calcium\n Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Clindamycin 7. Famotidine 8. Fentanyl Citrate 9. Heparin 10.\n Magnesium Sulfate Replacement (Oncology)\n 11. MetRONIDAZOLE (FLagyl) 12. Midazolam 13. Norepinephrine 14.\n Ondansetron 15. Phenylephrine 16. Piperacillin-Tazobactam\n 17. Potassium Chloride Replacement (Oncology) 18. Potassium Phosphate\n 19. Senna 20. Sodium Chloride 0.9% Flush\n 21. Sodium Chloride 0.9% Flush 22. Vasopressin 23. Vancomycin\n 24 Hour Events:\n - Pt continued to show evidence of septic shock, with hyperdynamic CO\n and requiring triple pressors for BP mgmt. monitor placed. Urine\n output laging and multiple blood products given in context of presumed\n hypovolemia, anemia, and thrombocytopenia. ID consulted and\n recommending d/c flagyl and addition of clindamycin for eagle effect.\n CORDIS/INTRODUCER - START 08:00 AM\n ARTERIAL LINE - START 08:00 AM\n Sheath/aline from angiography suite. flushes easily with good blood\n return.\n ARTERIAL LINE - START 11:30 AM\n ultrasound guided placement of left axillary aline\n ARTERIAL LINE - STOP 05:26 PM\n MULTI LUMEN - START 06:30 PM\n Line placed previous shift confirmed by xray outgoing RN.\n CORDIS/INTRODUCER - STOP 06:35 PM\n MULTI LUMEN - STOP 06:38 PM\n Line placed previous shift confirmed by xray outgoing RN.\n Post operative day:\n POD#1 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Vancomycin - 09:48 AM\n Metronidazole - 01:00 AM\n Piperacillin - 05:37 AM\n Clindamycin - 06:16 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.16 mcg/Kg/min\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 97 (87 - 113) bpm\n BP: 101/71(84) {85/50(63) - 140/92(110)} mmHg\n RR: 28 (6 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 23 (14 - 323) mmHg\n Total In:\n 13,772 mL\n 1,811 mL\n PO:\n Tube feeding:\n 240 mL\n 9 mL\n IV Fluid:\n 7,838 mL\n 718 mL\n Blood products:\n 5,574 mL\n 1,084 mL\n Total out:\n 1,411 mL\n 85 mL\n Urine:\n 611 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 12,361 mL\n 1,726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.9 cmH2O/mL\n SPO2: 97%\n ABG: 7.34/40/101/21/-3\n Ve: 9.9 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : , Rhonchorous : )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present, No(t) Diminished), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities, Sedated\n Labs / Radiology\n 59 K/uL\n 10.1 g/dL\n 134 mg/dL\n 2.6 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 39 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.4 %\n 14.3 K/uL\n [image002.jpg]\n 07:06 AM\n 09:44 AM\n 10:56 AM\n 03:12 PM\n 03:45 PM\n 05:02 PM\n 09:47 PM\n 10:05 PM\n 02:02 AM\n 02:29 AM\n WBC\n 18.4\n 12.1\n 14.3\n Hct\n 22.2\n 29.0\n 23.7\n 28.4\n Plt\n 33\n 47\n 26\n 59\n Creatinine\n 2.4\n 2.5\n 2.6\n TCO2\n 19\n 22\n 22\n 22\n 23\n Glucose\n 145\n 145\n 144\n 134\n Other labs: PT / PTT / INR:14.2/24.9/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:96/145, Alk-Phos / T bili:96/1.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:286 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Imaging: Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n Vaginal US: 8mm endometrial stripe, no retained products\n seen\n CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR unofficial - decreased haziness, no cardiomegaly\n .\n Assessment and Plan\n ALTERATION IN NUTRITION, INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Assessment: 19F G1P1 PP 11 with severe septic shock due to acute\n osteomyelitis of left hip, now s/p debridement of left hip and\n angiography.\n .\n Plan: 19F post partum now w/septic shock, multiorgan failure\n Neuro: midaz/fentanyl for sedation/analgesia. Attempted wean of\n midazolam, wake-up not tolerated. Avoiding use of propofol secondary\n to potential decrease in SVR.\n CV: requiring 2 pressors (levo, vasopressin); will wean as tolerated;\n monitoring in RIght Ax a line, unreliable values given double\n counting of dicrotic notch in aline tracing, despite adjustment of\n catheter. Echo WNL with mild MR. now.\n Resp: ventilated, ARDS protocol, esophageal balloon.\n GI: NGT in place. TF at 20.\n Renal: acute renal failure, likely ATN; with decreased preload in\n context of decreased FENa. Will follow creatinine and UOP . Check\n urine sediment. Renal following, may need dialysis.\n Endo:Random cortisol WNL\n Heme: given 7U PRBCs, 1U ffp 2U plt, 1U cryo on floor prior to angio.\n Post angio recieved 2u RBC, 2u plt, 1FFP, 250 albumin. Follow Hcts.\n Thrombocytopenia sepsis, transfuse for PLTs <80 given OR today.\n ID: empiric coverage for osteomyelitis with vanc/zosyn d/c flagyl &\n clinda per ID recs. GNR at OSH. f/u speciation/sensitivities ID\n consulting . Vanco level.\n Ortho: Plan for washout this AM\n Gyn: Plan for d&c for potential infectious source during AM OR with\n Ortho.\n Prophylaxis: boots, PPI\n Code status: FULL\n Consults: ortho, gyn, IR, ID\n Communication:\n :\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 40 min\n" }, { "category": "Nursing", "chartdate": "2199-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490154, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains paralyzed and sedated on fentanyl, versed, and cisatricurium\n gtts\n - T 101.7 this evening (previous culture @ 0400)\n - Tachycardic with elevated temp, up to \n - BP stable, remains off presssors\n - Lungs diminished with exp wheezes\n - Sats stable on current settings with episode desat to low 80\ns with\n turn\n - Improving sats this am > 97% consistently\n paO2 >100\n - Rash on body worsening over night\n - Area around hip incision with + erytherma but difficult to\n distinguish rash from erythema around site\n - Continues to make good urine output\n Action:\n - Per Dr unable to increase frequency of Tylenol or add Motrin\n so at placed on cooling blanket with ice packs\n - Cool bath given\n - Albuterol MDI frequency increased\n - Suction d/t increasing rhonchi but minimal secretions\n - Dr notified of worsening rash\n - ORTHO resident in this am and assessed hip incision\n Response:\n - Fever down to normal but increasing again this morning\n - HR down to 90\ns with normal temp but increasing again this am with\n fever\n - BUN / CReat down this am\n Plan:\n Plan to wean peep to 12 today, increased vanco dose d/t low through\n yesterday, ? d/c cipro as most likely contributor to drug rash. Dr\n aware rash worse overnight despite no additional cipro dose.\n Monitor rash and hip incision.\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488576, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n None responsive to noxious stimuli with absent gag/cough reflex. Perrl\n 4-5mm/brisk bilaterally. Monitor shows SR/ST without ectopy with bp\n 104/61 and map 70 and CVP 14-16 and pressor support of levophed at\n .15mcg/kg/min and vasopressin at 1.2units/hr. Maintained on vent\n support CMV 60%/500/5/28. Lungs clear bilaterally with minimal\n secretions. 02 sat 96-98%. Uo 25-100cc/hr with bun/cr 36 and 2.4\n respectively.\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489439, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n received at change of shift on CMV with 18 peep, Fio2 50%\n sats 94-97%\n bs with scattered rhonchi throughout and occasional\n inspiratory/expiratory wheezes\n suctioned for sm amts thick yellow sputum\n Action:\n vigorous pulmonary toilet\n triadyne bed with rotation and percussion\n placed in swimmers position for 2\n hours this am\n peep decreased to 17 and then to 15\n Response:\n improved PO2 to 144 on 17 peep,\n sats decreased to 88% when peep dropped to 15 requiring increase in\n peep back to 18 and Fi02 to 70%\n Plan:\n slowly wean Fio2 back down to 50% (currently on 60%)\n wean peep slowly\n continue to rotate patient and use percussion\n attempt swimmers position x per shift\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-10-08 00:00:00.000", "description": "Intensivist Note", "row_id": 489569, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n .\n Chief complaint:\n sepsis\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Cisatracurium Besylate\n Famotidine\n Fentanyl Citrate\n Furosemide\n Heparin\n Insulin\n Meropenem\n Midazolam\n Vancomycin\n 24 Hour Events:\n Weaned off pressors. Did not tolerate decrease in PEEP to 15,\n recovered after returning to 18. Continues diuresis on lasix drip.\n Persistently febrile with mild tachycardia. Resent blood and urine\n cultures.\n BLOOD CULTURED - At 11:00 PM\n SPUTUM CULTURE - At 05:16 AM\n URINE CULTURE - At 05:16 AM\n FEVER - 101.4\nF - 05:00 AM\n Post operative day:\n POD#5 - I & D Lt ileum and Sacroiliac joint debridement\n POD#4 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 07:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:11 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 7 mg/hour\n Fentanyl - 450 mcg/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 AM\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.6\nC (101.4\n HR: 116 (95 - 116) bpm\n BP: 109/64(80) {91/50(64) - 121/75(92)} mmHg\n RR: 20 (3 - 28) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (13 - 26) mmHg\n Total In:\n 3,380 mL\n 697 mL\n PO:\n Tube feeding:\n 480 mL\n 119 mL\n IV Fluid:\n 2,300 mL\n 579 mL\n Blood products:\n 600 mL\n Total out:\n 3,925 mL\n 1,305 mL\n Urine:\n 3,925 mL\n 1,305 mL\n NG:\n Stool:\n Drains:\n Balance:\n -545 mL\n -608 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 33 cmH2O\n Compliance: 24.5 cmH2O/mL\n SPO2: 98%\n ABG: 7.41/41/109/25/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Crackles : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Cool)\n Right Extremities: (Edema: 2+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 62 K/uL\n 8.9 g/dL\n 106 mg/dL\n 3.3 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 49 mg/dL\n 104 mEq/L\n 138 mEq/L\n 25.6 %\n 9.0 K/uL\n [image002.jpg]\n 04:32 PM\n 04:40 PM\n 10:17 PM\n 02:17 AM\n 02:27 AM\n 06:24 AM\n 12:07 PM\n 05:14 PM\n 02:11 AM\n 02:26 AM\n WBC\n 12.9\n 10.3\n 9.0\n Hct\n 28.7\n 28.4\n 25.6\n Plt\n 45\n 50\n 62\n Creatinine\n 3.2\n 3.3\n 3.3\n TCO2\n 24\n 24\n 26\n 28\n 24\n 22\n 27\n Glucose\n 90\n 94\n 90\n 103\n 101\n 106\n Other labs: PT / PTT / INR:17.9/31.6/1.6, CK / CK-MB / Troponin\n T:374//, ALT / AST:17/23, Alk-Phos / T bili:167/4.7, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:627 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:3.2\n mg/dL\n Imaging: : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n Microbiology: Micro:\n - Outside hospital BCx GNR, species pending.\n - BCx - NGTD\n - Wound Cx (OR) - GNR ( samples)\n - UCx - negative\n - BCx - pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course\n Neuro: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. Will consider weaning muscle relaxant or giving\n paralytic holiday.\n CV: s/p triple pressors; monitoring\n Resp: AC 0.5, 28x350, PEEP 18, ARDS protocol, daily CXR, wean as\n tolerated\n FEN/GI: NGT in place. TF Impact at 20mL/hr. H2B\n Renal: ARF with lasix drip and adequate diuresis. Following daily\n creatinine with albumin to promote extravascular diuresis\n Endo: Random cortisol WNL, RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Mild anemia with goal Hct 30,\n transfuse PRBCs prn. Thrombocytopenic, ?BM suppression. SQH and boots\n ID: Vanc/ for GNR from wound and blood cx from OSH. F/u\n speciation/sensitivities. ID consulting. Monitor vanco level.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Gyn: S/p D&C; no further plans at this time.\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Communication:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:46 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2199-10-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488644, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Sbp ranging 90\ns-100\ns on vasopressin and levophed. HR 100\ns, sinus/no\n ectopy. Urine ouput 10-15cc\ns/hr, Creatinine increasing 2.5 -> 2.6\n (from 2.4). Plt count 26. Hct 23.7 (from 29), no outward signs of\n bleeding. Left hip dressing intact, jp no longer able to maintain\n suction (sicu h.o.o aware). K+ 3.4.\n Action:\n Levophed and vasopressin rates unchanged. Pt received 500cc\ns of 5%\n albumin. Pt also received 2 units platelets, 2 units prbc. Received\n 60meq of Kcl\n Response:\n Plt count improved to 59, hct improved to 28.4. Urine output remains\n poor.\n Plan:\n Monitor labs, monitor urine output, wean pressors as tolerated, to o.r\n this morning for washout and possible D&C.\n Pain control (acute pain, chronic pain)\n Assessment:\n Fentynal gtt infusing at 100mcg/hr, Versed at 1mg/hr. Pt appears\n uncomfortable and anxious with stimulation/turning\n Action:\n Fentynal gtt increased gradually to 200mcg/hr. Versed increased to\n 2mg/hr.\n Response:\n Pt appears more comfortable.\n Plan:\n Continue to monitor and titrate sedation/pain medication as necessary.\n" }, { "category": "Physician ", "chartdate": "2199-10-04 00:00:00.000", "description": "Intensivist Note", "row_id": 488710, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At patient evaluated by OB gyn and a Vaginal US was\n performed which did not show retained products. Refused bimanual\n exam. Pt now on three pressors, increasing renal failure,\n increased WBC in 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n septic shock\n PMHx:\n PMHx: G1P1\n .\n PShx: Tonsillectomy, episotomy\n .\n : None\n .\n All: NKDA\n .\n SHx: NC\n .\n Fhx: NC\n .\n Current medications:\n Albumin 5% (25g / 500mL) 2. Bisacodyl 3. Calcium Gluconate 4. Calcium\n Gluconate 5. Chlorhexidine Gluconate 0.12% Oral Rinse\n 6. Clindamycin 7. Famotidine 8. Fentanyl Citrate 9. Heparin 10.\n Magnesium Sulfate Replacement (Oncology)\n 11. MetRONIDAZOLE (FLagyl) 12. Midazolam 13. Norepinephrine 14.\n Ondansetron 15. Phenylephrine 16. Piperacillin-Tazobactam\n 17. Potassium Chloride Replacement (Oncology) 18. Potassium Phosphate\n 19. Senna 20. Sodium Chloride 0.9% Flush\n 21. Sodium Chloride 0.9% Flush 22. Vasopressin 23. Vancomycin\n 24 Hour Events:\n - Pt continued to show evidence of septic shock, with hyperdynamic CO\n and requiring triple pressors for BP mgmt. monitor placed. Urine\n output laging and multiple blood products given in context of presumed\n hypovolemia, anemia, and thrombocytopenia. ID consulted and\n recommending d/c flagyl and addition of clindamycin for eagle effect.\n CORDIS/INTRODUCER - START 08:00 AM\n ARTERIAL LINE - START 08:00 AM\n Sheath/aline from angiography suite. flushes easily with good blood\n return.\n ARTERIAL LINE - START 11:30 AM\n ultrasound guided placement of left axillary aline\n ARTERIAL LINE - STOP 05:26 PM\n MULTI LUMEN - START 06:30 PM\n Line placed previous shift confirmed by xray outgoing RN.\n CORDIS/INTRODUCER - STOP 06:35 PM\n MULTI LUMEN - STOP 06:38 PM\n Line placed previous shift confirmed by xray outgoing RN.\n Post operative day:\n POD#1 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Vancomycin - 09:48 AM\n Metronidazole - 01:00 AM\n Piperacillin - 05:37 AM\n Clindamycin - 06:16 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.16 mcg/Kg/min\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 97 (87 - 113) bpm\n BP: 101/71(84) {85/50(63) - 140/92(110)} mmHg\n RR: 28 (6 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 23 (14 - 323) mmHg\n Total In:\n 13,772 mL\n 1,811 mL\n PO:\n Tube feeding:\n 240 mL\n 9 mL\n IV Fluid:\n 7,838 mL\n 718 mL\n Blood products:\n 5,574 mL\n 1,084 mL\n Total out:\n 1,411 mL\n 85 mL\n Urine:\n 611 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 12,361 mL\n 1,726 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.9 cmH2O/mL\n SPO2: 97%\n ABG: 7.34/40/101/21/-3\n Ve: 9.9 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Crackles : , Rhonchorous : )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present, No(t) Diminished), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities, Sedated\n Labs / Radiology\n 59 K/uL\n 10.1 g/dL\n 134 mg/dL\n 2.6 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 39 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.4 %\n 14.3 K/uL\n [image002.jpg]\n 07:06 AM\n 09:44 AM\n 10:56 AM\n 03:12 PM\n 03:45 PM\n 05:02 PM\n 09:47 PM\n 10:05 PM\n 02:02 AM\n 02:29 AM\n WBC\n 18.4\n 12.1\n 14.3\n Hct\n 22.2\n 29.0\n 23.7\n 28.4\n Plt\n 33\n 47\n 26\n 59\n Creatinine\n 2.4\n 2.5\n 2.6\n TCO2\n 19\n 22\n 22\n 22\n 23\n Glucose\n 145\n 145\n 144\n 134\n Other labs: PT / PTT / INR:14.2/24.9/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:96/145, Alk-Phos / T bili:96/1.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:286 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Imaging: Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n Vaginal US: 8mm endometrial stripe, no retained products\n seen\n CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR unofficial - decreased haziness, no cardiomegaly\n .\n Assessment and Plan\n ALTERATION IN NUTRITION, INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Assessment: 19F G1P1 PP 11 with severe septic shock due to acute\n osteomyelitis of left hip, now s/p debridement of left hip and\n angiography.\n .\n Plan: 19F post partum now w/septic shock, multiorgan failure\n Neuro: midaz/fentanyl for sedation/analgesia. Attempted wean of\n midazolam, wake-up not tolerated. Avoiding use of propofol secondary\n to potential decrease in SVR.\n CV: requiring 2 pressors (levo, vasopressin); will wean as tolerated;\n monitoring in RIght Ax a line, unreliable values given double\n counting of dicrotic notch in aline tracing, despite adjustment of\n catheter. Echo WNL with mild MR.\n Resp: ventilated, ARDS protocol, low tidal volumes in context of high\n pressures, esophageal balloon.\n GI: NGT in place. TF at 20\n Renal: acute renal failure; with decreased preload in context of\n decreased FENa. mucomyst and bicarb given prior to angio; will follow\n creatinine and UOP\n Endo:Random cortisol WNL\n Heme: downtrailing serial Hct ; given 7U PRBCs, 1U ffp 2U plt, 1U cryo\n on floor prior to angio. Post angio recieved 2u RBC, 2u plt, 1FFP, 250\n albumin\n ID: empiric coverage for osteomyelitis with vanc/zosyn/clinda d/c\n flagyl. GNR at OSH. f/u speciation/sensitivities ID consulting .\n Vanco level.\n Ortho: Plan for washout this AM\n Gyn: Plan for d&c for potential infectious source during AM procedure\n Prophy: boots\n Code status: FULL\n Consults: ortho, gyn, IR, ID\n Communication:\n :\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2199-10-04 00:00:00.000", "description": "Intensivist Note", "row_id": 488719, "text": "SICU\n HPI:\n 55 y.o. Male w/ extensive medical history including severe\n CAD/mult stents/last LAD , DM, CKD III (creat 1.5), PAD,\n known brainstem meningioma, chronic hyponatremia, h/o congential\n pulm stenosis s/p valvuloplasty, Afib s/p ablation on coumadin\n Reccent admission for tooth extraction noted to have 1.1 x 1cm C1/C2\n spinal mass causing severe spinal narrowing and cord compression. .\n He has also had issue with lower extremity cellulitis that has\n been noted to poorly heal due to pt's poor peripheral vascular\n disease. On evaluation by the medicine team the RLE particularly\n the right heel showed concerns of an infection.\n for anterior fusion of c4/c5. Procedure unremarkable, but\n required awake FOI secondary to cervical mass. Decision to come to\n SICU remaining intubated in anticipation of return to OR following day\n to address C1 compression and possible C56 posterior fusion\n Chief complaint:\n upper extremity weakness\n PMHx:\n All: PCN/keflex\n .\n PMH\n (1) Type 2 diabetes mellitus, requiring insulin, and the\n complications from years of poor glycemic control:\n -hypertension\n -severe peripheral vascular disease\n -peripheral neuropathy\n -pressure, venous stasis, and neuropathic ulcers on his right\n and left lower extremities\n -stage 3 diabetic nephropathy\n -renal insufficiency (baseline creatinine 1.5 to 1.7)\n (2) Atrial fibrillation status post ablation and , on\n coumadin\n (3) Congenital pulmonic valve stenosis status post two childhood\n surgeries\n -history of RV failure\n -history of peripheral edema and anasarca\n (4) Chronic hyponatremia\n (5) Chronic low back pain status post car accident\n (6) Spinal cord meningioma compressing his spinal cord at C1/C2\n (7) COPD\n (8) Coronary artery disease status post stenting (bare\n metal stent by Dr. ()) and repeat\n stenting at in (bare metal stent - see d/c summary\n )\n (9) MI in \n .\n : Docusate Sodium,Furosemide, Ascorbic Acid, Pantoprazole,\n metoprolol, trazodone, APAP, Petrolatum Ointment, Methocarbamol,\n Albuterol, Actuation, Hydromorphone, Simvastatin, Senna, Hydroxyzine,\n Polyethylene Glycol, Bisacodyl, ativan, Ketoconazole, Glycerin supp,\n vicodin, Heparin drip.\n Current medications:\n . 2. Albuterol Inhaler 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Clonazepam 5. Famotidine\n 6. Gentamicin 7. HYDROmorphone (Dilaudid) 8. HydrOXYzine 9.\n Hydrocodone-Acetaminophen 10. Influenza Virus Vaccine\n 11. Insulin 12. Ketoconazole 2% 13. Metoprolol Tartrate 14.\n Methocarbamol 15. Metoprolol Tartrate\n 16. Propofol 17. Sodium Chloride 0.9% Flush 18. Vancomycin\n 24 Hour Events:\n No major events overnight. To OR this AM\n CORDIS/INTRODUCER - START 08:00 AM\n ARTERIAL LINE - START 08:00 AM\n Sheath/aline from angiography suite. flushes easily with good blood\n return.\n ARTERIAL LINE - START 11:30 AM\n ultrasound guided placement of left axillary aline\n ARTERIAL LINE - STOP 05:26 PM\n MULTI LUMEN - START 06:30 PM\n Line placed previous shift confirmed by xray outgoing RN.\n CORDIS/INTRODUCER - STOP 06:35 PM\n MULTI LUMEN - STOP 06:38 PM\n Line placed previous shift confirmed by xray outgoing RN.\n Post operative day:\n POD#1 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Vancomycin - 09:48 AM\n Metronidazole - 01:00 AM\n Piperacillin - 05:37 AM\n Clindamycin - 06:16 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.16 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 93 (89 - 113) bpm\n BP: 97/68(80) {85/50(63) - 131/86(103)} mmHg\n RR: 0 (0 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 23 (14 - 323) mmHg\n Total In:\n 13,772 mL\n 1,824 mL\n PO:\n Tube feeding:\n 240 mL\n 9 mL\n IV Fluid:\n 7,838 mL\n 731 mL\n Blood products:\n 5,574 mL\n 1,084 mL\n Total out:\n 1,411 mL\n 85 mL\n Urine:\n 611 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 12,361 mL\n 1,739 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.9 cmH2O/mL\n SPO2: 97%\n ABG: 7.34/40/101/21/-3\n Ve: 9.9 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 3+), (Pulse - Dorsalis pedis: Diminished),\n (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Pulse - Dorsalis pedis: Diminished),\n (Pulse - Posterior tibial: Diminished)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 59 K/uL\n 10.1 g/dL\n 134 mg/dL\n 2.6 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 39 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.4 %\n 14.3 K/uL\n [image002.jpg]\n 07:06 AM\n 09:44 AM\n 10:56 AM\n 03:12 PM\n 03:45 PM\n 05:02 PM\n 09:47 PM\n 10:05 PM\n 02:02 AM\n 02:29 AM\n WBC\n 18.4\n 12.1\n 14.3\n Hct\n 22.2\n 29.0\n 23.7\n 28.4\n Plt\n 33\n 47\n 26\n 59\n Creatinine\n 2.4\n 2.5\n 2.6\n TCO2\n 19\n 22\n 22\n 22\n 23\n Glucose\n 145\n 145\n 144\n 134\n Other labs: PT / PTT / INR:14.2/24.9/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:96/145, Alk-Phos / T bili:96/1.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:286 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Imaging: CT Cervical Spine - Post surgical changes with subcutaneous\n emphysema, and new interval placement of anterior fusion hardware at\n C5-C6 level, with no definite evidence of immidiate complication.\n - Stable mass, likely meningeoma at C1 level, with associated canal\n compression, as described in more details on recent MRI of the C-spine.\n Assessment and Plan\n ALTERATION IN NUTRITION, INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Neuro: C1/C2 meningioma: Pt has known meningioma\n impinging the\n spinal cord at the level of C1/C2, which may cause some of pt's\n neurological symptoms and debilitation. Periodic wakeup tests over\n course of evening to assess neuro fx. Cervical CT. Propofol for\n sedation, diluadid pain. Return to OR in AM for posterior fusion and\n removal of meningioma.\n CVS: h/o of Afib and HTN, continuing home meds including PRN IV\n metoprolol\n Pulm: Difficult intubation secondary to cervical compression. Keep\n intubated overnight in anticipation of returning to OR in AM\n GI/FEN: GI propylaxis, IVF\n Renal: CRF\n Endo: DMII, checking BS, insulin SS. Vascular consulted for lower ext\n mottling. Recommending plavix and compression. Holding plavix in\n context of procedure.\n ID: perioperative vancomycin/gentamycin - levels to be obtained\n Wounds/injuries:\n Consults: Vascular, needs medical consult\n Code: Full\n Neurologic:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489335, "text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Known difficult intubation Yes\n Procedure location:\n Reason: emergent\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n :\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Bedside Procedures:\n Comments: Pt has esophageal balloon in place. No measurements made this\n shift. Pt remains on ARDSNET.\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489437, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489440, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n received at change of shift on CMV with 18 peep, Fio2 50%\n sats 94-97%\n bs with scattered rhonchi throughout and occasional\n inspiratory/expiratory wheezes\n suctioned for sm amts thick yellow sputum\n remains paralyzed on cistatcurium\n fentanyl and versed gtts for sedation while on high peep and paralytic\n Action:\n vigorous pulmonary toilet\n triadyne bed with rotation and percussion\n placed in swimmers position for 2\n hours this am\n peep decreased to 17 and then to 15\n Response:\n improved PO2 to 144 on 17 peep,\n sats decreased to 88% when peep dropped to 15 requiring increase in\n peep back to 18 and Fi02 to 70%\n Plan:\n slowly wean Fio2 back down to 50% (currently on 60%)\n wean peep slowly\n continue to rotate patient and use percussion\n attempt swimmers position x per shift\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n temp 100.1-100.3\n received patient at change of shift on levo at 0.03 mcg/kg/min\n lasix gtt at 5mg with good urine output\n incision clean and draining moderate amounts serous fluid\n vanco level 16.9\n Action:\n vancomycin renally dosed and pt given 750mg q48hrs\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489267, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n Bedside Procedures:\n Pleural pressure measurement (10:00)\n Comments:\n Esophageal balloon placed, TP=16\n" }, { "category": "Respiratory ", "chartdate": "2199-10-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488897, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated; Comments: Pa02 dropped when\n peep was decreased.Will decrease peep slowly as tol.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Will cont tot monitor resp status.\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489326, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on AC 350 x 28 peep 18 fiO2\n - Lungs with rhonchi throughout and wheezes right > left\n - Sats improved sustaining in mid to high 90\ns when rotating\n and on swimmers on right\n - Sats low 90\ns when on swimmers on left\n - PaO2s improved 90-100\n Action:\n - Positioned in swimmers once each on each side\n - Continuous rotation when not in swimmers position\n - Frequent percussion when rotating\n -\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2199-10-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 489414, "text": "Subjective: Tube feeds at 20mL/hr, tolerating RN.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 95.5 kg\n 111.3 kg ( )\n 33.9\n Pertinent medications: Cisatracurium, Fentanyl, Versed,\n Norephinephrine, lasix drip, famotidine, others noted\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 02:17 AM\n Glucose Finger Stick\n 92\n 10:00 AM\n BUN\n 48 mg/dL\n 02:17 AM\n Creatinine\n 3.3 mg/dL\n 02:17 AM\n Sodium\n 141 mEq/L\n 02:17 AM\n Potassium\n 3.9 mEq/L\n 02:17 AM\n Chloride\n 108 mEq/L\n 02:17 AM\n TCO2\n 22 mEq/L\n 02:17 AM\n PO2 (arterial)\n 144 mm Hg\n 12:07 PM\n PCO2 (arterial)\n 37 mm Hg\n 12:07 PM\n pH (arterial)\n 7.41 units\n 12:07 PM\n pH (urine)\n 5.0 units\n 10:25 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 12:07 PM\n Albumin\n 2.3 g/dL\n 02:12 AM\n Calcium non-ionized\n 8.1 mg/dL\n 02:17 AM\n Phosphorus\n 3.3 mg/dL\n 02:17 AM\n Ionized Calcium\n 1.03 mmol/L\n 12:07 PM\n Magnesium\n 2.1 mg/dL\n 02:17 AM\n ALT\n 21 IU/L\n 02:17 AM\n Alkaline Phosphate\n 133 IU/L\n 02:17 AM\n AST\n 20 IU/L\n 02:17 AM\n Total Bilirubin\n 6.3 mg/dL\n 02:17 AM\n WBC\n 10.3 K/uL\n 02:17 AM\n Hgb\n 9.8 g/dL\n 02:17 AM\n Hematocrit\n 28.4 %\n 02:17 AM\n Current diet order / nutrition support: Tube Feeds: Impact with Fiber @\n 20mL/hr\n GI: abd soft, hypoactive bowel sounds\n Assessment of Nutritional Status\n 19 y.o. female 13 days post-partum from NSVD presents with nausea,\n diarrhea, weakness and back/abd pain, found to have osteomyelitis of\n left hip. Patient s/p washout/debridement of infection , c/b\n bleeding requiring coiling x10 in angio. Patient remains intubated,\n sedated and on pressor x1, also paralyzed and on ARDS protocol.\n Trophic tube feeds are running via NGT, patient is tolerating with no\n residuals, however has not had a BM since admit. Patient is in\n swimmers position, and HOB is kept 30degrees RN. Recommend\n continue with trophic tube feeds; if patient unable to have tube feed\n rate advanced, patient may need TPN temporarily.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with tube feeds, with eventual goal of Impact with\n Fiber @ 70mL /hr (1680kcals, 94g protein).\n Check residuals q4hrs, hold if greater than 150mL.\n Monitor abd exam closely. Recommend bowel regimen for BM.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489486, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n received at change of shift on CMV with 18 peep, Fio2 50%\n sats 94-97%\n bs with scattered rhonchi throughout and occasional\n inspiratory/expiratory wheezes\n suctioned for sm amts thick yellow sputum\n remains paralyzed on cistatcurium\n fentanyl and versed gtts for sedation while on high peep and paralytic\n Action:\n vigorous pulmonary toilet\n triadyne bed with rotation and percussion\n placed in swimmers position for 2\n hours this am on right side\n peep decreased to 17 and then to 15\n attempted to place in swimmers position on left side at 1530\n Response:\n improved PO2 to 144 on 17 peep, when in right swimmers position\n sats decreased to 88% when peep dropped to 15 requiring increase in\n peep back to 18 and Fi02 to 70%\n desat to 78% when in left swimmers position= placed on back, suctioned\n Plan:\n slowly wean Fio2 back down to 50% (currently on 60%)\n wean peep slowly\n continue to rotate patient and use percussion\n attempt swimmers position x per shift\n continue cistatacurium , fentanyl and versed gtts\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n temp 100.1-100.3\n received patient at change of shift on levo at 0.03 mcg/kg/min\n lasix gtt at 5mg with good urine output\n incision clean and draining moderate amounts serous fluid\n vanco level 16.9\n Action:\n vancomycin renally dosed and pt given 750mg q48hrs\n levo weaned to off with map >65\n lasix gtt weaned to 4mg/hr\n pt given 500cc albumin this am\n Response:\n Bp stable off levophed\n Continues to diuresis on lower lasix dose\n Plan:\n Continue to monitor hemodynamics\n Maintain lasix gtt at current level\n Await culture reports from yesterday\n Monitor labs including wbc\n" }, { "category": "Respiratory ", "chartdate": "2199-10-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489478, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm atincisor\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Hemodynimic instability, Underlying\n illness not resolved\n Bedside Procedures:\n Pleural pressure measurement (17:00)\n Comments:\n TP press 18, -4\n" }, { "category": "Respiratory ", "chartdate": "2199-10-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489546, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved.Esophageal balloon remains in place\n with no measurements made this shift.\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489984, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 04:30 AM\n Vancomycin - 08:10 AM\n Infusions:\n Fentanyl - 400 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Flowsheet Data as of 01:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.8\nC (100\n HR: 107 (98 - 126) bpm\n BP: 95/50(66) {95/48(65) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 16 (15 - 23) mmHg\n Total In:\n 2,908 mL\n 1,990 mL\n PO:\n Tube feeding:\n 741 mL\n 549 mL\n IV Fluid:\n 1,767 mL\n 1,341 mL\n Blood products:\n 400 mL\n 100 mL\n Total out:\n 3,380 mL\n 1,495 mL\n Urine:\n 3,380 mL\n 1,495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -472 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/45/85./24/-1\n Ve: 9.7 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact, Erythema), some blanching\n erythema noted around incision site\n Neurologic: (Responds to: Unresponsive), Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 118 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n 09:13 AM\n WBC\n 10.2\n 7.6\n Hct\n 33\n 28.1\n 24.8\n Plt\n 79\n 70\n Creatinine\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n 25\n Glucose\n 107\n 115\n 113\n 107\n 118\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Imaging: CXR: persistent hazy opacities B\n Microbiology: SPUTUM:\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Commensal Respiratory Flora Absent.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n GRAM POSITIVE RODS.\n CONSISTENT WITH CLOSTRIDIUM\n OR\n BACILLUS SPECIES.\n TISSUE: Fusobacterium\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n Neurologic: paralyzed with Cis, on fent/midaz.\n Cardiovascular: HD stable, off pressors.\n Pulmonary: Cont ETT, (Ventilator mode: CMV); wean PEEP slowly, if\n stable consider d/c Cis\n Gastrointestinal / Abdomen: NGT in place.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, No need for CVVH. Diuresing well with PRN\n lasix.\n Hematology: Serial Hct, Stable anemia.\n Endocrine: RISS\n Infectious Disease: Check cultures, Discussed with ID coverage given\n new cx data: Fusobacterium and a Gram positive rod (? clostridium vs\n bacillus species), continue current regimen. CT torso to eval for\n collection. Change R IJ CVL and send tip for cx.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings, Follow wound.\n Imaging: CXR today, LE vascular US , Ct torso today. RUQ u/s and LENIS\n today.\n Fluids: KVO\n Consults: Ortho, Gynecology, Nephrology, Nutrition\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines: R IJ CVL\n change line, A-line\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: sq hep, boots\n Stress ulcer: H2\n VAP bundle: HOB > 30, mouth care, no daily wake-up (paralyzed),\n Comments:\n Communication:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 min\n" }, { "category": "Physician ", "chartdate": "2199-10-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488198, "text": "Chief Complaint: hypotension\n HPI:\n History of Present Illness: 19 year old female G1P1 11 days post partum\n who presented to OSH yesterday with hypotension. Patient notes that\n she had an uncomplicated pregnancy without hypertension or DM,\n delivered vaginally in 3.5 hours with episiotomy, denies spinal\n anesthesia or any other spinal block. She was never hypotensive. She\n felt well when she got home, but then had increasing fatigue,\n intermittent loose stool but denied fever, chills, abdominal pain,\n nausea, vomiting, vaginal bleeding or discharge, bleeding, bruising or\n rash. Over the last 5 days she has increased watery, non-bloody\n diarrhea and dizziness with standing and extreme fatigue. She reports\n one episode of vision loss associated with standing up. She denies any\n sick contact, new or uncooked foods or cheeses, drugs, ETOH, ingestion,\n exposures. She does not believe she has ever had an STD and did not\n require antibiotics during delivery as far as she knows (did not know\n her group B strep status).\n .\n At the OSH her initial BP was 89/36 but she dropped to SBPs 70s(per\n report). Her HCT was 28, her creatinine was 3.1, albumin 1.8. She was\n given 6.5L of NS, Zosyn and started on dopamine and med-flighted to\n ED.\n .\n In the ED, initial vs were: T:99.2 P126 BP98/57 R20 O2 95 sat.\n Central line was placed. Patient was started on levo and neo given\n Vanco and 2.5L fluids. OB was consulted and did a bedside ultrasound\n that did not show evidence of retained placenta. On labs, patient noted\n to have stable HCT 28, WBC of 7.7 and PLT of 22. Her AST/ALT and T.\n Bili were elevated. Her creatinine was 2.9 and K was 2.4, bicarb 13.\n INR was 1.3 and fibrinogen was 479. Urine and serum tox were negative.\n On transfer to the floor T:98.0, HR 112, BP 102/53, RR: 30, 02 sats\n 100on2L and VBG showed ph 7.25, pco2:25 p02 of 66. Per the patient's\n parents the patient was mentating well this entire time.\n .\n On the floor, the patient was tachypneic on arrival. She developed\n crampy pelvic pain similar to her menstrual pain but more severe in\n nature and she complained of worsening left buttock pain without\n radiation. She intially required 3 pressors to keep her MAPs>65 and\n was bolused with LR. Urine output was marginal. Heme ONC was\n consulted and looked at her blood smear and did not see shistocytes or\n blasts. Hemolysis labs were ordered and did not show evidence of\n hemolysis.\n .\n .\n Review of sytems:\n (+) Per HPI:\n (-) Denies Denies headache, sinus tenderness, rhinorrhea or congestion.\n Denied cough, shortness of breath prior to admission. Denied chest pain\n or tightness, palpitations. Denied nausea, vomiting, constipation. No\n dysuria.\n Patient admitted from: ER, after t'fer from OSH\n History obtained from Patient, Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:41 AM\n Piperacillin - 12:00 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 08:14 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n no medical or surgical history\n G1P1 s/p vaginal delivery with episiotomy 11 days PTA. Pregnancy\n otherwise uncomplicated.\n no family history of multiple pregnancy loss.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient lives in with her mom, dad, brother (17yo),\n 11d old daughter and her boyfriend (father of the baby). She never\n smoked tobacco, previously drank ETOH but none since prior to her\n pregnancy.\n Review of systems:\n Flowsheet Data as of 12:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 35.5\nC (95.9\n HR: 105 (94 - 112) bpm\n BP: 138/76(92) {84/39(47) - 138/96(101)} mmHg\n RR: 45 (18 - 46) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 16 (13 - 16)mmHg\n Mixed Venous O2% Sat: 68 - 68\n Total In:\n 14,226 mL\n PO:\n 900 mL\n TF:\n IVF:\n 3,976 mL\n Blood products:\n Total out:\n 0 mL\n 2,020 mL\n Urine:\n 515 mL\n NG:\n 675 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 12,206 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.18/20/64/11/-18\n Physical Examination\n General Appearance: Well nourished, Anxious, Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t)\n Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ),\n tachypneic\n Abdominal: Soft, Bowel sounds present, Tender: tender with deep\n palpation throughout\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, thing, Movement: Not assessed,\n Tone: Normal, CN 2-12 grossly intact\n Labs / Radiology\n 52 K/uL\n 8.7 g/dL\n 141 mg/dL\n 2.9 mg/dL\n 41 mg/dL\n 11 mEq/L\n 115 mEq/L\n 4.1 mEq/L\n 143 mEq/L\n 26.8 %\n 38.8 K/uL\n [image002.jpg]\n \n 2:33 A9/30/ 04:35 AM\n \n 10:20 P9/30/ 05:53 AM\n \n 1:20 P9/30/ 09:43 AM\n \n 11:50 P9/30/ 10:46 AM\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 49.3\n 48.1\n 38.8\n Hct\n 32.2\n 28.2\n 26.8\n Plt\n 66\n 59\n 52\n Cr\n 3.1\n 2.9\n TC02\n 8\n Glucose\n 107\n 141\n Other labs: PT / PTT / INR:16.6/30.5/1.5, ALT / AST:62/152, Alk Phos /\n T Bili:152/1.9, Differential-Neuts:91.0 %, Band:5.0 %, Lymph:1.0 %,\n Mono:1.0 %, Eos:0.0 %, Fibrinogen:426 mg/dL, Lactic Acid:3.7 mmol/L,\n Albumin:2.2 g/dL, LDH:483 IU/L, Ca++:6.4 mg/dL, Mg++:2.1 mg/dL, PO4:4.3\n mg/dL\n Assessment and Plan\n Assessment and Plan: 19 year old female 11 days post partum who\n presented to OSH with non-bloody diarrhea, found to be hypotensive and\n transferred to the ICU on 3 vasopressors for hypotension found to have\n acute renal failure, transaminitis, direct hyperbilirubinemia,\n thrombocytopenia, rapidly increasing Leukocytosis and metabolic\n acidosis.\n .\n #Sepsis: Given sudden increase in WBC count with hypotension,\n presentation is most consistent with infection. Most likely GU\n source-endometritis, retained placenta, retained foreign body. GI\n source also possible given liver labs, abdominal pain,. Back pain\n concerning for retroperitoneal abscess, pyelonephritis or possible\n epidural abscess (though no neuro SX). Intial concern for TTP-HUS with\n thrombocytopenia, ARF and liver abnormalities but no hemolysis on labs\n or smear make this less likely. Although no report of hypotension must\n consider causing hypotension as well as cardiogenic (could\n have postpartum cardiomyopathy with decompensation though physical exam\n not consistent). HELLP syndrome could explain most abnormalities but\n patient would likely be hypertensive, have had preecclampsia during\n pregnancy and HELLP is atypical this far post-partum.\n -IVF to keep CVP 12-14, initially with LR until K comes up and then\n consider d5 with bicarb.\n -follow CV02 and if low can consider blood transfusions\n -Levo/Vaso to keep MAP>65\n Infectious:\n -Vanc/Zosyn/Flagyl\n -blood cultures, urine cultures\n -Pelvic, abdominal and renal ultrasound with dopplers\n -abd/pelvic CT with PO contrast if patient tolerates\n -OB/GYN consult\n -surgery consult for possible laparotomy.\n TTP-HUS:\n -f/u all hemolysis labs and ADAMS13 labs\n -f/u ONC recs\n -trend platelets and keep >50\n Hypothalamic:\n -check pituitary axis hormones\n Cardiac:\n -TTE\n .\n #Acute Renal Failure: Most likely related to hypotension. Given\n dizziness symptoms of hypotension have been present at least 5 days,\n with added watery diarrhea and poor PO intake, likely several days of\n worsening renal function from intravascular volume depletion. Patient\n does not currently meet need for dialysis.\n -renal ultrasound\n -urine lytes\n -monitor UOP\n -urine EOS\n -renal consult (urine sediment analysis)\n -renally dose medications.\n .\n #LFT abnormalitis: Mild Transaminitis with rising direct bilirubinemia.\n Given low platelets, low albumin, increasing INR, possible that there\n is an underlying liver abnormality however, most likely hypotension\n but AFLP or cholestasis of pregnancy or cholangitis possible (though no\n pain). HELLP less likely as above.\n -trend LFTs\n -liver u/s with dopplers to eval for thrombosis.\n -call for patient's OSH records for any prior medication exposures,\n underlying liver dz and most recent labs.\n .\n #Thrombocytopenia: nadir at 22 on arrival and now increasing.\n Most likely sepsis. ITP also possible but wouldn't expect such a\n recovery. TTP less likely as no hemolysis on smear. HIT unlikely as\n patient with <50, no known heparin injections during birthing\n process.\n - \n -t'fuse for <50 or bleeding\n -abd u/s to eval spleen\n -repeat smear\n -trend hemolysis labs to ensure no trend towards TTP or DIC\n .\n #Metabolic Acidosis: Both gap and non-gap acidosis with respiratory\n compensation. Likely gap due to sepsis/lactate and non-gap from renal\n failure and diarrhea.\n -A line\n -Serial ABGs for monitoring\n -when K replete >3.5 then start fluids with bicarb\n -correct underlying issues\n .\n FEN: IVF, replete electrolytes, NPO for now\n .\n Prophylaxis: Pneumoboots\n .\n Access: Right IJ placed in the ED on PM, periphreals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient and her parents\n .\n Disposition: pending clinical improvement\n .\n , PGY-2\n \n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489852, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Not triggering\n Comments: Pt on paralytic/sedated\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated .\n Esophageal balloon remains in place. No measurements made this shift.\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489963, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Meropenem - 04:30 AM\n Vancomycin - 08:10 AM\n Infusions:\n Fentanyl - 400 mcg/hour\n Midazolam (Versed) - 6 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Flowsheet Data as of 01:53 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.8\nC (100\n HR: 107 (98 - 126) bpm\n BP: 95/50(66) {95/48(65) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 16 (15 - 23) mmHg\n Total In:\n 2,908 mL\n 1,990 mL\n PO:\n Tube feeding:\n 741 mL\n 549 mL\n IV Fluid:\n 1,767 mL\n 1,341 mL\n Blood products:\n 400 mL\n 100 mL\n Total out:\n 3,380 mL\n 1,495 mL\n Urine:\n 3,380 mL\n 1,495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -472 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/45/85./24/-1\n Ve: 9.7 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : throughout)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact, Erythema), some blanching\n erythema noted around incision site\n Neurologic: (Responds to: Unresponsive), Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 118 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n 09:13 AM\n WBC\n 10.2\n 7.6\n Hct\n 33\n 28.1\n 24.8\n Plt\n 79\n 70\n Creatinine\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n 25\n Glucose\n 107\n 115\n 113\n 107\n 118\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Imaging: CXR: persistent hazy opacities B\n Microbiology: SPUTUM:\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n NO MICROORGANISMS SEEN.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary):\n Commensal Respiratory Flora Absent.\n GRAM NEGATIVE ROD(S). SPARSE GROWTH\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n TISSUE (Preliminary):\n GRAM POSITIVE RODS.\n CONSISTENT WITH CLOSTRIDIUM\n OR\n BACILLUS SPECIES.\n TISSUE: Fusobacterium\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n Neurologic: paralyzed with Cis, on fent/midaz.\n Cardiovascular: HD stable, off pressors.\n Pulmonary: Cont ETT, (Ventilator mode: CMV); wean PEEP slowly, if\n stable consider d/c Cis\n Gastrointestinal / Abdomen: NGT in place.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, No need for CVVH. Diuresing well with PRN\n lasix.\n Hematology: Serial Hct, Stable anemia.\n Endocrine: RISS\n Infectious Disease: Check cultures, Discussed with ID coverage given\n new cx data: Fusobacterium and a Gram positive rod (? clostridium vs\n bacillus species), continue current regimen. CT torso to eval for\n collection. Change R IJ CVL and send tip for cx.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings, Follow wound.\n Imaging: CXR today, LE vascular US , Ct torso today. RUQ u/s and LENIS\n today.\n Fluids: KVO\n Consults: Ortho, Gynecology, Nephrology, Nutrition\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines: R IJ CVL\n change line, A-line\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: sq hep, boots\n Stress ulcer: H2\n VAP bundle: HOB > 30, mouth care, no daily wake-up (paralyzed),\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 min\n" }, { "category": "Nursing", "chartdate": "2199-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489967, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains off pressors with map >65\n Temp max 100.5 po\n Wbc =\n Vanco level 10.7\n Action:\n Vancomycin administered as ordered\n USN LE and abdominal done at bedside\n CT scan of chest and torso done\n RIJ triple lumen changed over wire- tip for culture\n Fungal blood culture sent\n Antibiotics given as ordered\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489969, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CMV with 15 peep, Fio2 50%, tv 350 and rate 28\n Breath sounds clear but diminished in bases r>l\n O2 sats 92-97%\n Cisatracurium , versed and fentanyl gtts infusing\n Action:\n Rotating on triadyne bed with percussion q2hrs\n Suctioned prn\n Peep decreased to 14\n Abg obtained as ordered\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains off pressors with map >65\n Temp max 100.5 po\n Wbc = 7.6\n Vanco level 10.7\n Action:\n Vancomycin administered as ordered\n USN LE and abdominal done at bedside\n CT scan of chest and torso done\n RIJ triple lumen changed over wire- tip for culture\n Fungal blood culture sent\n Antibiotics given as ordered\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2199-10-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 489974, "text": "Subjective: Patient is intubated and sedated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 95.5 kg\n 104.3 kg ()\n 33.9\n Pertinent medications: Cisatracurium, Fentanyl, Versed, ABx,\n Famotidine, lasix prn, others noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 09:13 AM\n Glucose Finger Stick\n 125\n 10:00 PM\n BUN\n 54 mg/dL\n 02:13 AM\n Creatinine\n 3.1 mg/dL\n 02:13 AM\n Sodium\n 138 mEq/L\n 02:13 AM\n Potassium\n 4.4 mEq/L\n 02:13 AM\n Chloride\n 104 mEq/L\n 02:13 AM\n TCO2\n 24 mEq/L\n 02:13 AM\n PO2 (arterial)\n 85. mm Hg\n 09:13 AM\n PO2 (venous)\n 63 mm Hg\n 12:00 AM\n PCO2 (arterial)\n 45 mm Hg\n 09:13 AM\n PCO2 (venous)\n 50 mm Hg\n 12:00 AM\n pH (arterial)\n 7.34 units\n 09:13 AM\n pH (venous)\n 7.10 units\n 12:00 AM\n pH (urine)\n 5.0 units\n 10:25 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 09:13 AM\n CO2 (Calc) venous\n 16 mEq/L\n 12:00 AM\n Albumin\n 2.8 g/dL\n 02:11 AM\n Calcium non-ionized\n 7.7 mg/dL\n 02:13 AM\n Phosphorus\n 3.8 mg/dL\n 02:13 AM\n Ionized Calcium\n 1.04 mmol/L\n 09:13 AM\n Magnesium\n 1.8 mg/dL\n 02:13 AM\n ALT\n 14 IU/L\n 02:13 AM\n Alkaline Phosphate\n 172 IU/L\n 02:13 AM\n AST\n 27 IU/L\n 02:13 AM\n Total Bilirubin\n 3.0 mg/dL\n 02:13 AM\n WBC\n 7.6 K/uL\n 02:13 AM\n Hgb\n 8.4 g/dL\n 02:13 AM\n Hematocrit\n 24.8 %\n 02:13 AM\n Current diet order / nutrition support: Tube Feeds: Impact with Fiber @\n 60mL/hr (1440kcals, 81g protein)\n GI: abd soft, bowel sounds present, + flatus, no BM\n Assessment of Nutritional Status\n 19 y.o. Female 19 days post partum c/b hip infection, septic shock,\n ARDS and multiorgan failure with improving clinical course. Patient\n remains intubated, sedated and paralyzed due to respiratory status.\n Patient tolerated trophic tube feeds and feeds have now been advanced.\n Current tube feed rate does not meet nutritional needs; recommend\n increasing goal rate to 70mL/hr. Noted patient has not had BM yet.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feeding goal of Impact with Fiber @ 70mL/hr\n (1680kcals, 94g protein).\n Check residuals q4hrs, hold if greater than 150mL.\n Monitor abd exam. Recommend bowel meds if no BM.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2199-10-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488284, "text": "19yo femaile, PSH tonsillectomy. PMH: 11 postpartum after delivery of\n regular, vaginal birth without complications. No other hx.\n Presents to ED after tx from Center ED where she\n initially presented with hypotension. She was sent to by\n Urgent Care where she went to be seen for 1d hx of buttock/low\n back pain and general weakness and fatigue since delivery. In\n addition, reports N/D for 5 days pta accompanied by intermittent\n abdominal pain. Denies sob, cough, fever, cp, cardiac related\n symptoms.\n She reports minimal bleeding since delivery, no significant discharge,\n no clots.\n Transferred from on dopa gtt which was dc\nd in ED, TLC\n placed and confirmed. Started on levophed gtt. Remained hypotensive\n and started on neo gtt as well. OB saw pt for consult for eval of\n possible endomyetritis or other etiology of infection. U/S reported to\n be without evidence of any retained parts. No evidence of\n endomyometritis or other to explain sepsis and pain. Approx total\n fluid pta arrival to 10L.\n Tx\nd to for management.\n Events: Vaginal and abdominal ultrasounds and cardiac echo performed at\n bedside. CT of pelvis abdomen showed air in the ileacus muscle, sacral\n iliac joint and ileus and large, bilateral pleural effusions.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt pale and lethargic this am and able to converse appropriately. She\n sleeps in short naps and follows simple commands. WBC was 46 with\n lactate of 3.4. Pt was afebrile, tachpnic with respiratory ranged\n 29-50 on 4Lnc stating her breathing felt\nfine\n. Lungs were clear and\n decreased at the bases. Uo was 5-20cc/hr of amber sludge with a\n creatnine of and BP was supported by neo gtt at 2mcg/kg/min, levophed\n at .25mcg/kg/min and vasopressin at 2.4 units/hr. HR was sinus in the\n mid 90\ns with a rare pvc. HR gradually increased to 120-130 range in\n later afternoon and early evening with 02 sat dropping to 87-90 range.\n ABG showed metabolic acidosis with\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-10-02 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 488131, "text": "TITLE: MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I would emphasize\n and add the following points: 19F previously healthy G1P1 presents 11d\n s/p NSVD (epsiotomy / epidural) with progressive weakness, non-bloody\n diarrhea, and back / abd pain. Hypotensive with normal WBC and\n prominent bandemia and plts 22 on initial presentation, subsequently\n evolved 3-pressor requirement and progressive drop in UOP, AG\n acidosis with WBC now approaching 50K, confirmed on repeat.\n Exam notable for Tm 98 BP 110/70 HR 112 RR 22 with sat 99 on 2LNC CVP\n 13 CvO2 68. Toxic appearing woman, writhing, c/o back and lower abd\n pain. Cool skin, decreased pulses. CTA B. RRR s1s2 hyperdynamic. Soft\n +BS, prominent tenderness BLQ, no rebound, no . Labs notable\n for WBC 48K, HCT 28, Plts 59, K+ 2.7, Cr 3.1, lactate 3.7, AG 19, TB\n 2.5, LDH 400s. CXR with clear lungs.\n Critically ill 19F 11d post-partum p/w refractory shock and multiorgan\n dysfunction. Most likely unifying dx is abdominal sepsis from GU or GI\n source, will cover with vanco / zosyn / flagyl, place arterial line,\n image with USG now while continuing volume resuscitation and pressor\n support with VPA / levophed. Major concerns for retained POC,\n endometritis, appendicitis, or lower GI perf / abscess following\n epsiotomy. OB following, consult surgery now, will try to obtain CT\n with PO/PR (if not IV) contrast when stable to leave ICU. Given CvO2,\n CVP and exam, will check cardiac echo / repeat ECG now as well to\n assess LVEF and r/o vegitations / pericardial disease. Hold off on\n steorids / APC for the moment given possible need for operative\n intervention.\n Other concerns include pitutary apoplexy (check TSH, cortisol, FSH/LH,\n now), TTP-HUS spectrum of disease (esp given diarrhea) - check stool\n cx for toxigenic E. coli, heme has seen, no schistocytes, hold off on\n phresis but consider ADAMTS-13 activity level if plts don't rebound.\n HELLP (somewhat late presentation, LFTs probably on the low side for\n this, will follow trend and r/o biliary obstruction with USG), ITP\n (though rise in plts overnight make this less likely), or heme\n malignancy (would favor BMBx if septic focus not identified or if\n preipheral smear with early forms in the setting of dramatic rise in\n WBC count and ongoing thrombocytopenia; heme following).\n ARF likely driven by hemodynamics, continue volume resuscitation, check\n UA / sed, RD meds. Acidosis likely combined effects of lactate and ARF,\n trend via art line, consider NaHCO3 for resuscitation fluid if pH\n <7.20.\n Patient is critically ill\n Total time: 120 min\n" }, { "category": "Nursing", "chartdate": "2199-10-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488135, "text": "19yo femaile, PSH tonsillectomy. PMH: 11 postpartum after delivery of\n regular, vaginal birth without complications. No other hx.\n Presents to ED after tx from Center ED where she\n initially presented with hypotension. She was sent to by\n Urgent Care where she went to be seen for 1d hx of buttock/low\n back pain and general weakness and fatigue since delivery. In\n addition, reports N/D for 5 days pta accompanied by intermittent\n abdominal pain. Denies sob, cough, fever, cp, cardiac related\n symptoms.\n She reports minimal bleeding since delivery, no significant discharge,\n no clots.\n Transferred from on dopa gtt which was dc\nd in ED, TLC\n placed and confirmed. Started on levophed gtt. Remained hypotensive\n and started on neo gtt as well. OB saw pt for consult for eval of\n possible endomyetritis or other etiology of infection. U/S reported to\n be without evidence of any retained parts. No evidence of\n endomyometritis or other to explain sepsis and pain. Approx total\n fluid pta arrival to 10L.\n Tx\nd to for management.\n Sepsis, Severe (with organ dysfunction) E. Coli bacteremia vs TTP-HUS\n vs Help vs other etiology\n Assessment:\n Pt rec\nd on levo gtt and neo gtts with SBP 80\ns-130. HR 110\ns-120\n RR 35-50. Pt denies sob but resp shallow and rapid. Sats >97% on 4l\n nc. Lungs clear and diminished. Pt is with c/o feeling very hot.\n Ext\ns are cool and clammy. Initial temp of 98. CVP 13-15. WBC 48.\n Vanco x 1 given in ED as well as first Zosyn dose. K 2.7.\n Action:\n Vasopressin initiated per order and neo being titrated down\n respectively. Vaso gtt at 2.4u/hr, neo at 1.0mcg/kg/min, and levophed\n at .25mcg/kg/min. Titrating as tol. Bolused with !L LR and started on\n LR at 150cc/hr. BC x 1 set sent. All stat labs sent. Given flagyl\n and zosyn. Infusing 20 meq kcl # 1 0f 3.\n Response:\n MAPS maintained >60. Temp currently 95.6.\n Plan:\n Cont to maintain MAP >60. F/U all cx data. To have renal and\n abd/pelvis u/s\ns. Fluid rescusitation. Replete lytes. Abx as\n ordered. Consult . OB involved. Echo. Place aline.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abd/pelvis cramping and lower back pain and upper buttock pain\n .\n Action:\n 1mg morphine given, repositioning, cool clothes to forehead, icepack to\n pelvis.\n Response:\n Pain level down to 5/10 s/p morphine.\n Plan:\n Cont to assess pain scale and medicate as needed per order.\n" }, { "category": "Physician ", "chartdate": "2199-10-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 488139, "text": "Chief Complaint: Hypotension, acute renal failure, acidosis,\n thrombocytopenia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient continues to complain about cramping abdominal pain. No\n dyspnea. BP 130 systolic on levophed, vasporessin, and phenylephrine,\n which is now being weaned. Minimial urine output. Creat rising. WBC up\n markedly from presentation.\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 06:41 AM\n Infusions:\n Phenylephrine - 1 mcg/Kg/min\n Norepinephrine - 0.25 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Morphine Sulfate - 08:14 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.7\nC (98\n HR: 109 (94 - 112) bpm\n BP: 135/76(79) {84/39(47) - 135/76(92)} mmHg\n RR: 33 (18 - 46) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 15 (13 - 15)mmHg\n Mixed Venous O2% Sat: 68 - 68\n Total In:\n 11,219 mL\n PO:\n TF:\n IVF:\n 1,869 mL\n Blood products:\n Total out:\n 0 mL\n 860 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 10,359 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///10/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Dry oral mucosa\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical), (Breath\n Sounds: Clear : Anterior and lateral, No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present, No(t)\n Distended, Tender: Diffuse, mild, no rebound, Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 59 K/uL\n 107 mg/dL\n 3.1 mg/dL\n 10 mEq/L\n 2.7 mEq/L\n 40 mg/dL\n 114 mEq/L\n 143 mEq/L\n 28.2 %\n 48.1 K/uL\n [image002.jpg]\n 04:35 AM\n 05:53 AM\n WBC\n 49.3\n 48.1\n Hct\n 32.2\n 28.2\n Plt\n 66\n 59\n Cr\n 3.1\n Glucose\n 107\n Other labs: PT / PTT / INR:15.2/31.2/1.3, ALT / AST:66/113, Alk Phos /\n T Bili:178/2.5, Differential-Neuts:91.0 %, Band:5.0 %, Lymph:1.0 %,\n Mono:1.0 %, Eos:0.0 %, Fibrinogen:481 mg/dL, Lactic Acid:3.7 mmol/L,\n LDH:484 IU/L, Ca++:6.7 mg/dL, Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPOTENSION\n ACUTE RENAL FAIULRE\n ACIDOSIS\n THROMBOCYTOPENIA\n ANEMIA\n =========================\n Patient with evidence of probable severe infection with marked\n leuckocytosis and hypotension. Acute renal failure likely due to ATN.\n CVP is 13; would continue fluids for now as we try to reduce/eliminate\n phenylephrine. Once a-line in place, monitor pulsse pressure with\n respiratory cycle to further assess intravascular volume. Patient\n getting repeat ultrasound to look for evidence of ascites and\n hydronephrosis. Smear negative for schistocytes arguing against TTP.\n With hx of low back pain, concern for a retroperitoneal process/pelvic\n sepsis. Bacterial colonic infection also a consideration. Cultures\n sent. Patient on broad spectrum antibiotics.Will probably need CT but\n would like to avoid IV contrast to minimize chances of permanent renal\n failure.\n Acidosis a mixed picture of anion and nonanion gap acidosis. Diarrhea\n and treatment with NS likely contributing to the nongap acidosis. Use\n LR or D5W with bicarb rather than normal saline for additional volume\n resuscitation. Surgery and gyn consulted. Need to be careful giving\n bicarb with hypokalemia; would not give any until K is above 3. Will\n need to give potassium with frequent checks; given oliguria, we don't\n want to overshoot potassium replacement. Renal should be consulted.\n Anemia likely related to her recent pregnancy and marrow suppression\n from acute infection. Not at transfusion threshold. Smear negative for\n evidence of intravacuilar hemolysis. No evidnce of GI bleeding at this\n time or by hx. Check stool guaiac.\n Thrombocytopenia of unclear etiology; probalby related to sepsis.\n Values rising now making ITP/TTP less likely. Continue to monitor. As\n above, no evidence of intravascular consumption.\n LFT's elevated. Ultraslund to assess for obstruction. Transaminitis\n probably related to hypotension.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments: Not applicable\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488335, "text": "Pre-op Narrative Note:\n Pt arrived from at approx 1900 -> Alert, and oriented, denying\n pain, HR sinus 130\ns, SBP 100\ns, temp. 96.4, RR 30\nlow 40\ns, c/o of\n mild shortness of breath, ls were clear bilaterally. Pt was seen by\n Ortho attending, surgery planned for am. Decision to electively\n intubate was then made by MICU. Several unsuccessful attempts at\n a-line were made prior to intubation. Anesthesia at bedside to\n perform intubation. Intubation was difficult initially, pt became\n hypotensive to 60\ns with intermittent periods of hypoxia. Skin became\n mottled in the hips/thighs and there was much difficulty obtaining a\n blood pressure with automatic cuff at this time. Levo and Neo were\n added to Vasopressin which was already running. Pt received total of 3\n liters LR fluid boluses for hypotension during this time.\n Fentynal/versed gtt\ns started for sedation. MICU attending at the\n bedside after intubation, femoral a-line attempted unsuccessfully.\n Carotid pulse was lost very briefly, but returned immediately just as\n compressions were initiated. Pt received total 30meq potassium over\n 1.5 hours, 1 amp sodium bicarbonate given, 1 unit of platelets given.\n 22:00 dose of flagyl given, 22:00 dose of zosyn sent to o.r. with\n patient to be given with anesthesia, cipro also sent to the o.r. to be\n given by anesthesia. Pt sent to o.r. at 2330. Mother and father\n arrived shortly after, MICU resident and attending spoke with family.\n Nursing supervisor notified and with family to offer additional\n support.\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489920, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn. Now on Vanco, Cipro\n and Meropenem\n Chief complaint:\n Septic Shock\n PMHx: G1P1\n Current medications:\n Heparin SQ \n Famotidine\n Vanco\n Meropenem\n Cipro\n Albumin 5% (250ml) x 1\n 24 Hour Events:\n : BP remains stable off pressors. PEEP down to 15. Temp spike\n (given tylenol) and tachy to 130s. Added Cipro. Good UOP, but decreased\n when pt became tachy to 130's. Good HR response to 250cc of 5% albumin.\n No new cx.\n : Temp spike despite starting Cipro. Blood Cx resent. Will check\n Vanco level. RUQ u/s and LENIs ordered.\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.28 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.7\nC (101.6\n HR: 115 (98 - 126) bpm\n BP: 119/73(91) {96/53(67) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 15 (15 - 23) mmHg\n CO/CI (Thermodilution): (10.2 L/min) / (5 L/min/m2)\n SVR: 463 dynes*sec/cm5\n Mixed Venous O2% sat: 82 - 82\n SV: 103 mL\n SVI: 50 mL/m2\n Total In:\n 2,893 mL\n 918 mL\n PO:\n Tube feeding:\n 741 mL\n 382 mL\n IV Fluid:\n 1,752 mL\n 536 mL\n Blood products:\n 400 mL\n Total out:\n 3,380 mL\n 890 mL\n Urine:\n 3,380 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n -487 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 99%\n ABG: 7.38/41/98./24/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Erythema), Area on thigh marked\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 107 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n WBC\n 9.0\n 10.2\n 7.6\n Hct\n 25.6\n 33\n 28.1\n 24.8\n Plt\n 62\n 79\n 70\n Creatinine\n 3.3\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n Glucose\n 106\n 107\n 115\n 113\n 107\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course Pt continues to\n spike temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. Cont paralysis w/ cisatricurium.\n Cardiovascular: off all pressors; monitoring. Tachy with good\n responce to albumin. Consider TEE in light of persistent fevers & broad\n abx coverage\n Pulmonary: PEEP down to 15, ARDS protocol, daily CXR, wean as tolerated\n Gastrointestinal / Abdomen: Tolerating tube feeds. RUQ U/S to r/o\n acalculus cholecystits as etiology of fevers\n Nutrition: NGT in place. TF Impact w/ fiber at 60mL/hr\n Renal: NGT in place. TF Impact w/ fiber at 60mL/hr\n Hematology: Hx of SGA bleed s/p coiling in IR. Mild anemia with goal\n Hct 30, transfuse PRBCs prn. Thrombocytopenic, ?BM suppression. SQH and\n bootsHct= 24.8, will recheck Hct. No obvious sources of bleeding, will\n recheck HCt.. BLE Doppler to r/o DVT.\n Endocrine: no issues\n Infectious Disease: Vanc/ for GNR from wound and blood cx from OSH.\n F/u speciation/sensitivities. ID c/s. Monitor vanco level. Added\n Cipro.Ortho: S/p Washout ; no plans for return to OR at this time.\n Gyn: S/p D&C; no further plans at this time. Re-scan torso. Send\n mycolytic cultures.\n Lines / Tubes / Drains: Re-wire CVL and send tip for cx.\n Wounds: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation.\n Imaging: No new images\n Fluids: KVO\n Consults: Ortho, ID\n Billing Diagnosis: Septic Shock\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:31 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: SQH, SCD\n Stress ulcer: H2B\n VAP bundle: HOB, mouth care, paralyzed so no wake up,\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2199-10-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488269, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2199-10-02 00:00:00.000", "description": "Generic Note", "row_id": 488317, "text": "TITLE: CRITICAL CARE\n Arrived in SICU from . Remains tachypneic, breathing shallowly,\n anxious. UO remains poor and creat is 2.9 so dosing all meds for\n severe renal failure. Plan now is for operative debridement tomorrow\n am. Given her dense lower lobe consolidations, RR 40, marginal ABG,\n however, will intubate electively this evening. Will likely require\n high Ve given pH and PCO2. Will review abx coverage with ID. Family\n aware of plan for surgery and intubation\n Time spent 40 min\n Critically ill\n" }, { "category": "General", "chartdate": "2199-10-02 00:00:00.000", "description": "ICU Event Note", "row_id": 488318, "text": "Clinician: Attending\n Critical Care\n Discussion with son about her recent decline with worsening pulm edema\n despite diuresis of > 5L. Discussed potential need for intubation. He\n believes a short intubation is consistent with her wishes but if her\n heart failure cannot be managed medically to a better level of function\n he believes she would prefer comfort. Plan is to diurese aggressively,\n intubate if necessary with either improvement or reduced level of care.\n Total time spent: 45 minutes\n Patient is critically ill.\n" }, { "category": "General", "chartdate": "2199-10-02 00:00:00.000", "description": "ICU Event Note", "row_id": 488326, "text": "Clinician: Attending\n Patient with intubation performed--intubation completed and patient\n with good CO2 change, bilateral breath sounds when I was called to see\n patient.\n She had significant hypotension requiring IVF bolus (LR and D5/HCO3)\n with persistent hypotension noted and this required re-initiation of 3\n pressors. Patient did transiently have absence of pulse but with 3\n beats of CPR patient opened eyes and pulse returned without\n administration of medications.\n Attempts at radial and brachial arterial line were not successful\n despite attempts by anesthesia, surgery and myself. Patient is able to\n get non-invasive blood pressure and VBG was sent. Patient had venous\n catheter placed in right femoral vein, central venous catheter in place\n in right IJ positon.\n Given significant and worsening decline seen rapidly with persistent\n sepsis likely secondary to pelvic region infection surgery and ortho\n services asked to re-evaluate patient for operative intervention\n tonight with clear and significant worsening at this time likely\n related to infection and sepsis.\n mother was updated by phone with worsening decline and\n plans for OR intervetion if surgical services in agreement.\n Total time spent: 70 minutes\n Patient is critically ill.\n" }, { "category": "Respiratory ", "chartdate": "2199-10-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489051, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n" }, { "category": "Radiology", "chartdate": "2199-10-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1102686, "text": " 8:57 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: SL PICC 46 cm to R basilic. Pls confirm tip placement.\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n SL PICC 46 cm to R basilic. Pls confirm tip placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female with hypotension. Placement of right PICC\n line. Evaluation for position.\n\n TECHNIQUE: Single portable chest radiograph obtained in the upright position.\n\n COMPARISON: Portable chest radiograph dated .\n\n FINDINGS: There has been interval placement of a right-sided PICC line with\n course in the expected position. The line can be followed to the mid superior\n vena cava however cannot be followed beyond that point. There is no\n pneumothorax or evidence of other complication. An NG tube courses in the\n expected position below the diaphragm and out of the field of view of the\n radiograph. A right internal jugular line terminates within the right atrium.\n The appearance of multifocal opacities within the lung is unchanged.\n\n IMPRESSION: Right-sided PICC line traced to level of mid SVC however cannot\n be followed beyond that. If needed, an oblique projection could be obtained\n to better visualize PICC. Right IJ terminates within right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100692, "text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with ARDS, intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female with ARDS, intubated. Evaluate for interval\n change.\n\n Single AP chest radiograph compared to shows improved\n moderate severe confluent bilateral airspace edema, left greater than right.\n Moderate cardiomegaly is increased since the initial exam. Bilateral pleural\n effusions are small and unchanged. No pneumothorax. ET tube terminates 2.9 cm\n above the carina. Right IJ central venous catheter tip is at the distal SVC.\n Stomach remains distended despite NG tube placement.\n\n IMPRESSION:\n 1. Improved moderate-severe pulmonary edema since . Given\n rapid improvement ARDS unlikely.\n 2. Marked distension of the stomach despite NG tube.\n Findings discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1100383, "text": " 12:40 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with central line placed\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old woman status post placement of central line.\n\n COMPARISON: None.\n\n SINGLE UPRIGHT VIEW OF THE CHEST: A right internal jugular catheter\n terminates in the lower SVC. Lungs demonstrate increased interstitial\n opacities and Kerley B lines. There is hilar fullness and mild cephalization\n of pulmonary vasculature. The heart size is slightly enlarged. There is no\n mediastinal enlargement. There is no pneumothorax or lobar consolidation. No\n pleural effusions are noted.\n\n IMPRESSION:\n 1. Right internal jugular catheter terminates in the lower SVC.\n 2. Mild interstitial edema and fluid overload. Right hilar fullness most\n likely related to fluid overload. However, if there is clinical concern for\n lymphadenopathy followup imaging recommended following treatment of fluid\n status.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101200, "text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with ARDS, intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: ARDS, intubated.\n\n FINDINGS: The position of the ET tube is satisfactory 5 cm above the carina,\n right internal jugular central venous catheter is unchanged.\n The apparent improvement in the bilateral parenchymal opacities may be\n accounted for by increased ventilatory pressures. No new consolidation or\n pneumothorax, the cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: Apparent improvement probably due to increased ventilator\n pressures. No new consolidation or pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101530, "text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change in ARDS\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with septic shock, ARDS\n REASON FOR THIS EXAMINATION:\n ?interval change in ARDS\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The bilateral parenchymal opacities are of unchanged extent and\n distribution. Also unchanged is the size of the cardiac silhouette and the\n extent of the retrocardiac atelectasis. There is no evidence of newly\n occurred focal parenchymal opacities. Unchanged course and position of the\n monitoring and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101949, "text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution of intrapulmonary processs\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with worsening resp status\n REASON FOR THIS EXAMINATION:\n evolution of intrapulmonary processs\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Worsening respiratory status.\n\n Comparison is made to the prior study from .\n\n FINDINGS: ET tube remains at the thoracic inlet. Nasogastric tube courses\n below the diaphragm but the tip is not seen. Right IJ catheter terminates at\n the cavoatrial junction. Multiple additional lines project over the chest.\n There is multifocal airspace opacity in both lungs. This could represent ARDS\n or severe pulmonary edema. The appearance has not significantly changed.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101995, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolving exam\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n evolving exam\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: ARDS.\n\n FINDINGS:\n Comparison is made to the prior study from . Heart is enlarged.\n There is patchy multifocal airspace opacity consistent with given history of\n ARDS. Right IJ catheter terminates at the cavoatrial junction. Endotracheal\n tube terminates at the thoracic inlet. Nasogastric tube courses below the\n diaphragm but the tip is not seen. No appreciable change since the prior\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1100410, "text": " 7:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please eval liver and gallbladder for pathology, please eval\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with direct bilirubinemia, thrombocytopenia, ?sepsis\n REASON FOR THIS EXAMINATION:\n please eval liver and gallbladder for pathology, please eval for splenomegaly,\n please do doppler to rule out clot\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 11:14 AM\n Normal liver echotexture and vascularity. Bladder wall thickening without\n other signs of acute cholecystitis. Echogenic kidneys which is nonspecific,\n but in the setting of sepsis, pyelonephritis is not excluded. Splenomegaly.\n Bilateral pleural effusions and trace ascites.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old female with direct bilirubinemia, thrombocytopenia\n and possible sepsis. Evaluate liver and gallbladder for pathology and perform\n Doppler to rule out clot.\n\n COMPARISON: No prior study available for comparison.\n\n ABDOMINAL ULTRASOUND: The liver echotexture is normal without focal\n abnormality. There is no intra- or extra-hepatic biliary ductal dilatation\n and the common bile duct measures 3 mm. The gallbladder wall is thickened up\n to 1 cm. However, the gallbladder is relaxed without stones, sludge, or\n hypervascularity. The spleen is enlarged measuring up to 16.5 cm. The\n bilateral kidneys demonstrate increased echogenicity, which is a nonspecific\n finding; however, in the setting of apparent sepsis, pyelonephritis is not\n excluded. The aorta is of normal caliber throughout, although the distal aorta\n is not well visualized. There is trace ascites and bilateral pleural\n effusions.\n\n LIVER DOPPLER: The main portal vein is patent with hepatopetal flow. The\n right and left portal veins are normal. The hepatic arterial and venous\n vessels are also patent with normal flow and waveforms.\n\n IMPRESSION:\n\n 1. Normal liver echotexture and vascularity.\n\n 2. Gallbladder wall thickening without other son signs of acute\n cholecystitis, likely reflects third spacing.\n\n 3. Echogenic kidneys, a nonspecific finding. However, in the presence of\n apparent sepsis, pyelonephritis can not be excluded and clinical correlation\n is recommended.\n\n 4. Splenomegaly.\n\n (Over)\n\n 7:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please eval liver and gallbladder for pathology, please eval\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Bilateral pleural effusions and trace ascites.\n\n Findings were communicated to Dr. at the time of interpretation on\n .\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 1100411, "text": ", M. MED 7:54 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: please eval liver and gallbladder for pathology, please eval\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with direct bilirubinemia, thrombocytopenia, ?sepsis\n REASON FOR THIS EXAMINATION:\n please eval liver and gallbladder for pathology, please eval for splenomegaly,\n please do doppler to rule out clot\n ______________________________________________________________________________\n PFI REPORT\n Normal liver echotexture and vascularity. Bladder wall thickening without\n other signs of acute cholecystitis. Echogenic kidneys which is nonspecific,\n but in the setting of sepsis, pyelonephritis is not excluded. Splenomegaly.\n Bilateral pleural effusions and trace ascites.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1100458, "text": ", M. MED 1:53 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please do abd/pelvic CT with PO and PR contrast to eval for\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman 11d post-partum (episiotomy) with sepsis of unclear ,\n ARF, liver failure with WBC=48\n REASON FOR THIS EXAMINATION:\n please do abd/pelvic CT with PO and PR contrast to eval for abscess,\n ?appendicitis (with possible perferation) or colitis, or other intraabdominal\n or pelvic pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n PFI REPORT\n Gas within the left iliacus and piriformis and minimal phlegmon adjacent to\n the left sacroiliac joint with rarefaction of the left iliac bone, highly\n concerning for septic arthritis. Bilateral pleural effusions with associated\n atelectasis, but pneumonia cannot be excluded. Diffuse edema and small amount\n of free fluid in the pelvis. No evidence of appendicitis or colitis.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-03 00:00:00.000", "description": "TRANCATHETER EMBOLIZATION", "row_id": 1100531, "text": " 4:07 AM\n ABDOMINAL AORTA Clip # \n Reason: plesae check for arterial bleeding from left gluteal vessels\n Admitting Diagnosis: HYPOTENSION\n Contrast: VISAPAQUE Amt: 100\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO PELVIS SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with signfincant HCT drop post op. Suspect gluteal artery\n bleeding after pelvic debridment.\n REASON FOR THIS EXAMINATION:\n plesae check for arterial bleeding from left gluteal vessels or other. Had\n signifncant pelvic debridment for osteomyelitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old woman status post left iliac debridement for\n osteomyelitis with subsequent bleeding from the left superior gluteal artery\n with active bleeding seen during surgery and hematocrit drop from 26 to 13.\n\n ANESTHESIA: General anesthesia, and approximately 5 ml of local lidocaine.\n The patient was intubated prior to procedure.\n\n OPERATORS: Drs. and , the attending radiologist, who was present\n and performed the procedure.\n\n PROCEDURE: As the patient was intubated, the risks and benefits of the\n procedure were explained to the patient's mother and informed consent was\n obtained over the telephone with a witness. The patient was brought to the\n angiography suite and placed supine on the table. The patient was prepped and\n draped in standard sterile fashion. A preprocedure timeout and huddle were\n performed per protocol. After local anesthesia with approximately \n cc of lidocaine 1%, access was gained into the right common femoral artery\n with a 19-gauge needle. A 0.035 Bentson guidewire was advanced through the\n needle into the abdominal aorta. The needle was removed and a 5 French sheath\n was inserted. The sheath was connected to a continuous side-arm flush. A 5\n French Omniflush catheter was then advanced over the wire under\n fluoroscopic guidance and the wire was advanced into the left internal iliac\n artery. As the location of the bleeding was known after discussion with the\n orthopedic surgeon and due to the patient's acute renal failure, a selected\n arteriogram of only the left iliac artery was performed. A C2 cobra catheter\n was advanced over the wire and an arteriogram of the left internal iliac\n artery demonstrated active contrast extravasation from the left superior\n gluteal artery. Based on the diagnostic findings, the decision was made to\n perform embolization. Gelfoam was administered proximal to area of bleeding\n within the left superior gluteal artery. A microcatheter then was advanced\n through the Cobra catheter and placed distal to the area of active\n extravasation. This artery was embolized with a total of 10 coils, five\n distallly and five proximal to area of active bleeding. A final run of the\n (Over)\n\n 4:07 AM\n ABDOMINAL AORTA Clip # \n Reason: plesae check for arterial bleeding from left gluteal vessels\n Admitting Diagnosis: HYPOTENSION\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n left internal iliac artery demonstrated no active bleeding from the left\n superior gluteal artery.\n\n As the patient was in acute renal failure, Visipaque was used and the patient\n was well hydrated and premedicated with bicarbonate. A total of 100 cc of\n Visipaque was used during the arteriogram.\n\n Due to the request from the team as the previous arterial access was difficult\n to obtain, the right femoral artery sheath was left in place and secured with\n 0 silk stitch. The need for continuous flushing of this sheath with 60 cc of\n saline per hour was discussed with the SICU team and orders were entered.\n\n IMPRESSION: Area of active bleeding seen from left superior gluteal artery\n with subsequent embolization with gelfoam and coils with good angiographic\n result and no immediate complications.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100965, "text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman w/septic shock, intubated, ARDS\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n AN AP CHEST 5:27 A.M. \n\n HISTORY: Septic shock. Intubated. ARDS.\n\n IMPRESSION: AP chest compared to and 3. Severe infiltrative\n pulmonary abnormality has not improved. Vascular engorgement in the\n mediastinum and at least a small to moderate right pleural effusion suggests\n volume overload, and heart is mildly enlarged though partially obscured by\n parenchymal abnormality in the left lung. ET tube is at the level of the\n sternal notch. Nasogastric tube passes below the diaphragm and out of view.\n Right jugular line ends in the upper SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101717, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evolution of exam\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n evolution of exam\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: ARDS.\n\n Comparison to made to prior studies including .\n\n Diffuse parenchymal lung opacities worse in the left lower lobe are unchanged.\n Small right pleural effusion is unchanged. There is no pneumothorax\n Cardiomediastinal contour is unchanged\n\n" }, { "category": "Radiology", "chartdate": "2199-10-02 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1100509, "text": " 9:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p intubation, ETT placement check\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with sepsis s/p intubation.\n REASON FOR THIS EXAMINATION:\n s/p intubation, ETT placement check\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Woman with sepsis, status post intubation. Check ET tube\n placement.\n\n COMPARISON: , 00:39 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 5 cm above the carina.\n The right-sided central venous access line is unchanged in course and\n position. Newly occurred bilateral dense parenchymal opacities suggestive of\n generalized edema or ARDS. Multiple air bronchograms are seen, but major\n pleural effusions are not present.\n\n There is no change in the size of the cardiac silhouette.\n\n Massive overinflation of the stomach, this could be released by a nasogastric\n tube placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-09 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1101391, "text": " 9:16 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with fevers, recently post-partum\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fevers. Evaluate for DVT.\n\n FINDINGS: The bilateral superficial femoral, common femoral, and popliteal\n veins demonstrate normal compressibility, color flow, and response to\n augmentation. The calf veins also demonstrate normal color flow. There is\n symmetric and normal venous waveforms in the bilateral common femoral veins.\n\n IMPRESSION:\n\n No evidence of DVT in the bilateral legs.\n\n\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488593, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n None responsive to noxious stimuli with absent gag/cough reflex. Perrl\n 4-5mm/brisk bilaterally. Monitor shows SR/ST without ectopy with bp\n 104/61 and map 70 and CVP 14-16 and pressor support of levophed at\n .15mcg/kg/min and vasopressin at 1.2units/hr. Maintained on vent\n support CMV 60%/500/5/28. Lungs clear bilaterally with minimal\n secretions. 02 sat 96-98%. ABG 7.30/43/117/-4. Uo 25-100cc/hr with\n bun/cr 36 and 2.4 respectively. Lactate level 3.4 with wbc 15.6 and pt\n is afebrile. Pedal pulses + by Doppler and toes are cool to touch. JP\n at surgical site drained total of 100cc serosanganous fluid this shift.\n Action:\n Versed gtt turned off and fentanyl turned down to 75mcg/hr. Levophed\n gtt increased to .16 for sbp 85/50. Right axillary arterial\n line placed by ICU team and monitoring initiated. Pt transfused\n with 2units PRBC for hct 22 and given one unit FFP and one unit\n platelets for platelet count of 33. Esophageal balloon inserted by RT\n service and vent settings adjusted to 40%/350/15/28. All labs redrawn\n at 1530 and platelet count repeated post transfusion. Antibiotic\n coverage increased per .\n Response:\n Pt began to open eyes spontaneously with return of weak cough reflex\n and some spontaneous movement of hands. MAP maintained at >65 with\n increased CVP to 18. trouble shot for fling with call out to rep\n for further instruction and values currently deemed unreliable. Uo\n dropped to 5-20cc/hr and Bun/Cr are unchanged. Hct increased\n appropriately to 29, lactate down to 1.8 and increase noted in wbc to\n 18.4. Post vent change ABG 7.31/42/111/-4 with 02 sat 100%. Feet are\n warm with CRT<3 and weakly palpable pulses.\n Plan:\n Titrate fentanyl for patient comfort with daily wake up for neuro\n assessment. Continue to titrate pressors and provide fluids to keep\n map>60. ICU team to pull axial art line back to assess improvement in\n aline wave form and accuracy of data. Follow ABG\ns, CXR and\n respiratory effort, attempt wean settings when clinically appropriate.\n Follow UO bun/cr and notify team of further oliguria or rise in lab\n values. Follow culture data and continue antibiotic coverage as ordered\n with Vancomycin level before next dose. Follow HCT and JP drainage,note\n increased output or drop in HCT. For OR over next two days for wash out\n per Ortho team.\n Ineffective Coping\n Assessment:\n Family at bedside by mid day with pts mother expressing anxiety and\n inability to sleep or make decisions. She expresses great stress over\n pts instability and critical illness over the last 24hrs.\n Action:\n Social worker for support, and clergy at family\n request. Explanations re: pt condition and plan of care offered by\n nursing, ICU team and infectious disease service who were rounding\n during family visit.\n Response:\n Family continues to need information repeated and ask the same\n questions frequently. They are tearful at times and reluctant to leave\n the bedside.\n Plan:\n Continue to offer emotional support, validate feelings and concerns and\n keep them updated on pt condition and plan of care. Encourage rest and\n nutrition and provide information on temporary living quarters.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO since admission and po intake had been poor for 5dys +\n prior to admission Abd obese with + bowel sounds.\n Action:\n Enteral nutrition initiated and maintained at 20cc/hr via NGT.\n Nutrition service consulted.\n Response:\n Tube feed residual after 4 hrs was 30cc and abdomen remained soft with\n +bowel sounds.\n Plan:\n Residual check q4hr and hold for residual >200cc. Notify team of any\n emesis or change in abdominal assessment. Nutrition service to follow.\n" }, { "category": "Nursing", "chartdate": "2199-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490257, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n - Received patient on FiO2 .50; Vt 350 X f 28 X PEEP 14 on maximum\n cisatracurium, TOF with 20 mA. Lung sounds rhonchorous all around\n with small amount of thick white secretions. Tolerating rotating bed.\n Action:\n - Shut cisatracurium off. Repeat ABG showed improved oxygenation to PO2\n 147 from 109 on AM labs. PEEP weaned to 12, midaz gtt weaned to 4.\n Response:\n - Repeat ABG 153-39-7.36, FiO2 decreased to 40. Tol midaz wean so midaz\n gtt off\n getting PRN boluses of midaz 2-4 mg Q 2. Lung sounds clear\n compared to this morning, remains rhonchorous in RUL.\n - Pt opening eyes to voice and command, flexing all extremities to\n pain, moving head spontaneously.\n Plan:\n - Overnight, no further vent changes. Wean fent if tolerated. Cont to\n wean tomorrow as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains hemodynamically stable in sinus/sinus tach 94-118, no ectopy\n noted. Mean BPs 60-90 without support. Urine output >50/hour. T max\n this shift 99.4. Cont to have blanchable red rash throughout body.\n Action:\n - Cooling blanket removed. Cipro discontinued as probable cause of body\n rash. Antibiotics admin as ordered. Cdiff number 2 sent. IV flagyl\n added.\n Response:\n - T current 98.9.\n Plan:\n - Cont antibiotic admin; f/u cultures.\n" }, { "category": "Respiratory ", "chartdate": "2199-10-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490395, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23cm at teeth\n Route: po\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments/Plan\n Pt remains intubated, fully vent supported. Slowly weaning vent\n support over past 24hrs, pt tolerating well. ABG\ns stable. Pt still\n remains fluid positive, though, so aggressive weaning probably\n premature. Secretions remain thick also. See flowsheet for further pt\n data. Will follow.\n 05:16\n" }, { "category": "Nursing", "chartdate": "2199-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490616, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CMV 350 X 28 X PEEP 8. Sedated on fent gtt and midaz PRN.\n LS rhonchorous, diminished in bases. Sxn sm amt of white/yellow\n secretions.\n Action:\n Switched patient to PSV 12/8. Turned off fent gtt and started\n administering PRN dilaudid and continued to admin. PRN midaz. Admin\n lasix X 1 with goal 1 L negative today.\n Response:\n ABG on PSV 169-39-7.37. Agitated off fent gtt\n awake, looks anxious,\n is scared, tachycardic and tachypneic to 50s. Correct conversion of 400\n mcg fent per hour is 6 mg of dilaudid, so PRN dose increased.\n Administering 2-4 mg/hour with good effect. Pt still generally anxious\n upon wakening\n trying to talk to and reassure patient that she is\n getting better. Negative about 400 thus far, diuresed about 400 to\n lasix.\n Plan:\n PSV, cont PRN dilaudid and midaz.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 102.5 oral at 0730, with accompanying tachycardia to 145.\n Pattern noticed of patient spiking and rash worsening after meropenem\n doses\n at least last 3 doses.\n Action:\n Pan cultured. Acetaminophen; cooling blanket; ice packs to underarms\n and near groin. Meropenem D/Ced. Clinda and Cipro added.\n Response:\n T decreased to 99.4 after above interventions, T current 99.9. Prelim\n cultures: sputum gram stain neg, UA neg.\n Plan:\n Cont to monitor, follow up cultures, treat fever as needed.\n" }, { "category": "Nursing", "chartdate": "2199-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489828, "text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 101.6. Tachycardic to 110\ns. New area of Erythema noted\n around left hip incision.\n Action:\n Blood cultures x\ns 2 obtained, Tylenol given. Erythema outlined, sicu\n h.o notified. Vanco/meropenum/cipro continues.\n Response:\n Pending\n Plan:\n Continue tomonitor.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vent. settings: 50% fi02, 15 peep, rate 28, TV 350, no changes made.\n LS noted for intermittent inspiratory wheezes. Suctioned for thick\n white sputum. Abg\ns unchanged.\n Action:\n Continues rotation on Tryadine bed, percussion used intermittently.\n Chest x-ray obtained this morning.\n Response:\n Unchanged vent. status.\n Plan:\n Continue pulmonary toileting, monitor abg\ns and continue to wean peep\n as tolerated.\n" }, { "category": "Social Work", "chartdate": "2199-10-11 00:00:00.000", "description": "Social Work Progress Note", "row_id": 490540, "text": "Have been following pt\ns progress and working with her parents\n throughout this SICU admission. Parents are able to be at the bedside\n daily and are working well with the team. Have provided parents with\n discount parking stickers and have assisted in the completion of\n paperwork for the FMLA for pt\ns grandmother to be off from work to\n provide 24/7 care to pt\ns newborn.\n Also, provided documentation of pt\ns hospitalization that parents took\n to the court, parents have assumed the role of temporary guardianship\n of the newborn.\n Will continue to follow in anticipation of working with pt re: coping\n with this hospitalization.\n" }, { "category": "Nutrition", "chartdate": "2199-10-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 490542, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 95.5 kg\n 104.3 kg ( )\n 33.9\n Pertinent medications: Famotidine, heparin, abx, others noted\n Labs:\n Value\n Date\n Glucose\n 102 mg/dL\n 10:01 AM\n Glucose Finger Stick\n 123\n 10:00 PM\n BUN\n 57 mg/dL\n 02:37 AM\n Creatinine\n 2.5 mg/dL\n 02:37 AM\n Sodium\n 140 mEq/L\n 02:37 AM\n Potassium\n 4.0 mEq/L\n 02:37 AM\n Chloride\n 107 mEq/L\n 02:37 AM\n TCO2\n 24 mEq/L\n 02:37 AM\n PO2 (arterial)\n 164 mm Hg\n 10:01 AM\n PO2 (venous)\n 63 mm Hg\n 12:00 AM\n PCO2 (arterial)\n 39 mm Hg\n 10:01 AM\n PCO2 (venous)\n 50 mm Hg\n 12:00 AM\n pH (arterial)\n 7.37 units\n 10:01 AM\n pH (venous)\n 7.10 units\n 12:00 AM\n pH (urine)\n 5.5 units\n 07:28 AM\n CO2 (Calc) arterial\n 23 mEq/L\n 10:01 AM\n CO2 (Calc) venous\n 16 mEq/L\n 12:00 AM\n Albumin\n 2.8 g/dL\n 02:11 AM\n Calcium non-ionized\n 8.1 mg/dL\n 02:37 AM\n Phosphorus\n 3.5 mg/dL\n 02:37 AM\n Ionized Calcium\n 1.13 mmol/L\n 06:22 AM\n Magnesium\n 1.8 mg/dL\n 02:37 AM\n ALT\n 14 IU/L\n 02:13 AM\n Alkaline Phosphate\n 172 IU/L\n 02:13 AM\n AST\n 27 IU/L\n 02:13 AM\n Total Bilirubin\n 3.0 mg/dL\n 02:13 AM\n WBC\n 9.5 K/uL\n 02:37 AM\n Hgb\n 8.7 g/dL\n 02:37 AM\n Hematocrit\n 26.6 %\n 02:37 AM\n Current diet order / nutrition support: Tube Feeds: Impact with Fiber @\n 70mL/hr (1680kcals, 94g protein)\n GI: + loose stool\n Assessment of Nutritional Status\n 19 y.o. Female post partum complicated by w/ septic shock, ARDS,\n multiorgan failure with improving clinical course. Patient is\n tolerating tube feeds at goal, which provide 100% of estimated needs.\n Noted patient is having loose stool output\n c. diff negative x1. CXR\n worse this morning\n needs to be further diuresed before extubation.\n If team would like tube feeds to be more concentrated, recommend\n changing to Nutren 2.0 @ 35ml/hr + 25g Beneprotein (1769kcals, 89g\n protein).\n" }, { "category": "Respiratory ", "chartdate": "2199-10-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489725, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Comments: ETT retaped & rotated in\n evening\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PEEP weaned cautiously!!!\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2199-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489722, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received this am on CMV .50% 28X350 and 18/peep\n Lungs clear to diminished at the bases\n Pt remains on paralytic med and fent/midaz gtt\n Lasix gtt up at 2mg/hr\n Action:\n Peep weaned to 15\n Lungs sounds remain unchanged\n CXR showing improving lung fields\n Pt with increased amts of secretions\n Lasix gtt stopped\n Response:\n Tolerating peep of 15 Pa02\ns >90\n Lasix stopped after CXR showing improvement pt cont to\n diurese on own > 100/hr unit 6pm\n Pt cont to tolerate rotation\n Plan:\n Cont with slow vent wean as tolerated\n Pt to remain at current vent settings MD \n ? stopping cist tomorrow if pt cont to tolerate peep wean\n tomorrow\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Low grade temps most of day\n Spiked to 101.9 @ 1600\n Pt tachycardic post temp spike\n Action:\n Tylenol given\n Pt u/o dropped off post spike and tachycardia\n Pt given 250 albumin X1\n Labs sent\n Cipro added to med regimine\n Response:\n Temp slowly coming down\n WBC\ns unchanged\n Lactate unchanged\n Plan:\n F/U Blood cultures\n Monitor for increased WBC\n Monitor for s/s of worsening sepsis\n Family updated and is aware of daily events will be in\n tomorrow\n" }, { "category": "Nursing", "chartdate": "2199-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490383, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on A/C .40% TV 350X28 with 10/PEEP\n Pt with Rhonchi in bilat upper lobes clearing with suction\n Pt more more arousable\n Sxn for thick white secretions\n + Productive cough with stimulated\n Action:\n Rotating most of night\n Percussion done frequently\n Peep decreased to 8\n Fent weaned to 350mcgs\n Response:\n Appears to be tolerating peep wean well\n Sats >98%\n ABG pending\n Tolerating pulmonary toilet well\n Plan:\n Cont to wean pt as tolerated\n Wean fent as tolerated\n ? possible CPAP trail\n F/U BC\n Cont with supportive care to pt and family\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489912, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn. Now on Vanco, Cipro\n and Meropenem\n Chief complaint:\n Septic Shock\n PMHx: G1P1\n Current medications:\n Heparin SQ \n Famotidine\n Vanco\n Meropenem\n Cipro\n Albumin 5% (250ml) x 1\n 24 Hour Events:\n : BP remains stable off pressors. PEEP down to 15. Temp spike\n (given tylenol) and tachy to 130s. Added Cipro. Good UOP, but decreased\n when pt became tachy to 130's. Good HR response to 250cc of 5% albumin.\n No new cx.\n : Temp spike despite starting Cipro. Blood Cx resent. Will check\n Vanco level.\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.28 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.7\nC (101.6\n HR: 115 (98 - 126) bpm\n BP: 119/73(91) {96/53(67) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 15 (15 - 23) mmHg\n CO/CI (Thermodilution): (10.2 L/min) / (5 L/min/m2)\n SVR: 463 dynes*sec/cm5\n Mixed Venous O2% sat: 82 - 82\n SV: 103 mL\n SVI: 50 mL/m2\n Total In:\n 2,893 mL\n 918 mL\n PO:\n Tube feeding:\n 741 mL\n 382 mL\n IV Fluid:\n 1,752 mL\n 536 mL\n Blood products:\n 400 mL\n Total out:\n 3,380 mL\n 890 mL\n Urine:\n 3,380 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n -487 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 99%\n ABG: 7.38/41/98./24/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Erythema), Area on thigh marked\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 107 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n WBC\n 9.0\n 10.2\n 7.6\n Hct\n 25.6\n 33\n 28.1\n 24.8\n Plt\n 62\n 79\n 70\n Creatinine\n 3.3\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n Glucose\n 106\n 107\n 115\n 113\n 107\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course\n Neuro: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. cont paralysis w/cisatricurium. Pt continues to spike\n temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. cont paralysis w/cisatricurium.\n Cardiovascular: off all pressors; monitoring. Tachy with good\n responce to albumin. Consider TEE in light of persistent fevers & broad\n abx coverage\n Pulmonary: PEEP down to 15, ARDS protocol, daily CXR, wean as tolerated\n Gastrointestinal / Abdomen: Tolerating tube feeds. RUQ U/S to r/o\n acalculus cholecystits as etiology of fevers\n Nutrition: NGT in place. TF Impact w/ fiber at 60mL/hr\n Renal: NGT in place. TF Impact w/ fiber at 60mL/hr\n Hematology: Hx of SGA bleed s/p coiling in IR. Mild anemia with goal\n Hct 30, transfuse PRBCs prn. Thrombocytopenic, ?BM suppression. SQH and\n bootsHct= 24.8, will recheck Hct. No obvious sources of bleeding, will\n recheck HCt. On SQH , may consider increasing DVT proph in light of\n fevers. Consider BLE Doppler to r/o DVT.\n Endocrine: no issues\n Infectious Disease: Vanc/ for GNR from wound and blood cx from OSH.\n F/u speciation/sensitivities. ID c/s. Monitor vanco level.Added\n Cipro.Ortho: S/p Washout ; no plans for return to OR at this time.\n Gyn: S/p D&C; no further plans at this time Consider swicthoing.\n Lines / Tubes / Drains:\n Wounds: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation.\n Imaging: No new images\n Fluids: KVO\n Consults: Ortho, ID\n Billing Diagnosis: Septic Shock\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:31 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: SQH, SCD\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Rehab Services", "chartdate": "2199-10-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 491488, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: sepsis / 038.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 19 yo F admitted\n with hypotension and weakness following 5 days of n/v/d, found to\n have prominent bandemia/thrombocytopenia and developed ARF with 3\n pressor requirement, sepsis presumed to be from GU source. CT showed L\n retroperitoneal abscess with air c/w SI osteomyelitis, went to the OR\n for I&D on , post-op course c/b L superior gluteal artery bleed\n requiring IR intervention, post-op remained intubated and sedated.\n Subsequent I&D on . Self-extubated on .\n Past Medical / Surgical History: 11 days post partum on admission,\n vaginal delivery with episiotomy\n Medications: flagyl, ciprofloxacin, lorazepam, haloperidol, lorazepam,\n fentanyl, methadone\n Radiology: CXR - Bilateral pleural effusions are increased.\n Extensive bilateral parenchymal opacities\n Labs:\n 22.4\n 7.2\n 363\n 6.3\n [image002.jpg]\n Other labs:\n Activity Orders: ok for OOB per sicu team, NWB LLE per ortho PA, ROM as\n tolerated\n Social / Occupational History: lives with her parents, brother,\n boyfriend, and daughter\n Environment: unknown\n Prior Functional Status / Activity Level: I pta\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented to\n self only, follows most simple commands. Minimally verbal, moaning and\n calling for \"mom\"\n Aerobic Capacity\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n 104\n 133/86\n 12\n 99% on FT\n Activity\n 116\n 139/70\n 16\n 93% on FT\n Recovery\n 100\n 124/76\n 13\n 98% on FT\n Total distance walked: 0\n Minutes:\n Pulmonary Status: shallow breathing, no cough noted, diminished BS at\n bases. On 100% FiO2 via face tent.\n Integumentary / Vascular: R IJ multi-lumen, R axillary a-line, foley,\n rectal tube, tele. 3+ peripheral edema\n Sensory Integrity: intact to light touch\n Pain / Limiting Symptoms: c/o L hip/thigh pain when at edge of bed\n Posture: obese\n Range of Motion\n Muscle Performance\n B LE's WNL\n grossly 2 to 2+/5 B LE's\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: unable to attain full stand or to transfer, \n transferred from bed to chair.\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n X2\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: able to maintain static sitting at edge of bed once\n positioned, able to weight shift minimally. Standing balance not\n assessed.\n Education / Communication: Reviewed PT and encouraged OOB.\n Communicated with nsg re: status. Spoke with ortho PA re: WB\n restrictions.\n Intervention:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired strength\n Clinical impression / Prognosis: 19 yo F with sepsis p/w above\n impairments a/w deconditioning. She is most limited by decreased\n strength and functional mobility a/w prolonged icu hospitalization with\n intubation/sedation. She is significantly below her baseline level,\n and given her medical acuity and her NWB status, she will likely not be\n safe for home for a prolonged period of time. As she has strong family\n support, she could potentially go home with 24-hour assist if she makes\n steady continuous progress in the next week, however if minimal\n progress is seen and she remains medically complex, she may require\n rehab upon d/c. PT to continue to follow up and progress as able, and\n reassess d/c dispo as appropriate.\n Goals\n Time frame: 1 week\n 1.\n Min A bed mobility, assess transfers\n 2.\n S static/dynamic sitting balance, assess standing\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerate daily strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, ambulation, balance, strengthening, education,\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2199-10-12 00:00:00.000", "description": "Intensivist Note", "row_id": 490730, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per records, patient\n has receieved a total of 9-10L of fluid before transfer, started\n empirically on Vanco and Zosyn.\n Chief complaint:\n buttock pain\n PMHx:\n G1P1, otherwise negative\n Current medications:\n Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1455\n HYDROmorphone (Dilaudid) 1-5 mg IV Q1H:PRN pain Order date: @\n 1247\n Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN fever Start: Order\n date: @ 1157\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n Albuterol Inhaler PUFF IH Q2H:PRN wheezing Order date: @\n 2227\n Lorazepam 1-2 mg IV Q1H:PRN agitation Order date: @ 0054\n Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date: \n @ 0429\n Magnesium Sulfate IV Sliding Scale Order date: @ 1023\n Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @ 1557\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0815\n Calcium Gluconate IV Sliding Scale Order date: @ 1557\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @ 0835\n Senna 1 TAB PO/NG :PRN Constipation Start: Order date:\n @ 1156\n Ciprofloxacin 400 mg IV Q12H Order date: @ 1039\n Enoxaparin Sodium 40 mg SC DAILY Order date: @ 0915\n Clindamycin 600 mg IV Q8H Order date: @ 0835\n Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n DiphenhydrAMINE 25 mg IV Q8H:PRN rash Order date: @ 2201\n 24 Hour Events:\n C diff neg x 1; diffuse rash, likely meropenem; d/c'd and\n cipro/clinda started; vanc d/c'd. D/c'd fentanyl and started PRN\n dilaudid; pt anxious overnight, requiring high doses of dilaudid and\n ativan.\n FEVER - 102.5\nF - 08:00 AM\n Post operative day:\n POD#9 - I & D Lt ileum and Sacroiliac joint debridement\n POD#8 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Meropenem - 04:00 AM\n Clindamycin - 08:00 PM\n Ciprofloxacin - 09:43 PM\n Metronidazole - 02:14 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Furosemide (Lasix) - 04:00 PM\n Midazolam (Versed) - 11:10 PM\n Lorazepam (Ativan) - 04:10 AM\n Hydromorphone (Dilaudid) - 05:10 AM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 37.5\nC (99.5\n HR: 128 (112 - 140) bpm\n BP: 149/96(117) {94/55(70) - 149/96(117)} mmHg\n RR: 13 (0 - 35) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 13 (7 - 14) mmHg\n Total In:\n 3,006 mL\n 502 mL\n PO:\n Tube feeding:\n 1,680 mL\n 375 mL\n IV Fluid:\n 1,177 mL\n 127 mL\n Blood products:\n Total out:\n 3,545 mL\n 360 mL\n Urine:\n 3,445 mL\n 360 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -539 mL\n 142 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 355 (355 - 704) mL\n PS : 12 cmH2O\n RR (Spontaneous): 32\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 143\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: 7.42/40/112/24/0\n Ve: 11.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General Appearance: Anxious, intermittently agitated\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: Rash: chest / arms / legs, (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 173 K/uL\n 8.1 g/dL\n 98 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 53 mg/dL\n 109 mEq/L\n 141 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 11:46 AM\n 02:26 PM\n 06:25 PM\n 02:37 AM\n 02:45 AM\n 06:22 AM\n 10:01 AM\n 12:10 AM\n 02:18 AM\n 02:57 AM\n WBC\n 8.4\n 9.5\n 8.3\n Hct\n 24.5\n 26.6\n 25.0\n Plt\n 92\n 118\n 173\n Creatinine\n 2.6\n 2.5\n 2.0\n TCO2\n 23\n 25\n 26\n 26\n 23\n 26\n 27\n Glucose\n 104\n 96\n 93\n 102\n 104\n 98\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:78.9 %, Band:2.0 %, Lymph:15.2 %,\n Mono:2.6 %, Eos:2.7 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.7 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Ativan PRN for agitation/anxiety, dilaudid prn for\n analgesia.\n Cardiovascular: off all pressors, stable; sinus tach\n Pulmonary: PEEP continuing to wean slowly, ARDS protocol\n Gastrointestinal / Abdomen: NGT in place, tube feeds at goal; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1). Esophageal\n balloon removed.\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition\n Renal: ARF, creatinine trending down\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS.\n Infectious Disease: No new culture data; cipro/clinda/flagyl for\n fusobacteria, bacillis sp. ID following. D/c' rash.\n Lines / Tubes / Drains:\n Wounds: L hip clean / dry / intact\n Imaging: none\n Fluids: HLIV\n Consults: orthopaedic surgery\n Billing Diagnosis: septic shock\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 12:12 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: SQH, boots\n Stress ulcer: H2B\n VAP bundle: +\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 45 min\n" }, { "category": "Nursing", "chartdate": "2199-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490299, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n - Received patient on FiO2 .50; Vt 350 X f 28 X PEEP 14 on maximum\n cisatracurium, TOF with 20 mA. Lung sounds rhonchorous all around\n with small amount of thick white secretions. Tolerating rotating bed.\n Action:\n - Shut cisatracurium off. Repeat ABG showed improved oxygenation to PO2\n 147 from 109 on AM labs. PEEP weaned to 12, midaz gtt weaned to 4.\n Repeat ABG 153-39-7.36\n FiO2 decreased to 40, PEEP to 10\n - Changed rotation setting to maximize gas exchange so patient is on\n right side longer than left side. Per AM CXR, more airspace in R lung.\n Response:\n - Last ABG 104-41-7.37 on FiO2 40-350 X 28 X peep 10.\n - Tolerating midaz wean so midaz gtt off\n getting PRN boluses of\n midaz 2-4 mg Q 2. Lung sounds clear compared to this morning, remains\n rhonchorous in RUL.\n - Pt opening eyes to voice and command, flexing all extremities to\n pain, moving head spontaneously.\n Plan:\n - Overnight, no further vent changes. Wean fent if tolerated. Cont to\n wean tomorrow as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains hemodynamically stable in sinus/sinus tach 94-118, no ectopy\n noted. Mean BPs 60-90 without support. Urine output >50/hour. T max\n this shift 99.9. Cont to have blanchable red rash throughout body.\n Action:\n - Cooling blanket removed. Cipro discontinued as probable cause of body\n rash. Antibiotics admin as ordered. Cdiff number 2 sent. IV flagyl\n added.\n - Ordered and applied multipodus boots due to patient prolonged bedrest\n and likely lengthy rehab ahead\n Response:\n - T current 99.6. Cr cont to trend down, currently 2.6\n Plan:\n - Cont antibiotic admin; f/u cultures.\n - Episiotomy\n 1 suture with slight tear. OB assessed. Plan is it will\n heal on its own or it can be repaired once her edema decreases. Blood\n from area\n keep clean, use hygiene pads PRN\n" }, { "category": "Nursing", "chartdate": "2199-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490951, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt initially sleeping quietly at start of shift but escalated in\n agitation and restlessness over the course of the shift. Pt started\n having increasing periods when her respiratory rate was into 50s, and\n tachycardia into 120s. During periods of agitation the pt was\n constantly shifting in bed, very restless. Pt nodding head\n pain. Pt given IV scheduled Ativan and PRN dosing Ativan with only\n brief, short term effects. Pt required low dose propofol to ultimately\n calm decrease restlessness and RR.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489873, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn. Now on Vanco, Cipro\n and Meropenem\n Chief complaint:\n Septic Shock\n PMHx:\n Current medications:\n 24 Hour Events:\n : BP remains stable off pressors. PEEP down to 15. Temp spike\n (given tylenol) and tachy to 130s. Added Cipro. Good UOP, but decreased\n when pt became tachy to 130's. Good HR response to 250cc of 5% albumin.\n No new cx.\n : Temp spike despite starting Cipro. Blood Cx resent. Will check\n Vanco level.\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.28 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.7\nC (101.6\n HR: 115 (98 - 126) bpm\n BP: 119/73(91) {96/53(67) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 15 (15 - 23) mmHg\n CO/CI (Thermodilution): (10.2 L/min) / (5 L/min/m2)\n SVR: 463 dynes*sec/cm5\n Mixed Venous O2% sat: 82 - 82\n SV: 103 mL\n SVI: 50 mL/m2\n Total In:\n 2,893 mL\n 918 mL\n PO:\n Tube feeding:\n 741 mL\n 382 mL\n IV Fluid:\n 1,752 mL\n 536 mL\n Blood products:\n 400 mL\n Total out:\n 3,380 mL\n 890 mL\n Urine:\n 3,380 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n -487 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 99%\n ABG: 7.38/41/98./24/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Erythema), Area on thigh marked\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 107 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n WBC\n 9.0\n 10.2\n 7.6\n Hct\n 25.6\n 33\n 28.1\n 24.8\n Plt\n 62\n 79\n 70\n Creatinine\n 3.3\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n Glucose\n 106\n 107\n 115\n 113\n 107\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:31 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490857, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt had episode of tachycardia, tachypnea in the 60s with\n nasal flaring and ^WOB noted. Increased vent settings temporarily.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: Wean PS as tol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2199-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490946, "text": "Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-10-13 00:00:00.000", "description": "Intensivist Note", "row_id": 491005, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n Septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n . Acetaminophen (Liquid) 4. Albuterol Inhaler 9. Ciprofloxacin 10.\n Clindamycin 11. Clonidine Patch 0.2 mg/24 hr\n 12. CloniDINE 13. DiphenhydrAMINE 14. Enoxaparin Sodium 15. Famotidine\n 16. Fentanyl Citrate 17. Insulin\n 18. Lorazepam 121. MetRONIDAZOLE (FLagyl) 22. Methadone 23.\n Ondansetron Propofol 27. Senna\n 24 Hour Events:\n Started on methadone, clonidine. Intolerate of sedation schedule; with\n increased respiratory effort and need to transiently increase\n ventilatory settings. Febrile. Intermittently on propofol. Started\n on standing ativan and fentanyl drip.\n FEVER - 101.9\nF - 11:00 AM\n Post operative day:\n POD#10 - I & D Lt ileum and Sacroiliac joint debridement\n POD#9 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Meropenem - 04:00 AM\n Metronidazole - 06:00 PM\n Ciprofloxacin - 10:49 PM\n Clindamycin - 03:54 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Fentanyl - 300 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:45 AM\n Fentanyl - 11:10 AM\n Lorazepam (Ativan) - 10:49 PM\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.8\nC (100\n HR: 110 (91 - 137) bpm\n BP: 111/67(85) {89/40(56) - 154/94(117)} mmHg\n RR: 26 (15 - 41) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 11 (6 - 16) mmHg\n Total In:\n 3,177 mL\n 643 mL\n PO:\n Tube feeding:\n 1,682 mL\n 372 mL\n IV Fluid:\n 1,495 mL\n 271 mL\n Blood products:\n Total out:\n 2,860 mL\n 925 mL\n Urine:\n 2,860 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 317 mL\n -282 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (317 - 427) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Agitated\n PIP: 19 cmH2O\n SPO2: 98%\n ABG: 7.41/42/125/23/2\n Ve: 10.3 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: Rash:\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 173 K/uL\n 8.1 g/dL\n 107 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 50 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.5 %\n 8.3 K/uL\n [image002.jpg]\n 10:01 AM\n 12:10 AM\n 02:18 AM\n 02:57 AM\n 12:14 PM\n 02:12 PM\n 09:20 PM\n 02:47 AM\n 02:48 AM\n 03:11 AM\n WBC\n 8.3\n Hct\n 25.0\n 24.5\n Plt\n 173\n Creatinine\n 2.0\n 1.8\n TCO2\n 23\n 26\n 27\n 25\n 26\n 28\n 28\n Glucose\n 102\n 104\n 98\n 110\n 107\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:78.9 %, Band:2.0 %, Lymph:15.2 %,\n Mono:2.6 %, Eos:2.7 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:1.6 mg/dL, PO4:3.6\n mg/dL\n Imaging: : Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n : Vaginal US: 8mm endometrial stripe, no retained products\n seen\n : CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n : CXR - Apparent improvement probably due to increased ventilator\n pressures. No new consolidation or pneumothorax.\n Liver U/S Stable appearance of nonspecific gallbladder wall\n thickening which is likely to be related to third spacing. The\n appearance is not suggestive of acute cholecystitis, and furthermore\n the stability of gallbladder volume would also argue against acute\n cholecystitis.\n CXR - There is multifocal airspace opacity in both lungs. This\n could represent ARDS or severe pulmonary edema. The appearance has not\n significantly changed.\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n .\n Neuro: Scheduled ativan q6 and PRN, fentanyl drip, clonidine, methadone\n for sedation/analgesia star PO haldol\n CV: Off all pressors.\n Resp: PEEP down to 12/5, will wean slowly, ARDS protocol, daily CXR.\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1). Esophageal\n balloon removed.\n Renal: ARF, creatinine trending down.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with goal\n transfuse PRBCs prn. lovenox and boots.\n ID: cipro/clinda/flagyl for fusobacteria, bacillis sp. ID following.\n D/c' rash.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation. Wound care for episiotomy\n Prophylaxis: Lovenox, boots, H2B\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:41 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: H2B\n VAP bundle:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 min\n" }, { "category": "Physician ", "chartdate": "2199-10-09 00:00:00.000", "description": "Intensivist Note", "row_id": 489894, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn. Now on Vanco, Cipro\n and Meropenem\n Chief complaint:\n Septic Shock\n PMHx: G1P1\n Current medications:\n Heparin SQ \n Famotidine\n Vanco\n Meropenem\n Cipro\n Albumin 5% (250ml) x 1\n 24 Hour Events:\n : BP remains stable off pressors. PEEP down to 15. Temp spike\n (given tylenol) and tachy to 130s. Added Cipro. Good UOP, but decreased\n when pt became tachy to 130's. Good HR response to 250cc of 5% albumin.\n No new cx.\n : Temp spike despite starting Cipro. Blood Cx resent. Will check\n Vanco level.\n BLOOD CULTURED - At 04:19 AM\n FEVER - 101.9\nF - 04:00 PM\n Post operative day:\n POD#6 - I & D Lt ileum and Sacroiliac joint debridement\n POD#5 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:30 AM\n Infusions:\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.28 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 38.7\nC (101.6\n HR: 115 (98 - 126) bpm\n BP: 119/73(91) {96/53(67) - 137/86(106)} mmHg\n RR: 28 (0 - 28) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 15 (15 - 23) mmHg\n CO/CI (Thermodilution): (10.2 L/min) / (5 L/min/m2)\n SVR: 463 dynes*sec/cm5\n Mixed Venous O2% sat: 82 - 82\n SV: 103 mL\n SVI: 50 mL/m2\n Total In:\n 2,893 mL\n 918 mL\n PO:\n Tube feeding:\n 741 mL\n 382 mL\n IV Fluid:\n 1,752 mL\n 536 mL\n Blood products:\n 400 mL\n Total out:\n 3,380 mL\n 890 mL\n Urine:\n 3,380 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n -487 mL\n 28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 99%\n ABG: 7.38/41/98./24/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Skin: (Incision: Erythema), Area on thigh marked\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 70 K/uL\n 8.4 g/dL\n 107 mg/dL\n 3.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 54 mg/dL\n 104 mEq/L\n 138 mEq/L\n 24.8 %\n 7.6 K/uL\n [image002.jpg]\n 02:11 AM\n 02:26 AM\n 08:01 AM\n 09:25 AM\n 10:49 AM\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n WBC\n 9.0\n 10.2\n 7.6\n Hct\n 25.6\n 33\n 28.1\n 24.8\n Plt\n 62\n 79\n 70\n Creatinine\n 3.3\n 3.2\n 3.1\n TCO2\n 27\n 26\n 26\n 28\n 25\n 25\n Glucose\n 106\n 107\n 115\n 113\n 107\n Other labs: PT / PTT / INR:17.2/34.7/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:3.8\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course\n Neuro: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. cont paralysis w/cisatricurium. Pt continues to spike\n temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. cont paralysis w/cisatricurium.\n Cardiovascular: off all pressors; monitoring. Tachy with good\n responce to albumin. Consider TEE in light of persistent fevers & broad\n abx coverage\n Pulmonary: PEEP down to 15, ARDS protocol, daily CXR, wean as tolerated\n Gastrointestinal / Abdomen: Tolerating tube feeds\n Nutrition: NGT in place. TF Impact w/ fiber at 60mL/hr\n Renal: NGT in place. TF Impact w/ fiber at 60mL/hr\n Hematology: Hx of SGA bleed s/p coiling in IR. Mild anemia with goal\n Hct 30, transfuse PRBCs prn. Thrombocytopenic, ?BM suppression. SQH and\n bootsHct= 24.8, will recheck Hct. No obvious sources of bleeding, will\n recheck HCt. On SQH , may consider increasing DVT proph in light of\n fevers. Consider BLE Doppler to r/o DVT.\n Endocrine: no issues\n Infectious Disease: Vanc/ for GNR from wound and blood cx from OSH.\n F/u speciation/sensitivities. ID c/s. Monitor vanco level.Added\n Cipro.Ortho: S/p Washout ; no plans for return to OR at this time.\n Gyn: S/p D&C; no further plans at this time Consider swicthoing.\n Lines / Tubes / Drains:\n Wounds: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation.\n Imaging: No new images\n Fluids: KVO\n Consults: Ortho, ID\n Billing Diagnosis: Septic Shock\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:31 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: SQH, SCD\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n" }, { "category": "Nursing", "chartdate": "2199-10-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489079, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Received this am on dobutamine gtt\n Levophed and vaso off\n Pt more tachycardic on doputamine and SVR decreasing in the\n presence of CO >10\n Pt remains afebrile\n Tissue sample from OR growing out GNR per micro\n U/O better over noc\n ELWI 10\n Action:\n Per ICU attending pt to be placed back on Levo vs dobutamine\n Sputum culture to be obtain\n 2 units of RBC\ns given with lasix inbetween\n Albumin added to facilitate diuresis\n Response:\n On levo pt with better CO/CI/SVR\n Slow able to wean levo over coarse of day\n Pt with good response to lasix to start lasix gtt hopefully\n with help with better ventilation since pt resp status declining (see\n below)\n Vanco dose decreased today cont on Zosyn\n Plan:\n Cont to monitor hemodynamics closely\n Monitor HCT and platelets\n Monitor electrolytes while pt is on lasix gtt\n Respiratory failure, acute ( ARDS/)\n Assessment:\n Started shift on .40% 12 of peep\n Pt with continued discoordination with vent throughout the\n day\n Pa02\ns dropping to 60\ns Sats 88-91% PIP\ns up to 40 from 20\n Lungs remain Rhonchorus throughout\n Sxn for Thick yellow/tan secretions\n Action:\n Mult vent changes\n Recruitment breathes X2\n Sedation increased\n Response:\n Despite above interventions respiratiory status cont to\n decline\n MD pt to be paralyzed\n Sedation increased to adequate level\n Cist started\n Post paralyzing pt ABG showing slightly better Pa 02 of 99\n Current vent setting .50% 16/peep 350X28\n Plan:\n Cont to monitor pt closely\n Supportive care to family\n" }, { "category": "Physician ", "chartdate": "2199-10-11 00:00:00.000", "description": "Intensivist Note", "row_id": 490460, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n Current medications:\n Acetaminophen (Liquid)\n Albuterol Inhaler\n Bisacodyl\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n DiphenhydrAMINE\n Famotidine\n Fentanyl Citrate\n Heparin\n Insulin\n Magnesium Sulfate Replacement\n Meropenem\n MetRONIDAZOLE (FLagyl)\n Midazolam\n Ondansetron\n Potassium Chloride Replacement\n Potassium Phosphate\n Senna\n Vancomycin\n 24 Hour Events:\n cont to wean PEEP\n d/c cisatricurium\n d/c cipro\n started flagyl\n Post operative day:\n POD#8 - I & D Lt ileum and Sacroiliac joint debridement\n POD#7 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:30 PM\n Vancomycin - 08:20 AM\n Metronidazole - 01:06 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 36.9\nC (98.5\n HR: 117 (96 - 122) bpm\n BP: 113/69(87) {91/47(64) - 135/85(106)} mmHg\n RR: 28 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 16 (11 - 22) mmHg\n Total In:\n 3,296 mL\n 695 mL\n PO:\n Tube feeding:\n 1,680 mL\n 395 mL\n IV Fluid:\n 1,556 mL\n 301 mL\n Blood products:\n Total out:\n 2,965 mL\n 415 mL\n Urine:\n 2,365 mL\n 415 mL\n NG:\n Stool:\n 600 mL\n Drains:\n Balance:\n 331 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 25 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/45/124/24/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous : b/l)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: minimal drainage R hip incision\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 118 K/uL\n 8.7 g/dL\n 93 mg/dL\n 2.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 107 mEq/L\n 140 mEq/L\n 26.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:05 PM\n 03:57 PM\n 01:51 AM\n 01:57 AM\n 09:34 AM\n 11:46 AM\n 02:26 PM\n 06:25 PM\n 02:37 AM\n 02:45 AM\n WBC\n 7.2\n 8.4\n 9.5\n Hct\n 26.9\n 25.1\n 24.5\n 26.6\n Plt\n 81\n 92\n 118\n Creatinine\n 3.0\n 2.9\n 2.6\n 2.5\n TCO2\n 25\n 25\n 24\n 23\n 25\n 26\n Glucose\n 108\n 99\n 100\n 104\n 96\n 93\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:84.9 %, Band:2.0 %, Lymph:11.3 %,\n Mono:1.6 %, Eos:1.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n .\n Neuro: Midaz prn/dilaudid for sedation/analgesia.\n CV: Off all pressors\n Resp: PEEP down to 8, will wean slowly, PSV today. D/C esoph balloon\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1)\n Renal: ARF, creatinine trending down.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with goal\n transfuse PRBCs prn. SQH and boots.\n ID: Vanc//flagyl for fusobacteria. ID following. Monitor vanco\n level adjust as needed Pharm recs 1250 q 48hrs. D/c'd cipro \n rash. Start flagyl empirically for cdiff. Rash after MeroChange ABX tp\n clinda/cipro/flagyl\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation.\n Prophylaxis: SQH, boots, H2B\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 01:43 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Family meeting held , ICU consent signed\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill septic shock, resp failure\n" }, { "category": "Respiratory ", "chartdate": "2199-10-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489994, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PEEP weaned to 14 from 15, tolerating well, PaO2 90s.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n No complications\n" }, { "category": "Nursing", "chartdate": "2199-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489995, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CMV with 15 peep, Fio2 50%, tv 350 and rate 28\n Breath sounds clear but diminished in bases r>l\n O2 sats 92-97%\n Cisatracurium , versed and fentanyl gtts infusing\n Action:\n Rotating on triadyne bed with percussion q2hrs\n Suctioned prn\n Peep decreased to 14\n Abg obtained as ordered\n Response:\n Po2 85-90 on lower peep\n Continues to have minimal secretions\n Plan:\n Continue paralytics\n Rotate on triadyne bed as tolerated\n Suction prn\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains off pressors with map >65\n Temp max 101.6 po\n Wbc = 7.6\n Vanco level 10.7\n Action:\n Vancomycin administered as ordered , pt to receive extra dose of vanco\n this evening\n USN LE and abdominal done at bedside\n CT scan of chest and torso done\n RIJ triple lumen changed over wire- tip for culture\n Fungal blood culture sent\n Antibiotics given as ordered\n Response:\n Continues to be febrile\n Awaiting culture reports\n Awaiting ct report\n Plan:\n Continue antibiotics as ordered\n Monitor culture reports\n" }, { "category": "Nursing", "chartdate": "2199-10-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488977, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains sedated on fentanyl and versed gtt\n Arouses easily to stimulation and appears uncomfortable and anxious\n when stimulated\n Not following commands but moving all extremities\n Received on Levophed, Dobutamine, and Vasopressin gtt to maintains map\n > 65\n Per previous echo left ventricular dysfunction so per team wean off\n Levophed and on Dobutamine\n Lungs coarse with mod amt thick tan/brown secretions\n Received on AC 350x 28 peep 15 fio2 40%\n u/o 20-30\n Action:\n Fentanyl and versed gtt increased over course of night to increase\n comfort\n Levophed and Vasopressin off, Dobutamine 2-2.5 overnight\n Peep decreased to 12\n Cont on vanco and zosyn, vanco level sent this am d/t renal\n insufficiency\n set up at 0630 per Dr \n Response:\n Appears more comfortable on increased sedation\n Tolerated peep decrease with initial dip in pao2 to 70\ns but rechecked\n at 90\n CO 10.3, SVR 400, SV 25\n BUN/Creat up slightly\n HCT down to 25- no s/sx bleeding\n Plan:\n Transfuse d/t likely hypovolemic and wean Dobutamine and increase\n levophed per dr . No plans for CRRT at this time as pt making\n urine. Start Albumin. Wean vent.\n" }, { "category": "Physician ", "chartdate": "2199-10-14 00:00:00.000", "description": "Intensivist Note", "row_id": 491209, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n s/p septic shock\n PMHx:\n Post partum\n Current medications:\n Haldol\n Cipro\n Flagyl\n Clinda\n Lovenox\n Lorazepam\n Clonidine\n 24 Hour Events:\n Started on Haldol 2mg . EKG WNL. Increased Benzo dose.Will\n consider Dex if no improvement. Blood cx sent today spike on \n Pt continues to become agitated when turned. Required haldol to\n be given early.\n BLOOD CULTURED - At 09:35 AM\n Post operative day:\n POD#11 - I & D Lt ileum and Sacroiliac joint debridement\n POD#10 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 11:30 AM\n Metronidazole - 06:16 PM\n Clindamycin - 05:03 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Lorazepam (Ativan) - 03:02 AM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.6\nC (99.6\n HR: 141 (94 - 141) bpm\n BP: 153/95(120) {91/50(64) - 153/95(120)} mmHg\n RR: 39 (19 - 41) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 10 (4 - 12) mmHg\n Total In:\n 3,187 mL\n 546 mL\n PO:\n Tube feeding:\n 1,677 mL\n 357 mL\n IV Fluid:\n 1,509 mL\n 190 mL\n Blood products:\n Total out:\n 4,260 mL\n 960 mL\n Urine:\n 4,010 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 363 (330 - 367) mL\n PS : 12 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n SPO2: 88%\n ABG: ///25/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Anxious, when aroused\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm)\n Skin: (Incision: Erythema), no purulent drainage\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 349 K/uL\n 7.8 g/dL\n 113 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 45 mg/dL\n 110 mEq/L\n 144 mEq/L\n 23.5 %\n 6.8 K/uL\n [image002.jpg]\n 12:10 AM\n 02:18 AM\n 02:57 AM\n 12:14 PM\n 02:12 PM\n 09:20 PM\n 02:47 AM\n 02:48 AM\n 03:11 AM\n 02:20 AM\n WBC\n 8.3\n 6.8\n Hct\n 25.0\n 24.5\n 23.5\n Plt\n 173\n 349\n Creatinine\n 2.0\n 1.8\n 1.6\n TCO2\n 26\n 27\n 25\n 26\n 28\n 28\n Glucose\n 104\n 98\n 110\n 107\n 113\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned\n Neurologic: Scheduled ativan q6 and PRN, decrease fentanyl drip,\n clonidine,for sedation/analgesia. Added haldol. Still having agitation\n with awakening (anxiety, tachypnea, and desaturation).\n Cardiovascular: Stable, off pressors\n Pulmonary: PEEP down to 12/5, will wean slowly, ARDS protocol, daily\n CXR. Tachypnea and desaturations when agitated, otherwise stable.\n Gastrointestinal / Abdomen: NGT in place. TF Impact w/ fiber at 70mL/hr\n per nutrition; high output loose stool -- flexiseal, c-diff (neg x 1).\n Consider repeating CDiff if she re-spikes\n Nutrition: Tube feeding\n Renal: Foley, Cr continues to trend downward\n Hematology: Hct slowly trending downward.\n Endocrine: RISS\n Infectious Disease: On flagyl, cipro, clinda. ID following. rash\n resolving.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: Ortho, ID dept\n Billing Diagnosis: (Shock: Septic) Respiratory Failure\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 03:28 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots (Lovenox)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-10-05 00:00:00.000", "description": "Intensivist Note", "row_id": 488965, "text": "SICU\n HPI:\n POD 4/3/2 s/p drainage / washout of L pelvis and takeback to angio\n for bleeding\n Abx: vanc/zosyn\n PPx: boots\n TLD: ETT, , , R femoral , JP x1\n Admit Wt:\n .\n HPI: 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At patient evaluated by OB gyn and a Vaginal US was\n performed which did not show retained products. Refused bimanual\n exam. Pt now on three pressors, increasing renal failure,\n increased WBC in 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n .\n PMHx: G1P1\n .\n PShx: Tonsillectomy, episotomy\n .\n : None\n .\n All: NKDA\n .\n SHx: NC\n .\n Fhx: NC\n .\n PE:\n Neo @ 1\n Vaso: 2.4\n Levaphed: 0.25\n 98, 103 (ST), 124/96 CVP 15, 50, 95 4L\n Uncomfortable\n Tachycardic\n CTAB\n Soft, TTP RLQ, infraumbilical and suprapubic, no rebound\n tenderness or peritoneal signs, very uncomfortable during vaginal\n U/S, episotomy site appears c/d/i, no obvious fluctuance felt or\n surrounding erythema seen, no crepitus felt\n no c/c/e\n .\n Micro:Outside hospital GNR, species pending.No growth form cx here.\n .\n Imaging:\n Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n Vaginal US: 8mm endometrial stripe, no retained products\n seen\n CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR unofficial - decreased haziness, no carddiomegaly\n : CXR Improved moderate-severe pulmonary edema since\n .ARDS unlikely. Marked distension of the stomach despite NG tube\n .\n Events:\n transferred to MICU with hypotension, increasing kidney failure; 3\n pressors, intubated; taken to OR with ortho for washout / debridement\n of L hip; postop Hct 13, given massive transfusion and taken back to\n angio for bleeding, coils placed x10\n PM - Pt continued to show evidence of septic shock, with\n hyperdynamic CO and requiring triple pressors for BP mgmt. \n monitor placed. Urine output laging and multiple blood products given\n in context of presumed hypovolemia, anemia, and thrombocytopenia. ID\n consulted and recommending d/c flagyl and addition of clindamycin for\n eagle effect.\n : Renal consult:may need CVVH placement for dialysis by end of\n weekend. s/p I&D, washout of hip and D&C. Improved UOP in OR and\n ICU.TTE revealed septic mycardial depression,started on dobutamine gtt.\n hold HR>110, ScVo2=80\n .\n Assessment: 19F G1P1 PP 11 with severe septic shock due to acute\n osteomyelitis of left hip, now s/p debridement of left hip and\n angiography.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n OR SENT - At 01:45 PM\n OR RECEIVED - At 04:50 PM\n s/p washout of left hip and D&C\n ARTERIAL LINE - STOP 08:00 PM\n Sheath/ from angiography suite. flushes easily with good blood\n return.\n Post operative day:\n POD#2 - I & D Lt ileum and Sacroiliac joint debridement\n POD#1 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Metronidazole - 01:00 AM\n Clindamycin - 06:16 AM\n Vancomycin - 09:08 AM\n Piperacillin - 06:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dobutamine - 2 mcg/Kg/min\n Fentanyl - 250 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.6\nC (97.9\n HR: 121 (93 - 121) bpm\n BP: 103/67(81) {89/53(67) - 133/80(268)} mmHg\n RR: 28 (0 - 34) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 357 (15 - 357) mmHg\n CO/CI (Thermodilution): (10.3 L/min) / (5 L/min/m2)\n SVR: 489 dynes*sec/cm5\n SV: 85 mL\n SVI: 42 mL/m2\n Total In:\n 3,863 mL\n 240 mL\n PO:\n Tube feeding:\n 9 mL\n IV Fluid:\n 2,491 mL\n 240 mL\n Blood products:\n 1,363 mL\n Total out:\n 469 mL\n 478 mL\n Urine:\n 309 mL\n 198 mL\n NG:\n 70 mL\n 280 mL\n Stool:\n Drains:\n Balance:\n 3,394 mL\n -238 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 35 cmH2O\n Plateau: 30 cmH2O\n Compliance: 19.4 cmH2O/mL\n SPO2: 97%\n ABG: 7.36/38/98./20/-3\n Ve: 9.9 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated\n Labs / Radiology\n 38 K/uL\n 9.0 g/dL\n 95 mg/dL\n 3.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 42 mg/dL\n 110 mEq/L\n 139 mEq/L\n 25.2 %\n 10.9 K/uL\n [image002.jpg]\n 08:53 AM\n 09:05 AM\n 02:52 PM\n 06:23 PM\n 06:31 PM\n 10:03 PM\n 02:51 AM\n 03:08 AM\n 04:18 AM\n 06:03 AM\n WBC\n 14.4\n 16.0\n 11.0\n 10.9\n Hct\n 27.9\n 35\n 30\n 28.9\n 25.5\n 25.2\n Plt\n 40\n 53\n 41\n 38\n Creatinine\n 2.8\n 2.9\n 3.0\n TCO2\n 22\n 23\n 22\n 23\n 24\n 22\n Glucose\n 120\n 123\n 114\n 113\n 109\n 89\n 95\n Other labs: PT / PTT / INR:15.1/27.6/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:96/145, Alk-Phos / T bili:96/1.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:417 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Septic shock\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Change dobutamine to levophed\n Pulmonary: Cont ETT, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: Start TF\n Renal: Foley, Marginal U/O\n Hematology: SC Heparin. Transfuse 2 X PC\n Endocrine: RISS\n Infectious Disease: Check cultures, Vanco, zosyn\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: Ortho, Gynecology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2199-10-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 491345, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2199-10-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488949, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remains sedated on fentanyl and versed gtt\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 489149, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt having episodes of desat,needing recruitment breaths.Peep\n increased X-ray worse with patchy infiltrates. Plan to bronch this\n AM.Consider starting MDI\n" }, { "category": "Physician ", "chartdate": "2199-10-07 00:00:00.000", "description": "Intensivist Note", "row_id": 489383, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n At patient evaluated by OB gyn and a Vaginal US was performed\n which did not show retained products. Refused bimanual exam. Pt now on\n three pressors, increasing renal failure, increased WBC in 48.1, plt\n 59. FDP products increased. Per records, patient has receieved a total\n of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n buttock pain\n PMHx:\n G1P1\n Current medications:\n 14. Magnesium Sulfate Replacement (Oncology) IV Sliding Scale Order\n date: @ 1557\n 2. Albumin 25% (12.5g / 50mL) 12.5 g IV Q12H Duration: 48 Hours Order\n date: @ 0705\n 15. Meropenem 1000 mg IV Q12H Order date: @ 1356\n 3. Albuterol Inhaler PUFF IH Q6H:PRN wheezing Order date: @\n 2125\n 16. Midazolam 4-8 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0643\n 4. Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date:\n @ 0429\n 17. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP>65\n Order date: @ 1557\n 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 1557\n 18. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1557\n 19. Potassium Chloride Replacement (Oncology) IV Sliding Scale Order\n date: @ 1557\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n 20. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n 8. Cisatracurium Besylate 0.06-0.30 mg/kg/hr IV TITRATE TO paralytic\n effect\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 2042\n 21. Senna 1 TAB PO BID:PRN Constipation Order date: @ 1557\n 9. Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n 10. Fentanyl Citrate 100-500 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ 0705\n 11. Furosemide 1-5 mg/hr IV DRIP INFUSION Order date: @ 1524\n 12. Heparin 5000 UNIT SC BID\n start after afternoon hct Order date: @ 1557\n 25. Vancomycin 750 mg IV Q 24H Order date: @ 0947\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n 24 Hour Events:\n Stable respiratory status on PEEP 18. Tube feeds at 20mL/hr. Rotated\n intermittently to either side, breathing best when R side dependent.\n D/c'd zosyn and added meropenem for increased GNR coverage per ID\n recommendation.\n ESOPHOGEAL BALLOON - At 08:29 AM\n at bedside\n PAN CULTURE - At 11:00 AM\n Post operative day:\n POD#4 - I & D Lt ileum and Sacroiliac joint debridement\n POD#3 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 06:16 AM\n Vancomycin - 12:00 PM\n Piperacillin - 07:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Meropenem - 05:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38\nC (100.4\n HR: 101 (90 - 109) bpm\n BP: 102/59(75) {95/58(71) - 118/79(95)} mmHg\n RR: 25 (0 - 28) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 18 (16 - 22) mmHg\n CO/CI (Thermodilution): (8.73 L/min) / (4.3 L/min/m2)\n SVR: 605 dynes*sec/cm5\n Bladder pressure: 9 (9 - 9) mmHg\n SV: 96 mL\n SVI: 47 mL/m2\n Total In:\n 2,097 mL\n 655 mL\n PO:\n Tube feeding:\n 200 mL\n 124 mL\n IV Fluid:\n 1,597 mL\n 530 mL\n Blood products:\n 300 mL\n Total out:\n 2,445 mL\n 815 mL\n Urine:\n 2,245 mL\n 815 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -348 mL\n -160 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 41 cmH2O\n Plateau: 36 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 94%\n ABG: 7.31/49/118/22/-2\n Ve: 9.1 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: intubated, sedated, paralyzed\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Wheezes : b/l, Crackles : b/l\n throughout)\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 50 K/uL\n 9.8 g/dL\n 103 mg/dL\n 3.3 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 48 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:20 AM\n 06:02 AM\n 08:08 AM\n 12:24 PM\n 02:32 PM\n 04:32 PM\n 04:40 PM\n 10:17 PM\n 02:17 AM\n 02:27 AM\n WBC\n 12.9\n 10.3\n Hct\n 28.7\n 28.4\n Plt\n 45\n 50\n Creatinine\n 3.3\n 3.2\n 3.3\n TCO2\n 23\n 24\n 22\n 23\n 24\n 24\n 26\n Glucose\n 83\n 77\n 90\n 94\n 90\n 103\n Other labs: PT / PTT / INR:19.1/31.6/1.7, CK / CK-MB / Troponin\n T:374//, ALT / AST:21/20, Alk-Phos / T bili:133/6.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:417 mg/dL, Lactic Acid:1.0 mmol/L,\n Albumin:2.3 g/dL, LDH:326 IU/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium.\n Cardiovascular: Levophed, weaning as tolerated; monitoring in\n right axillary arterial line.\n Pulmonary: AC 0.5, 28x350, PEEP 18, ARDS protocol, f/u CXR. Wean vent\n as tolerated, trend ABGs.\n Gastrointestinal / Abdomen: NGT in place. Tolerating TFs, no BM to\n date.\n Nutrition: Tube feeds at 20mL/hr.\n Renal: Lasix drip, acute renal failure; follow creatinine and UOP,\n albumin , volume with albumin as needed.\n Hematology: Serial Hct, goal Hct 30, transfuse PRBCs prn.\n Thrombocytopenic, etiology unknown, currently not bleeding so no plt\n transfusions.\n Endocrine: Random cortisol WNL, RISS.\n Infectious Disease: GNR from wound, blood cx from OSH. Continue\n vanc/. F/u speciation/sensitivities. ID consulting. Monitor\n vanco level.\n Lines / Tubes / Drains: ETT, , , R femoral \n Wounds: L pelvic/hip wound, clean/dry/intact.\n Imaging: CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n Fluids: HLIV, Lasix gtt.\n Consults: ortho, IR, ID; gyn signed off \n Billing Diagnosis: septic shock, respiratory failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:28 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: SQH, SCDs\n Stress ulcer: H2B\n VAP bundle:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32 min\n" }, { "category": "Physician ", "chartdate": "2199-10-10 00:00:00.000", "description": "Intensivist Note", "row_id": 490204, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n Septic Shock\n PMHx:\n G1 P1\n Current medications:\n 1. 2. 3. Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Artificial\n Tears 6. Bisacodyl 7. Calcium Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Cisatracurium Besylate\n 10. Ciprofloxacin 11. Famotidine\n 12. Fentanyl Citrate 13. Heparin 14. Insulin 15. Magnesium Sulfate\n Replacement (Oncology) 16. Meropenem\n 17. Midazolam 18. Ondansetron 19. Potassium Chloride Replacement\n (Oncology) 20. Potassium Phosphate\n 21. Senna\n 25. Sodium Chloride 0.9% Flush 26. Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 09:00 AM\n liver, gallbladder, pancreas, bilateral lower extremities\n MULTI LUMEN - STOP 01:41 PM\n Line placed previous shift confirmed by xray outgoing RN.\n MULTI LUMEN - START 02:21 PM\n FEVER - 101.7\nF - 08:00 PM\n CT torso: changes to kidney parenchyma, no concern for ongoing\n collection. ? rash to Cipro after administration. Cx data with\n Fusobacterium, sent for speciation. Episiotomy incision separated.\n Increased stool output. Spiked last night,. C diff sent.\n Post operative day:\n POD#7 - I & D Lt ileum and Sacroiliac joint debridement\n POD#6 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Ciprofloxacin - 02:30 PM\n Meropenem - 04:00 AM\n Infusions:\n Cisatracurium - 0.3 mg/Kg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.7\nC (99.8\n HR: 110 (92 - 132) bpm\n BP: 130/82(102) {95/48(65) - 138/86(106)} mmHg\n RR: 14 (14 - 32) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (15 - 22) mmHg\n Total In:\n 3,927 mL\n 816 mL\n PO:\n Tube feeding:\n 1,525 mL\n 222 mL\n IV Fluid:\n 2,302 mL\n 594 mL\n Blood products:\n 100 mL\n Total out:\n 2,540 mL\n 885 mL\n Urine:\n 2,540 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,387 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n SPO2: 95%\n ABG: 7.38/41/109/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Crackles : ,\n Diminished: bases)\n Abdominal: Soft, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Sedated, paralyzed\n Skin: scatterd blanching maculopapular rash.\n Labs / Radiology\n 81 K/uL\n 8.1 g/dL\n 100 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 25.1 %\n 7.2 K/uL\n [image002.jpg]\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n 09:13 AM\n 02:05 PM\n 03:57 PM\n 01:51 AM\n 01:57 AM\n WBC\n 10.2\n 7.6\n 7.2\n Hct\n 28.1\n 24.8\n 26.9\n 25.1\n Plt\n 79\n 70\n 81\n Creatinine\n 3.2\n 3.1\n 3.0\n 2.9\n TCO2\n 28\n 25\n 25\n 25\n 25\n 25\n Glucose\n 115\n 113\n 107\n 118\n 108\n 99\n 100\n Other labs: PT / PTT / INR:15.9/38.9/1.4, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. Try to d/c paralysis w/cisatricurium today\n Cardiovascular: off all pressors; monitoring. Tachy with good\n response to albumin.\n Pulmonary: PEEP down to 14, ARDS protocol, daily CXR, wean as\n tolerated. XR slightly improved.\n Gastrointestinal / Abdomen: NGT in place. TF Impact w/ fiber at 70mL/hr\n per nutrition. RUQ U/S to r/o acalculus cholecystits as etiology of\n fevers negative,\n high output loose stool -- flexiseal, c-diff test PND\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition.\n Renal: ARF, off Lasix gtt. Following daily creatinine.\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn.\n Endocrine: Random cortisol WNL, RISS.\n Infectious Disease: Concern for possible suture line release at\n epesiotomy site -- contact GYN, / for GNR from wound and blood\n cx from OSH. F/u speciation/sensitivities. ID c/s. Monitor vanco level\n and adjust as needed Pharm recs 1250 q 48hrs. Added Cipro follow for\n possible allergy, DC cipro given rash. Start Flagyl for D diff empiric\n tx, stop if neg x 3 stools.\n Lines / Tubes / Drains: RIJ Triple lumen, A line\n Wounds: Dry dressings\n Fluids: KVO\n Consults: Ortho, GYN, ID\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Communication: ICU consent signed:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489065, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490988, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt initially sleeping quietly at start of shift but escalated in\n agitation and restlessness over the course of the shift. Pt started\n having increasing periods when her respiratory rate was into 50s, and\n tachycardia into 120s. During periods of agitation the pt was\n constantly shifting in bed, very restless. Pt nodding head\n pain. Pt given IV scheduled Ativan and PRN dosing Ativan with only\n brief, short term effects.\n Action:\n Pt required low dose propofol to ultimately decrease\n restlessness/agitation and lower HR/RR.\n Response:\n Pt RR back into 28-30s after propofol started at 15 mcg/kg/min. Pt calm\n and resting quietly in bed\n Plan:\n Wean propofol as if tolerated. AtivanATC. Methadone PO and clonidine\n patch initiated already. Await further plan from SICU team\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491189, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt had longer periods when she was in a calm restful state but\n continues to wake very agitated, restless. Pt able to move all\n extremities, follows commands and will occasionally nod head to simple\n questions. When agitated, pt\ns RR up into 50-60s and HR tachy into\n 120s-130s\n Action:\n -re-oriented pt frequently when pt awake\n -ativan 6mg every 6 hours ATC\n -standing haldol dosing of 2mg \n -pt with clonidine patch\n -fentanyl drip continues and dosing titrated down\n -standing methadone dose\n Response:\n Pt able to have longer rest periods between periods of agitation\n Plan:\n Continue current med regime, wean fentanyl down as tolerated\n Addendum: Pt with prolonged period of restlessness and agitation this\n AM where HR up into 140s and RR up into 50s. Pox dropping 88-90% and\n only elevating to 92% when pt was less restless. ABG drawn and Poa2\n down to 66. fio2 increased to 50% and pox subsequently improved. Hct\n 23.5 this AM, will recheck at 0800 per Dr. .\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491344, "text": "Anxiety\n Assessment:\n Pt received this am on CPAP .50% Fi02\n Pt still very restless at times with episodes of increased\n anxiety\n Pt appears very scared and frustrated. Attempting to mouth\n words\n Pt MAE\n Action:\n Haldol increased to IV Q2hrs PRN\n Pt OOB to chair via lift\n Family in today and at bedside\n Fent weaned to 100mcg\n Methadone cont at 20mg 3x daily\n IPS weaned to 10 this am\n Response:\n Pt with adequate response from PRN haldol\n Pt not requiring ativan Haldol more effective\n Pt tolerating IPS of 10 well pt did appear more tired and\n breathing appearing more labored after Pt hoyered back into bed. Resp\n is aware\n Pt mental status cont to improve pt nodding appropriately to\n questions and following commands\n Plan:\n Cont haldol ? possible transition to PO seraquel tomorrow\n per pharmacy rec\n Cont to wean IPS as tolerated\n Pt requiring much emotional support\n Possible extubation tomorrow\n Cont with current plan of care\n" }, { "category": "Nursing", "chartdate": "2199-10-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491525, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n fentanyl gtt infusing at 50mcg\n pt moaning continuosly\n denies pain when asked\n Action:\n fentanyl patch added\n methadone decreased to 15mg tid\n emotional support given\n Response:\n continues to deny pain\n continues to moan\n Plan:\n administer methadone as ordered\n ? decrease fentanyl gtt in am\n continue to assess frequently for pain\n Anxiety\n Assessment:\n moaning continuosly\n states she is frightened especially when turning in bed or when in\n lift\n Action:\n emotional support given\n family at bedside most of shift\n Response:\n pt has not required any haldol or ativan this shift\n Plan:\n emotional support as needed\n medicate with ativan or haldol only if needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt self-extubated last evening\n received on 100% open face tent\n continues to desat to low 90\ns when O2 off\n bs rhonchi throughout and diminished in bases\n Action:\n pulmonary toilet encouraged\n oob to chair for 3hrs\n dangeled at side of bed with PT\n changed to nasal cannula at 5 liters\n Response:\n O2 sats 95-97%\n tolerated being oob\n coughing but not raising\n Plan:\n pulmonary toilet\n monitor sats\n increase activity as tolerated\n" }, { "category": "Physician ", "chartdate": "2199-10-06 00:00:00.000", "description": "Intensivist Note", "row_id": 489134, "text": "SICU\n HPI:\n 19F presents with septic shock following birth/episiotomy, s/p septic\n joint washout\n Chief complaint:\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Bisacodyl\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n Cisatracurium Besylate\n Famotidine\n Fentanyl Citrate\n Furosemide\n Heparin\n Insulin\n Magnesium Sulfate Replacement\n Midazolam\n Ondansetron\n Piperacillin-Tazobactam\n Potassium Chloride\n Potassium Phosphate\n Senna\n Vancomycin\n 24 Hour Events:\n cont resp distress, paralyzed\n started lasix drip\n Post operative day:\n POD#3 - I & D Lt ileum and Sacroiliac joint debridement\n POD#2 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 01:00 AM\n Clindamycin - 06:16 AM\n Vancomycin - 12:00 PM\n Piperacillin - 07:00 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Midazolam (Versed) - 10 mg/hour\n Furosemide (Lasix) - 5 mg/hour\n Fentanyl - 450 mcg/hour\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Furosemide (Lasix) - 02:50 PM\n Cisatracurium - 03:45 PM\n Other medications:\n Flowsheet Data as of 04:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.8\nC (100.1\n HR: 107 (92 - 121) bpm\n BP: 95/63(75) {82/44(58) - 118/85(95)} mmHg\n RR: 19 (0 - 36) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 21 (11 - 357) mmHg\n CO/CI (Thermodilution): (9.3 L/min) / (4.5 L/min/m2)\n SVR: -2,305 dynes*sec/cm5\n SV: 92 mL\n SVI: 45 mL/m2\n Total In:\n 2,465 mL\n 247 mL\n PO:\n Tube feeding:\n 137 mL\n IV Fluid:\n 1,427 mL\n 247 mL\n Blood products:\n 902 mL\n Total out:\n 2,063 mL\n 295 mL\n Urine:\n 1,783 mL\n 295 mL\n NG:\n 280 mL\n Stool:\n Drains:\n Balance:\n 402 mL\n -48 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n PIP: 45 cmH2O\n Plateau: 42 cmH2O\n Compliance: 14.6 cmH2O/mL\n SPO2: 94%\n ABG: 7.32/43/82./21/-3\n Ve: 9.7 L/min\n PaO2 / FiO2: 166\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : b/l, Rhonchorous : b/l)\n Abdominal: Soft, Non-distended, Non-tender, No(t) Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 44 K/uL\n 10.3 g/dL\n 80 mg/dL\n 3.1 mg/dL\n 21 mEq/L\n 3.8 mEq/L\n 44 mg/dL\n 109 mEq/L\n 140 mEq/L\n 29.3 %\n 11.0 K/uL\n [image002.jpg]\n 02:16 PM\n 03:14 PM\n 05:48 PM\n 07:45 PM\n 10:04 PM\n 10:14 PM\n 10:31 PM\n 12:29 AM\n 02:12 AM\n 02:20 AM\n WBC\n 12.2\n 11.0\n Hct\n 30.4\n 29.3\n Plt\n 48\n 44\n Creatinine\n 3.1\n 3.1\n TCO2\n 23\n 22\n 23\n 20\n 24\n 23\n 21\n 23\n Glucose\n 93\n 100\n 80\n Other labs: PT / PTT / INR:17.0/29.5/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:28/23, Alk-Phos / T bili:137/5.8, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:417 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:2.3 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:2.0 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, Restraints, midaz/fentanyl for\n sedation/analgesia. paralyzed cisatricurium.\n Cardiovascular: off pressors; monitoring in right Ax a line\n Pulmonary: Cont ETT, ARDS protocol, f/u CXR\n Gastrointestinal / Abdomen: hold TF while paralyzed\n Nutrition: Tube feeding, TF on hold\n Renal: Foley, lasix drip\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, cont abx vanc/zosyn for GNR in\n wound\n Lines / Tubes / Drains: Foley, NGT, ETT, Surgical drains (hemovac, JP)\n Wounds: drain in place\n Imaging: CXR today\n Fluids: KVO, lasix drip\n Consults: Ortho, ID dept, Nephrology\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, (Shock:\n Septic)\n ICU Care\n Nutrition: TF on hold\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-10-08 00:00:00.000", "description": "Intensivist Note", "row_id": 489621, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n .\n Chief complaint:\n sepsis\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n Albumin 25% (12.5g / 50mL)\n Cisatracurium Besylate\n Famotidine\n Fentanyl Citrate\n Furosemide\n Heparin\n Insulin\n Meropenem\n Midazolam\n Vancomycin\n 24 Hour Events:\n Weaned off pressors. Did not tolerate decrease in PEEP to 15,\n recovered after returning to 18. Continues diuresis on lasix drip.\n Persistently febrile with mild tachycardia. Resent blood and urine\n cultures.\n BLOOD CULTURED - At 11:00 PM\n SPUTUM CULTURE - At 05:16 AM\n URINE CULTURE - At 05:16 AM\n FEVER - 101.4\nF - 05:00 AM\n Post operative day:\n POD#5 - I & D Lt ileum and Sacroiliac joint debridement\n POD#4 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 07:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Vancomycin - 09:16 AM\n Meropenem - 04:11 AM\n Infusions:\n Furosemide (Lasix) - 2 mg/hour\n Midazolam (Versed) - 7 mg/hour\n Fentanyl - 450 mcg/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 AM\n Heparin Sodium (Prophylaxis) - 08:11 PM\n Other medications:\n Flowsheet Data as of 06:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.6\nC (101.4\n HR: 116 (95 - 116) bpm\n BP: 109/64(80) {91/50(64) - 121/75(92)} mmHg\n RR: 20 (3 - 28) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (13 - 26) mmHg\n Total In:\n 3,380 mL\n 697 mL\n PO:\n Tube feeding:\n 480 mL\n 119 mL\n IV Fluid:\n 2,300 mL\n 579 mL\n Blood products:\n 600 mL\n Total out:\n 3,925 mL\n 1,305 mL\n Urine:\n 3,925 mL\n 1,305 mL\n NG:\n Stool:\n Drains:\n Balance:\n -545 mL\n -608 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 33 cmH2O\n Compliance: 24.5 cmH2O/mL\n SPO2: 98%\n ABG: 7.41/41/109/25/0\n Ve: 9.7 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n , Crackles : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Cool)\n Right Extremities: (Edema: 2+), (Temperature: Cool)\n Skin: (Incision: Clean / Dry / Intact, Erythema)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 62 K/uL\n 8.9 g/dL\n 106 mg/dL\n 3.3 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 49 mg/dL\n 104 mEq/L\n 138 mEq/L\n 25.6 %\n 9.0 K/uL\n [image002.jpg]\n 04:32 PM\n 04:40 PM\n 10:17 PM\n 02:17 AM\n 02:27 AM\n 06:24 AM\n 12:07 PM\n 05:14 PM\n 02:11 AM\n 02:26 AM\n WBC\n 12.9\n 10.3\n 9.0\n Hct\n 28.7\n 28.4\n 25.6\n Plt\n 45\n 50\n 62\n Creatinine\n 3.2\n 3.3\n 3.3\n TCO2\n 24\n 24\n 26\n 28\n 24\n 22\n 27\n Glucose\n 90\n 94\n 90\n 103\n 101\n 106\n Other labs: PT / PTT / INR:17.9/31.6/1.6, CK / CK-MB / Troponin\n T:374//, ALT / AST:17/23, Alk-Phos / T bili:167/4.7, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:627 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:3.2\n mg/dL\n Imaging: : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n Microbiology: Micro:\n - Outside hospital BCx GNR, species pending.\n - BCx - NGTD\n - Wound Cx (OR) - GNR ( samples)\n - UCx - negative\n - BCx - pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course\n Neuro: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. Will consider weaning muscle relaxant or giving\n paralytic holiday.\n CV: s/p triple pressors; monitoring\n Resp: AC 0.5, 28x350, PEEP 18, ARDS protocol, daily CXR, wean as\n tolerated\n FEN/GI: NGT in place. TF Impact at 20mL/hr. H2B\n Renal: ARF with lasix drip and adequate diuresis. Following daily\n creatinine with albumin to promote extravascular diuresis\n Endo: Random cortisol WNL, RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Mild anemia with goal Hct 30,\n transfuse PRBCs prn. Thrombocytopenic, ?BM suppression. SQH and boots\n ID: Vanc/ for GNR from wound and blood cx from OSH. F/u\n speciation/sensitivities. ID consulting. Monitor vanco level.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Gyn: S/p D&C; no further plans at this time.\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Communication:\n Billing Diagnosis: septic shock, resp failure\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:46 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: sq heparin, boots\n Stress ulcer: H2B\n VAP bundle:\n Code status: Full code\n Disposition: sicu\n Total time spent: 32 min\n" }, { "category": "Physician ", "chartdate": "2199-10-10 00:00:00.000", "description": "Intensivist Note", "row_id": 490171, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n Septic Shock\n PMHx:\n G1 P1\n Current medications:\n 1. 2. 3. Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Artificial\n Tears 6. Bisacodyl 7. Calcium Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Cisatracurium Besylate\n 10. Ciprofloxacin 11. Famotidine\n 12. Fentanyl Citrate 13. Heparin 14. Insulin 15. Magnesium Sulfate\n Replacement (Oncology) 16. Meropenem\n 17. Midazolam 18. Ondansetron 19. Potassium Chloride Replacement\n (Oncology) 20. Potassium Phosphate\n 21. Senna\n 25. Sodium Chloride 0.9% Flush 26. Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 09:00 AM\n liver, gallbladder, pancreas, bilateral lower extremities\n MULTI LUMEN - STOP 01:41 PM\n Line placed previous shift confirmed by xray outgoing RN.\n MULTI LUMEN - START 02:21 PM\n FEVER - 101.7\nF - 08:00 PM\n Post operative day:\n POD#7 - I & D Lt ileum and Sacroiliac joint debridement\n POD#6 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Ciprofloxacin - 02:30 PM\n Meropenem - 04:00 AM\n Infusions:\n Cisatracurium - 0.3 mg/Kg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.7\nC (99.8\n HR: 110 (92 - 132) bpm\n BP: 130/82(102) {95/48(65) - 138/86(106)} mmHg\n RR: 14 (14 - 32) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (15 - 22) mmHg\n Total In:\n 3,927 mL\n 816 mL\n PO:\n Tube feeding:\n 1,525 mL\n 222 mL\n IV Fluid:\n 2,302 mL\n 594 mL\n Blood products:\n 100 mL\n Total out:\n 2,540 mL\n 885 mL\n Urine:\n 2,540 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,387 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n SPO2: 95%\n ABG: 7.38/41/109/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Crackles : ,\n Diminished: bases)\n Abdominal: Soft, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Sedated\n Labs / Radiology\n 81 K/uL\n 8.1 g/dL\n 100 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 25.1 %\n 7.2 K/uL\n [image002.jpg]\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n 09:13 AM\n 02:05 PM\n 03:57 PM\n 01:51 AM\n 01:57 AM\n WBC\n 10.2\n 7.6\n 7.2\n Hct\n 28.1\n 24.8\n 26.9\n 25.1\n Plt\n 79\n 70\n 81\n Creatinine\n 3.2\n 3.1\n 3.0\n 2.9\n TCO2\n 28\n 25\n 25\n 25\n 25\n 25\n Glucose\n 115\n 113\n 107\n 118\n 108\n 99\n 100\n Other labs: PT / PTT / INR:15.9/38.9/1.4, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. cont paralysis w/cisatricurium\n Cardiovascular: off all pressors; monitoring. Tachy with good\n response to albumin.\n Pulmonary: PEEP down to 14, ARDS protocol, daily CXR, wean as tolerated\n Gastrointestinal / Abdomen: NGT in place. TF Impact w/ fiber at 70mL/hr\n per nutrition. RUQ U/S to r/o acalculus cholecystits as etiology of\n fevers negative,\n high output loose stool -- flexiseal, c-diff test PND\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition.\n Renal: ARF, off Lasix gtt. Following daily creatinine\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn.\n Endocrine: Random cortisol WNL, RISS.\n Infectious Disease: Concern for possible suture line release at\n epesiotomy site -- contact GYN, / for GNR from wound and blood\n cx from OSH. F/u speciation/sensitivities. ID c/s. Monitor vanco level\n and adjust as needed Pharm recs 1250 q 48hrs. Added Cipro follow for\n possible allergy, possibly DC cipro\n Lines / Tubes / Drains: RIJ Triple lumen, A line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Ortho\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-10-10 00:00:00.000", "description": "Intensivist Note", "row_id": 490186, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n Septic Shock\n PMHx:\n G1 P1\n Current medications:\n 1. 2. 3. Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Artificial\n Tears 6. Bisacodyl 7. Calcium Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Cisatracurium Besylate\n 10. Ciprofloxacin 11. Famotidine\n 12. Fentanyl Citrate 13. Heparin 14. Insulin 15. Magnesium Sulfate\n Replacement (Oncology) 16. Meropenem\n 17. Midazolam 18. Ondansetron 19. Potassium Chloride Replacement\n (Oncology) 20. Potassium Phosphate\n 21. Senna\n 25. Sodium Chloride 0.9% Flush 26. Vancomycin\n 24 Hour Events:\n ULTRASOUND - At 09:00 AM\n liver, gallbladder, pancreas, bilateral lower extremities\n MULTI LUMEN - STOP 01:41 PM\n Line placed previous shift confirmed by xray outgoing RN.\n MULTI LUMEN - START 02:21 PM\n FEVER - 101.7\nF - 08:00 PM\n CT torso: changes to kidney parenchyma, no concern for ongoing\n collection. ? rash to Cipro after administration. Cx data with\n Fusobacterium, sent for speciation. Episiotomy incision separated.\n Increased stool output. Spiked last night,. C diff sent.\n Post operative day:\n POD#7 - I & D Lt ileum and Sacroiliac joint debridement\n POD#6 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Ciprofloxacin - 02:30 PM\n Meropenem - 04:00 AM\n Infusions:\n Cisatracurium - 0.3 mg/Kg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 AM\n Heparin Sodium (Prophylaxis) - 08:10 AM\n Other medications:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.7\nC (99.8\n HR: 110 (92 - 132) bpm\n BP: 130/82(102) {95/48(65) - 138/86(106)} mmHg\n RR: 14 (14 - 32) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (15 - 22) mmHg\n Total In:\n 3,927 mL\n 816 mL\n PO:\n Tube feeding:\n 1,525 mL\n 222 mL\n IV Fluid:\n 2,302 mL\n 594 mL\n Blood products:\n 100 mL\n Total out:\n 2,540 mL\n 885 mL\n Urine:\n 2,540 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,387 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 37 cmH2O\n Plateau: 33 cmH2O\n SPO2: 95%\n ABG: 7.38/41/109/25/0\n Ve: 9.2 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Crackles : ,\n Diminished: bases)\n Abdominal: Soft, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Sedated, paralyzed\n Skin: scatterd blanching maculopapular rash.\n Labs / Radiology\n 81 K/uL\n 8.1 g/dL\n 100 mg/dL\n 2.9 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 25.1 %\n 7.2 K/uL\n [image002.jpg]\n 04:31 PM\n 04:40 PM\n 06:11 PM\n 02:13 AM\n 02:21 AM\n 09:13 AM\n 02:05 PM\n 03:57 PM\n 01:51 AM\n 01:57 AM\n WBC\n 10.2\n 7.6\n 7.2\n Hct\n 28.1\n 24.8\n 26.9\n 25.1\n Plt\n 79\n 70\n 81\n Creatinine\n 3.2\n 3.1\n 3.0\n 2.9\n TCO2\n 28\n 25\n 25\n 25\n 25\n 25\n Glucose\n 115\n 113\n 107\n 118\n 108\n 99\n 100\n Other labs: PT / PTT / INR:15.9/38.9/1.4, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:87.5 %, Band:2.0 %, Lymph:9.0 %,\n Mono:1.5 %, Eos:1.7 %, Fibrinogen:627 mg/dL, Lactic Acid:1.2 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:2.0 mg/dL, PO4:4.6\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium. Try to d/c paralysis w/cisatricurium today\n Cardiovascular: off all pressors; monitoring. Tachy with good\n response to albumin.\n Pulmonary: PEEP down to 14, ARDS protocol, daily CXR, wean as\n tolerated. XR slightly improved.\n Gastrointestinal / Abdomen: NGT in place. TF Impact w/ fiber at 70mL/hr\n per nutrition. RUQ U/S to r/o acalculus cholecystits as etiology of\n fevers negative,\n high output loose stool -- flexiseal, c-diff test PND\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition.\n Renal: ARF, off Lasix gtt. Following daily creatinine.\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn.\n Endocrine: Random cortisol WNL, RISS.\n Infectious Disease: Concern for possible suture line release at\n epesiotomy site -- contact GYN, / for GNR from wound and blood\n cx from OSH. F/u speciation/sensitivities. ID c/s. Monitor vanco level\n and adjust as needed Pharm recs 1250 q 48hrs. Added Cipro follow for\n possible allergy, DC cipro given rash. Start Flagyl for D diff empiric\n tx, stop if neg x 3 stools.\n Lines / Tubes / Drains: RIJ Triple lumen, A line\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Ortho, GYN, ID\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489135, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Received paralyzed and sedated d/t worsening respiratory status on\n previous shift\n - Received pt with no twitches but + twitches noted on later exam and +\n breath over vent after suction\n - Peak pressures remain in 40\n - Sustained elevated HR after suction\n - On low dose Levophed with MAP 70-80\n - CO/CI 5.3/2.6 SVR 900-1100 , CVP 18-22\n - Low grade temp Tmax 101.0\n - Lungs with rhonchi and crackles, diminished throughout but right more\n so than left\n - Sats decreasing to low 90\ns with paO2 in 70\n - Thick yellow secretions\n - Lasix gtt initiated to facilitate diurises with goal of improving\n oxygenation\n - Generalized edema \n Action:\n - Cisatricurium gtt increased slightly\n - Remains coordinate with ventilator and no auto peep noted\n - Levophed off d/t MAPs sustaining over 65 off gtt\n - Levophed restarted d/t CO > 9 with SVR 300\ns and decreasing u/o\n - On constant rotation with intermittent percussion\n - Recruitment maneuver and peep increased to 18\n - Suctioned frequently but unable to clear all secretions d/t no cough\n - Lasix gtt titrated up\n Response:\n - Continues to have twitches but no spontaneous respirations, HR\n stable despite intermittent stimulation\n - CO down to 6 and SVR up although no increase in UO so levophed back\n off MD \n - Levophed then restarted for decrease in BP (SBP 82/MAP 57)\n - Sats remaining >92% with paO2 in 80\ns, sats higher with right lung\n down\n - U/O with minimal increase with increase in lasix gtt\n - BUN/CReat and lytes stable.\n Plan:\n Likely bronch today, continue to diurese as tolerated, monitor\n hemodynamics and labs, provide family support.\n" }, { "category": "Physician ", "chartdate": "2199-10-07 00:00:00.000", "description": "Intensivist Note", "row_id": 489357, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n At patient evaluated by OB gyn and a Vaginal US was performed\n which did not show retained products. Refused bimanual exam. Pt now on\n three pressors, increasing renal failure, increased WBC in 48.1, plt\n 59. FDP products increased. Per records, patient has receieved a total\n of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n buttock pain\n PMHx:\n G1P1\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1557\n 14. Magnesium Sulfate Replacement (Oncology) IV Sliding Scale Order\n date: @ 1557\n 2. Albumin 25% (12.5g / 50mL) 12.5 g IV Q12H Duration: 48 Hours Order\n date: @ 0705\n 15. Meropenem 1000 mg IV Q12H Order date: @ 1356\n 3. Albuterol Inhaler PUFF IH Q6H:PRN wheezing Order date: @\n 2125\n 16. Midazolam 4-8 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0643\n 4. Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date:\n @ 0429\n 17. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP>65\n Order date: @ 1557\n 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 1557\n 18. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n 6. Calcium Gluconate IV Sliding Scale Order date: @ 1557\n 19. Potassium Chloride Replacement (Oncology) IV Sliding Scale Order\n date: @ 1557\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n 20. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n 8. Cisatracurium Besylate 0.06-0.30 mg/kg/hr IV TITRATE TO paralytic\n effect\n Patient should be ventilated and sedated prior to initiating NMBAs.\n Order date: @ 2042\n 21. Senna 1 TAB PO BID:PRN Constipation Order date: @ 1557\n 9. Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n 22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 10. Fentanyl Citrate 100-500 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ 0705\n 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 11. Furosemide 1-5 mg/hr IV DRIP INFUSION Order date: @ 1524\n 24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 12. Heparin 5000 UNIT SC BID\n start after afternoon hct Order date: @ 1557\n 25. Vancomycin 750 mg IV Q 24H Order date: @ 0947\n 13. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n 24 Hour Events:\n Stable respiratory status on PEEP 18. Tube feeds at 20mL/hr. Rotated\n intermittently to either side, breathing best when R side dependent.\n D/c'd zosyn and added meropenem for increased GNR coverage per ID\n recommendation.\n ESOPHOGEAL BALLOON - At 08:29 AM\n at bedside\n PAN CULTURE - At 11:00 AM\n Post operative day:\n POD#4 - I & D Lt ileum and Sacroiliac joint debridement\n POD#3 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Clindamycin - 06:16 AM\n Vancomycin - 12:00 PM\n Piperacillin - 07:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 PM\n Meropenem - 05:00 AM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Furosemide (Lasix) - 5 mg/hour\n Midazolam (Versed) - 6 mg/hour\n Cisatracurium - 0.2 mg/Kg/hour\n Fentanyl - 400 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38\nC (100.4\n HR: 101 (90 - 109) bpm\n BP: 102/59(75) {95/58(71) - 118/79(95)} mmHg\n RR: 25 (0 - 28) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 18 (16 - 22) mmHg\n CO/CI (Thermodilution): (8.73 L/min) / (4.3 L/min/m2)\n SVR: 605 dynes*sec/cm5\n Bladder pressure: 9 (9 - 9) mmHg\n SV: 96 mL\n SVI: 47 mL/m2\n Total In:\n 2,097 mL\n 655 mL\n PO:\n Tube feeding:\n 200 mL\n 124 mL\n IV Fluid:\n 1,597 mL\n 530 mL\n Blood products:\n 300 mL\n Total out:\n 2,445 mL\n 815 mL\n Urine:\n 2,245 mL\n 815 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -348 mL\n -160 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 41 cmH2O\n Plateau: 36 cmH2O\n Compliance: 20.2 cmH2O/mL\n SPO2: 94%\n ABG: 7.31/49/118/22/-2\n Ve: 9.1 L/min\n PaO2 / FiO2: 236\n Physical Examination\n General Appearance: intubated, sedated, paralyzed\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Wheezes : b/l, Crackles : b/l\n throughout)\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Sedated, Chemically paralyzed\n Labs / Radiology\n 50 K/uL\n 9.8 g/dL\n 103 mg/dL\n 3.3 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 48 mg/dL\n 108 mEq/L\n 141 mEq/L\n 28.4 %\n 10.3 K/uL\n [image002.jpg]\n 02:20 AM\n 06:02 AM\n 08:08 AM\n 12:24 PM\n 02:32 PM\n 04:32 PM\n 04:40 PM\n 10:17 PM\n 02:17 AM\n 02:27 AM\n WBC\n 12.9\n 10.3\n Hct\n 28.7\n 28.4\n Plt\n 45\n 50\n Creatinine\n 3.3\n 3.2\n 3.3\n TCO2\n 23\n 24\n 22\n 23\n 24\n 24\n 26\n Glucose\n 83\n 77\n 90\n 94\n 90\n 103\n Other labs: PT / PTT / INR:19.1/31.6/1.7, CK / CK-MB / Troponin\n T:374//, ALT / AST:21/20, Alk-Phos / T bili:133/6.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:417 mg/dL, Lactic Acid:1.0 mmol/L,\n Albumin:2.3 g/dL, LDH:326 IU/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:3.3\n mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Midaz/fentanyl for sedation/analgesia. Paralyzed with\n cisatricurium.\n Cardiovascular: Levophed, weaning as tolerated; monitoring in\n right axillary arterial line.\n Pulmonary: AC 0.5, 28x350, PEEP 18, ARDS protocol, f/u CXR. Wean vent\n as tolerated, trend ABGs.\n Gastrointestinal / Abdomen: NGT in place. Tolerating TFs, no BM to\n date.\n Nutrition: Tube feeds at 20mL/hr.\n Renal: Lasix drip, acute renal failure; follow creatinine and UOP,\n albumin , volume with albumin as needed.\n Hematology: Serial Hct, goal Hct 30, transfuse PRBCs prn.\n Thrombocytopenic, etiology unknown, currently not bleeding so no plt\n transfusions.\n Endocrine: Random cortisol WNL, RISS.\n Infectious Disease: GNR from wound, blood cx from OSH. Continue\n vanc/. F/u speciation/sensitivities. ID consulting. Monitor\n vanco level.\n Lines / Tubes / Drains: ETT, , , R femoral \n Wounds: L pelvic/hip wound, clean/dry/intact.\n Imaging: CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n Fluids: HLIV, Lasix gtt.\n Consults: ortho, IR, ID; gyn signed off \n Billing Diagnosis: septic shock\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:28 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: SQH, SCDs\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 45 min\n" }, { "category": "Respiratory ", "chartdate": "2199-10-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490176, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n" }, { "category": "Nursing", "chartdate": "2199-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490258, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n - Received patient on FiO2 .50; Vt 350 X f 28 X PEEP 14 on maximum\n cisatracurium, TOF with 20 mA. Lung sounds rhonchorous all around\n with small amount of thick white secretions. Tolerating rotating bed.\n Action:\n - Shut cisatracurium off. Repeat ABG showed improved oxygenation to PO2\n 147 from 109 on AM labs. PEEP weaned to 12, midaz gtt weaned to 4.\n Response:\n - Repeat ABG 153-39-7.36, FiO2 decreased to 40. Tol midaz wean so midaz\n gtt off\n getting PRN boluses of midaz 2-4 mg Q 2. Lung sounds clear\n compared to this morning, remains rhonchorous in RUL.\n - Pt opening eyes to voice and command, flexing all extremities to\n pain, moving head spontaneously.\n Plan:\n - Overnight, no further vent changes. Wean fent if tolerated. Cont to\n wean tomorrow as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains hemodynamically stable in sinus/sinus tach 94-118, no ectopy\n noted. Mean BPs 60-90 without support. Urine output >50/hour. T max\n this shift 99.4. Cont to have blanchable red rash throughout body.\n Action:\n - Cooling blanket removed. Cipro discontinued as probable cause of body\n rash. Antibiotics admin as ordered. Cdiff number 2 sent. IV flagyl\n added.\n Response:\n - T current 98.9. Cr cont to trend down, currently 2.6\n Plan:\n - Cont antibiotic admin; f/u cultures.\n" }, { "category": "Nursing", "chartdate": "2199-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490543, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CMV 350 X 28 X PEEP 8. Sedated on fent gtt and midaz PRN.\n LS rhonchorous, diminished in bases. Sxn sm amt of white/yellow\n secretions.\n Action:\n Switched patient to PSV 12/8. Turned off fent gtt and started\n administering PRN dilaudid and continued to admin. PRN midaz.\n Response:\n ABG on PSV 169-39-7.37. Agitated off fent gtt\n awake, looks anxious,\n scared, tachycardic and tachypneic to 50s. Correct conversion of 400\n mcg fent per hour is 6 mg of dilaudid, so PRN dose increased.\n Administering 2-4 mg/hour.\n Plan:\n PSV, ? diuresis, cont PRN dilaudid and midaz.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 102.5 oral at 0730, with accompanying tachycardia to 145.\n Pattern noticed of patient spiking and rash worsening after meropenem\n doses\n at least last 3 doses.\n Action:\n Pan cultured. Acetaminophen; cooling blanket; ice packs to underarms\n and near groin. Meropenem D/Ced. Clinda and Cipro added.\n Response:\n T decreased to 99.4 after above interventions, T current 100.6. Prelim\n cultures: sputum gram stain neg, UA neg.\n Plan:\n Cont to monitor, follow up cultures.\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489348, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Low grade fevers pan cx on previous shift\n - Low dose Levophed to maintain MAP > 70\n - CO/CI and SVR relatively stable\n - No s/sx bleeding\n Action:\n - monitor hemodynamics\n - wean Levophed as able\n - continue on abx\n Response:\n - hemodynamics unchanged\n - hct stable\n - wbc stable\n - inr and tbili up\n Plan:\n Continue to monitor, wean levophed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - Received on AC 350 x 28 peep 18 fiO2\n - Lungs with rhonchi throughout and wheezes right > left\n - Sats improved sustaining in mid to high 90\ns when rotating\n and on swimmers on right\n - Sats low 90\ns when on swimmers on left\n - PaO2s improved 90-100\n Action:\n - Positioned in swimmers once each on each side\n - Continuous rotation when not in swimmers position\n - Frequent percussion when rotating\n - Albuterol MDI\ns ordered and given\n - CXR done\n - Lasix gtt\n Response:\n - Tolerated right swimmers well and rotating with Sats 96-98%\n - Tolerating left swimmers with Sats 91-94%\n - CXR improved this am\n - Peak airway pressures down to mid 30\ns this morning\n - Fair urine output\n Plan:\n Evaluate need to continue paralytic, continue to diuresis with lasix\n gtt, continue with pulm hygiene and frequent repositioning. Evaluate\n weaning.\n" }, { "category": "Nursing", "chartdate": "2199-10-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489455, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n received at change of shift on CMV with 18 peep, Fio2 50%\n sats 94-97%\n bs with scattered rhonchi throughout and occasional\n inspiratory/expiratory wheezes\n suctioned for sm amts thick yellow sputum\n remains paralyzed on cistatcurium\n fentanyl and versed gtts for sedation while on high peep and paralytic\n Action:\n vigorous pulmonary toilet\n triadyne bed with rotation and percussion\n placed in swimmers position for 2\n hours this am on right side\n peep decreased to 17 and then to 15\n attempted to place in swimmers position on left side at 1530\n Response:\n improved PO2 to 144 on 17 peep, when in right swimmers position\n sats decreased to 88% when peep dropped to 15 requiring increase in\n peep back to 18 and Fi02 to 70%\n desat to 78% when in left swimmers position= placed on back, suctioned\n Plan:\n slowly wean Fio2 back down to 50% (currently on 60%)\n wean peep slowly\n continue to rotate patient and use percussion\n attempt swimmers position x per shift\n continue cistatacurium , fentanyl and versed gtts\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n temp 100.1-100.3\n received patient at change of shift on levo at 0.03 mcg/kg/min\n lasix gtt at 5mg with good urine output\n incision clean and draining moderate amounts serous fluid\n vanco level 16.9\n Action:\n vancomycin renally dosed and pt given 750mg q48hrs\n levo weaned to off with map >65\n lasix gtt weaned to 4mg/hr\n pt given 500cc albumin this am\n Response:\n Bp stable off levophed\n Continues to diuresis on lower lasix dose\n Plan:\n Continue to monitor hemodynamics\n Maintain lasix gtt at current level\n Await culture reports from yesterday\n Monitor labs including wbc\n" }, { "category": "Nursing", "chartdate": "2199-10-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 489601, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n LS noted for intermittent inpsiratory wheezes. Suctioned for small to\n moderate amounts thick yellow sputum. Mechanically ventilated on cmv,\n rate 28, fi02 50% and peep 18. Pt desaturated to 87 with attempt to\n place in the right sided swimmer\ns position.\n Action:\n Pt rotating left to right on tryadine bed, percussion and pulsation\n used. Sputum culture obtained. Peep not weaned. Paralyzed with\n cisat. Lasix gtt infusing.\n Response:\n Abg and 02 sat stable. Negative 500cc\ns by midnight and currently\n another 500cc\ns negative.\n Plan:\n Continue rotation, neuromuscular blockade, continue to diurese as\n tolerated and wean peep.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n t-max 101.4, tachycardic to 110\n Action:\n Tylenol given, pan cultured\n Response:\n Temp down to 100.2\n Plan:\n Conrtinue to monitor, cultures pending, vanco and meropenum\n" }, { "category": "Physician ", "chartdate": "2199-10-14 00:00:00.000", "description": "Intensivist Note", "row_id": 491177, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n s/p septic shock\n PMHx:\n Post partum\n Current medications:\n Haldol\n Cipro\n Flagyl\n Clinda\n Lovenox\n Lorazepam\n Clonidine\n 24 Hour Events:\n Started on Haldol 2mg . EKG WNL. Increased Benzo dose.Will\n consider Dex if no improvement. Blood cx sent today spike on \n Pt continues to become agitated when turned. Required haldol to\n be given early.\n BLOOD CULTURED - At 09:35 AM\n Post operative day:\n POD#11 - I & D Lt ileum and Sacroiliac joint debridement\n POD#10 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 11:30 AM\n Metronidazole - 06:16 PM\n Clindamycin - 05:03 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Lorazepam (Ativan) - 03:02 AM\n Other medications:\n Flowsheet Data as of 05:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.6\nC (99.6\n HR: 141 (94 - 141) bpm\n BP: 153/95(120) {91/50(64) - 153/95(120)} mmHg\n RR: 39 (19 - 41) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 10 (4 - 12) mmHg\n Total In:\n 3,187 mL\n 546 mL\n PO:\n Tube feeding:\n 1,677 mL\n 357 mL\n IV Fluid:\n 1,509 mL\n 190 mL\n Blood products:\n Total out:\n 4,260 mL\n 960 mL\n Urine:\n 4,010 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 363 (330 - 367) mL\n PS : 12 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 18 cmH2O\n SPO2: 88%\n ABG: ///25/\n Ve: 9.9 L/min\n Physical Examination\n General Appearance: Anxious, when aroused\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: No(t) Trace, 1+), (Temperature: Warm)\n Skin: (Incision: Erythema), no purulent drainage\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 349 K/uL\n 7.8 g/dL\n 113 mg/dL\n 1.6 mg/dL\n 25 mEq/L\n 3.9 mEq/L\n 45 mg/dL\n 110 mEq/L\n 144 mEq/L\n 23.5 %\n 6.8 K/uL\n [image002.jpg]\n 12:10 AM\n 02:18 AM\n 02:57 AM\n 12:14 PM\n 02:12 PM\n 09:20 PM\n 02:47 AM\n 02:48 AM\n 03:11 AM\n 02:20 AM\n WBC\n 8.3\n 6.8\n Hct\n 25.0\n 24.5\n 23.5\n Plt\n 173\n 349\n Creatinine\n 2.0\n 1.8\n 1.6\n TCO2\n 26\n 27\n 25\n 26\n 28\n 28\n Glucose\n 104\n 98\n 110\n 107\n 113\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned\n Neurologic: Scheduled ativan q6 and PRN, fentanyl drip, clonidine,for\n sedation/analgesia. Added haldol. Still having aagitation with\n awakening (anxiety, tachypnea, and desaturation). Consider\n dexmetatomidine gtt\n Cardiovascular: Stable, off pressors\n Pulmonary: PEEP down to 12/5, will wean slowly, ARDS protocol, daily\n CXR. Tachypnea and desaturations when agitated, otherwise stable.\n Gastrointestinal / Abdomen: NGT in place. TF Impact w/ fiber at 70mL/hr\n per nutrition; high output loose stool -- flexiseal, c-diff (neg x 1).\n Consider repeating CDiff if she re-spikes\n Nutrition: Tube feeding\n Renal: Foley, Cr continues to trend downward\n Hematology: Hct slowly trending downward.\n Endocrine: RISS\n Infectious Disease: On flagyl, cipro, clinda. ID following. rash\n resolving.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: Ortho, ID dept\n Billing Diagnosis: (Shock: Septic)\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 03:28 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots (Lovenox)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2199-10-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 491179, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No claim of dyspnea); Comments: Pt\n seems to not understand. Thrashing around with RR > than 35.\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: FI02 neede to be increased for drop inPa02.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: No RSBI done due to RR> than 35. Will cont to monitor resp\n status. MDI\nS given.\n" }, { "category": "Physician ", "chartdate": "2199-10-03 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 488493, "text": "TITLE:\n [NOTE ACURATE AS OF . PLEASE SEE ADDENDUM FOR ADDITIONAL\n INFORMATION]\n Chief Complaint:\n HPI:\n For full admission note please refer to initial H&P. Briefly this\n is a 19 y.o. post-partum G1P1 Female who initially presented to an OSH\n with hypotension to 70s.\n .\n On review of initial H&P it appears she recently had a vaginal delivery\n 11 days ago following a uncomplicated delivery. The vaginal delivery\n lasted 3.5hrs and included an episiotomy, she never experienced any\n hypotension at that time and received no spinal anaesthesia or spinal\n block. When she came home she noted some fatigue, intermittent loose\n stool. Over the next 5 days she noted progressive watery, non-bloody\n diarrhea, orthostatic symptoms, as well as one episode of vision \n upon standing. She denied any sick contact, new or uncooked foods or\n cheeses, drugs, ETOH, ingestion, exposures. She does not believe she\n has ever had an STD and did not require antibiotics during delivery as\n far as she knows (did not know her group B strep status).\n .\n At the OSH her initial BP was 89/36 but she dropped to SBPs 70s(per\n report). Her HCT was 28, her creatinine was 3.1, albumin 1.8. She was\n given 6.5L of NS, Zosyn and started on dopamine and med-flighted to\n ED.\n .\n In the ED, initial vs were: T:99.2 P126 BP98/57 R20 O2 95 sat.\n Central line was placed. Patient was started on levo and neo given\n Vanco and 2.5L fluids. OB was consulted and did a bedside ultrasound\n that did not show evidence of retained placenta. On labs, patient noted\n to have stable HCT 28, WBC of 7.7 and PLT of 22. Her AST/ALT and T.\n Bili were elevated. Her creatinine was 2.9 and K was 2.4, bicarb 13.\n INR was 1.3 and fibrinogen was 479. Urine and serum tox were negative.\n On transfer to the floor T:98.0, HR 112, BP 102/53, RR: 30, 02 sats\n 100on2L and VBG showed ph 7.25, pco2:25 p02 of 66. Per the patient's\n parents the patient was mentating well this entire time.\n .\n She was transferred to the where she was noted to be tachypneic on\n arrival. She developed crampy pelvic pain similar to her menstrual pain\n but more severe in nature and she complained of worsening left buttock\n pain without radiation. She intially required 3 pressors to keep her\n MAPs>65 and was bolused with LR. she was given a total of 13L of fluid\n total and was able to wean off from 3 pressors to just Vasopressin. She\n was noted to be thrombocytopenic from 22 to 50s-60s. Heme-Onc were\n consulted and her smear showed no schistocytes or blasts. Hemolysis\n labs were also negative. Given her pelvic pain a CT abd/pelvis was\n obtained which showed a prelim read concerning for gas within the left\n iliacus and piriformis and minimal phlegmon adjacent to the left\n sacroiliac joint with rarefaction of the left iliac bone, highly\n concerning for septic arthritis. Diffuse edema and a small amount of\n free fluid was noted in the pelvis along with bilateral pleural\n effusions with associated atelectasis. Orthopaedics were consulted and\n recommended debridement for possible nec fasc. Pt was then transferred\n from service to MICU Team.\n .\n Of note, the team called the OSH regarding culture data, pt had\n 4/4 bottles positive for Gram Negative Bacili.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Metronidazole - 08:48 AM\n Piperacillin - 08:48 AM\n Vancomycin - 09:48 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:57 PM\n Sodium Bicarbonate 8.4% (Amp) - 10:52 PM\n Home medications:\n None\n Past medical history:\n Family history:\n Social History:\n no medical or surgical history\n G1P1 s/p vaginal delivery with episiotomy 11 days PTA. Pregnancy\n otherwise uncomplicated.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 103 (87 - 136) bpm\n BP: 85/52(63) {31/20(-7) - 140/92(356)} mmHg\n RR: 28 (19 - 45) insp/min\n SpO2: 99%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 66 Inch\n CVP: 318 (5 - 332)mmHg\n Total In:\n 20,216 mL\n 10,878 mL\n PO:\n 900 mL\n TF:\n IVF:\n 9,792 mL\n 7,030 mL\n Blood products:\n 174 mL\n 3,848 mL\n Total out:\n 2,454 mL\n 1,098 mL\n Urine:\n 949 mL\n 438 mL\n NG:\n 675 mL\n Stool:\n Drains:\n 10 mL\n Balance:\n 17,762 mL\n 9,780 mL\n Respiratory\n Physical Examination\n General: Caucasian Female laying down in bed, tachypneic.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Crackles noted bilaterally.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 44 K/uL\n 7.8 g/dL\n 225 mg/dL\n 2.4 mg/dL\n 36 mg/dL\n 21 mEq/L\n 110 mEq/L\n 3.6 mEq/L\n 141 mEq/L\n 22.3 %\n 15.6 K/uL\n [image002.jpg]\n \n 2:33 A10/1/ 01:28 AM\n \n 10:20 P10/1/ 02:16 AM\n \n 1:20 P10/1/ 02:22 AM\n \n 11:50 P10/1/ 03:04 AM\n \n 1:20 A10/1/ 03:17 AM\n \n 7:20 P10/1/ 04:55 AM\n 1//11/006\n 1:23 P10/1/ 05:06 AM\n \n 1:20 P10/1/ 06:54 AM\n \n 11:20 P10/1/ 07:06 AM\n \n 4:20 P10/1/ 09:44 AM\n WBC\n 30.6\n 30.5\n 15.6\n Hct\n 24\n 13.8\n 12.7\n 12\n 30\n 22.3\n Plt\n 83\n 62\n 74\n 44\n Cr\n 2.5\n 2.4\n TC02\n 15\n 16\n 16\n 18\n 19\n 22\n Glucose\n 126\n 149\n 149\n 138\n 225\n Other labs: PT / PTT / INR:16.1/31.0/1.4, CK / CKMB / Troponin-T:374//,\n ALT / AST:62/152, Alk Phos / T Bili:152/1.3, Amylase / Lipase:/10,\n Differential-Neuts:90.0 %, Band:2.0 %, Lymph:6.0 %, Mono:2.0 %, Eos:0.0\n %, Fibrinogen:286 mg/dL, Lactic Acid:3.2 mmol/L, Albumin:1.6 g/dL,\n LDH:326 IU/L, Ca++:7.4 mg/dL, Mg++:1.4 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 19 year old female 11 days post partum who presented to OSH with\n non-bloody diarrhea, found to be hypotensive with , admitted to ICU\n in septic shock and found to have ?nec fasc in pelvis, transferred to\n for OR debridement.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n .\n ##. Septic Shock: Pt currently in septic shock with leukocytosis,\n vasopressor requirement with suspected source pelvic flora given recent\n vaginal delivery. CT scan notable for gas within the left iliacus and\n piriformis and minimal phlegmon adjacent to the left sacroiliac joint\n with rarefaction of the left iliac bone. Pt received fluid\n resiscitation and has now been weaned down to Vasopressin. Currently on\n narrowed spectrum of Zosyn/Flagyl given 4/4 bottles of GN bacilli at\n OSH. Pt currently awaiting OR debridement tonight versus tomorrow\n - will continue to fluid resuscitate for goal MAP >65\n - will attempt to wean of pressors\n - will continue on Zosyn/Flagyl given GN Bacilli results at OSH\n - will f/u labs from hospital\n - will discuss with Ortho regarding debridement this evening, will also\n touch base with surgery as it is unclear where the collection\n originated from, may involve bowel\n - will place art line\n .\n #Thrombocytopenia: Pt noted to be thrombocytopenic with an initial plt\n of 22 which was trending up to 60s and now trending down to 40. Given\n that she will undergo surgery will give plts prior to surgery. Heme/Onc\n consulted regarding thrombocytopenia and recommend several titer tests\n to determine origin. Suspect thrombocytopenia may be from sepsis.\n - trend Plt counts q4hrs\n - will transfuse plts prior to surgery\n - will f/u infectious titers\n .\n #Acute Renal Failure: Most likely pre-renal versus ATN given pt's\n septic shock. Will continue to trend Creatinine and monitor urine\n output for a goal >30cc/hr\n - monitor UOP\n - trend Creatinine\n - consider renal consult in the AM\n .\n #LFT abnormalitis: Mild Transaminitis with rising direct bilirubinemia.\n Given low platelets, low albumin, increasing INR, possible that there\n is an underlying liver abnormality however, most likely hypotension\n but AFLP or cholestasis of pregnancy or cholangitis possible (though no\n pain). -trend LFTs\n -call for patient's OSH records for any prior medication exposures,\n underlying liver dz and most recent labs.\n .\n #Metabolic Acidosis: Both gap and non-gap acidosis with respiratory\n compensation. Likely gap due to sepsis/lactate and non-gap from renal\n failure and diarrhea. Given pt's last ABG showing hypoxia as well as\n upcoming surgery and tachypnea will electively intubate pt.\n -Serial ABGs for monitoring\n - will give HCO3 with fluids as mentioned above\n - will electively intubate\n .\n FEN: Will continue IVF fluid with NaHCO3 3 amps in 1L D5W, replete\n electrolytes, NPO.\n .\n Prophylaxis: Subutaneous heparin\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient, will touch base with surgical teams. Met with\n pt's mother and father regarding her treatment course.\n .\n Disposition: pending clinical improvement\n" }, { "category": "Nutrition", "chartdate": "2199-10-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 488490, "text": "Subjective: Patient intubated and sedated. No family present.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 95.5 kg\n 33.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 162%\n 68 kg\n Diagnosis: Hypotensive\n PMHx: 13 days post-partum from NSVD with episiotomy (no epidural)\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Fentanyl, Versed, Vasopressin, Neosynephrine,\n Levophed, Mag, K and Ca repletions, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 225 mg/dL\n 06:54 AM\n Glucose Finger Stick\n 186\n 10:00 AM\n BUN\n 36 mg/dL\n 06:54 AM\n Creatinine\n 2.4 mg/dL\n 06:54 AM\n Sodium\n 141 mEq/L\n 06:54 AM\n Potassium\n 3.6 mEq/L\n 06:54 AM\n Chloride\n 110 mEq/L\n 06:54 AM\n TCO2\n 21 mEq/L\n 06:54 AM\n PO2 (arterial)\n 117 mm Hg\n 09:44 AM\n PO2 (venous)\n 63 mm Hg\n 12:00 AM\n PCO2 (arterial)\n 43 mm Hg\n 09:44 AM\n PCO2 (venous)\n 50 mm Hg\n 12:00 AM\n pH (arterial)\n 7.30 units\n 09:44 AM\n pH (venous)\n 7.10 units\n 12:00 AM\n pH (urine)\n 5.5 units\n 08:42 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 09:44 AM\n CO2 (Calc) venous\n 16 mEq/L\n 12:00 AM\n Albumin\n 1.6 g/dL\n 02:16 AM\n Calcium non-ionized\n 7.4 mg/dL\n 06:54 AM\n Phosphorus\n 4.7 mg/dL\n 06:54 AM\n Ionized Calcium\n 1.03 mmol/L\n 07:06 AM\n Magnesium\n 1.4 mg/dL\n 06:54 AM\n ALT\n 62 IU/L\n 10:46 AM\n Alkaline Phosphate\n 152 IU/L\n 10:46 AM\n AST\n 152 IU/L\n 10:46 AM\n Total Bilirubin\n 1.3 mg/dL\n 02:16 AM\n WBC\n 15.6 K/uL\n 06:54 AM\n Hgb\n 7.8 g/dL\n 06:54 AM\n Hematocrit\n 22.3 %\n 06:54 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Replete with Fiber @ 20mL/hr\n GI: NGT in place, abd obese, bowel sounds present\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: recently post-partum\n Estimated Nutritional Needs\n Calories: 1700-2040 ( 25-30 cal/kg)\n Protein: 75-102 (1.1-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate (NPO)\n Specifics:\n 19 y.o. Female 13 days post-partum from NSVD presents with nausea,\n diarrhea, weakness and back/abd pain, found to have osteomyelitis of\n left hip. Patient s/p washout/debridement of infection , c/b\n bleeding requiring coiling x10 in angio. Of note, patient is 17L\n positive from OR and in ARF. Patient is currently intubated, sedated\n and on pressors x3. Team would like to start trophic tube feeds\n today. Recommend waiting until patient is more hemodynamically stable\n before starting enteral feeding, as she may have hypoperfusion of her\n gut and feeding might cause bowel ischemia. If tube feeds are started,\n recommend proceeding with caution and advancing very slowly.\n Medical Nutrition Therapy Plan - Recommend the Following\n Monitor patient closely\n abd exam and residuals if tube\n feeds are started.\n Recommend keeping tube feeds at trophic rate until more\n hemodynamically stable.\n If tube feeds are able to be advanced, recommend changing\n formula to Boost Glucose Control with eventual goal of 70mL/hr\n (1781kcals, 97g protein).\n Monitor tolerance with abd exam and residual checks q4hrs.\n Hold tube feeds if abd exam worsens or if residuals are greater than\n 150mL.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488568, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488571, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488572, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n None responsive to noxious stimuli with absent gag/cough reflex. Perrl\n 4-5mm/brisk bilaterally. Monitor shows SR/ST without ectopy with bp\n 104/61 and map 70 and CVP 14-16. Maintained on\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488575, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n None responsive to noxious stimuli with absent gag/cough reflex. Perrl\n 4-5mm/brisk bilaterally. Monitor shows SR/ST without ectopy with bp\n 104/61 and map 70 and CVP 14-16. Maintained on vent support CMV\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2199-10-03 00:00:00.000", "description": "Intensivist Note", "row_id": 488456, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At patient evaluated by OB gyn and a Vaginal US was\n performed which did not show retained products. Refused bimanual\n exam. Pt now on three pressors, increasing renal failure,\n increased WBC in 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n Buttock pain\n PMHx:\n G1P1\n Current medications:\n 1. 1000 mL LR\n Continuous at 125 ml/hr Order date: @ 0229\n 12. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 0223\n 2. Acetylcysteine 20% 600 mg PO/NG Q4H Duration: 4 Doses\n Two doses prior to angio, two doses after. Order date: @ 0418\n 13. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP >65 Order\n date: @ 0223\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 0223\n 14. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 0659\n 4. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0223\n 15. Potassium Chloride Replacement (Oncology) IV Sliding Scale Order\n date: @ 0223\n 5. Epinephrine HCl 0.01-0.14 mcg/kg/min IV DRIP TITRATE TO MAP > 60\n Order date: @ 0223\n 16. Potassium Chloride 20 mEq / 50 ml SW IV X3 Order date: @\n 0223\n 6. Fentanyl Citrate 25-100 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ 0223\n 17. Senna 1 TAB PO BID:PRN Constipation Order date: @ 0223\n 7. Magnesium Sulfate Replacement (Oncology) IV Sliding Scale Order\n date: @ 0223\n 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0223\n 8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n day 1= Order date: @ 0223\n 19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0223\n 9. Midazolam 1 mg IV ONCE Duration: 1 Doses Order date: @ 0223\n 20. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP >65 Order date:\n @ 0223\n 10. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0223\n 21. Vancomycin 1000 mg IV Q48H\n ID Approval will be required for this order in 55 hours. Order date:\n @ 0223\n 11. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP>65\n Order date: @ 0223\n 24 Hour Events:\n transferred to MICU with hypotension, increasing kidney failure; 3\n pressors, intubated; taken to OR with ortho for washout / debridement\n of L hip; postop Hct 13, given massive transfusion and taken back to\n angio for bleeding, coils placed x10\n MULTI LUMEN - START 08:00 AM\n Line placed previous shift confirmed by xray outgoing RN.\n ULTRASOUND - At 08:29 AM\n bedside vaginal ultrasound\n ULTRASOUND - At 08:30 AM\n internal vaginal ultrasoud tolerated well\n ULTRASOUND - At 08:50 AM\n abdominal ultrasound.\n URINE CULTURE - At 09:06 AM\n TRANSTHORACIC ECHO - At 10:07 AM\n INTUBATION - At 09:15 PM\n INVASIVE VENTILATION - START 09:20 PM\n OR SENT - At 11:24 PM\n INVASIVE VENTILATION - STOP 11:25 PM\n OR RECEIVED - At 02:10 AM\n INVASIVE VENTILATION - START 02:16 AM\n ARTERIAL LINE - START 02:26 AM\n Post operative day:\n POD#0 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:00 PM\n Metronidazole - 10:29 PM\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Norepinephrine - 0.15 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Morphine Sulfate - 08:14 AM\n Midazolam (Versed) - 08:57 PM\n Sodium Bicarbonate 8.4% (Amp) - 10:52 PM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 35.7\nC (96.3\n HR: 104 (98 - 136) bpm\n BP: 101/55(73) {31/20(-7) - 137/78(356)} mmHg\n RR: 25 (19 - 46) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 23 (5 - 268) mmHg\n Total In:\n 20,216 mL\n 9,115 mL\n PO:\n 900 mL\n Tube feeding:\n IV Fluid:\n 9,792 mL\n 5,267 mL\n Blood products:\n 174 mL\n 3,848 mL\n Total out:\n 2,454 mL\n 933 mL\n Urine:\n 949 mL\n 273 mL\n NG:\n 675 mL\n Stool:\n Drains:\n 10 mL\n Balance:\n 17,762 mL\n 8,182 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 47 cmH2O\n Plateau: 38 cmH2O\n Compliance: 16.7 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/34/255/16/-6\n Ve: 11.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), L hip / leg ecchymoses, JP\n serosanguinous\n Neurologic: Sedated\n Labs / Radiology\n 74 K/uL\n 4.2 g/dL\n 138 mg/dL\n 2.5 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 110 mEq/L\n 135 mEq/L\n 30\n 30.5 K/uL\n [image002.jpg]\n 12:40 AM\n 01:00 AM\n 01:28 AM\n 02:16 AM\n 02:22 AM\n 03:04 AM\n 03:17 AM\n 04:55 AM\n 05:06 AM\n 07:06 AM\n WBC\n 30.6\n 30.5\n Hct\n 24\n 24\n 13.8\n 12.7\n 12\n 30\n Plt\n 40\n 83\n 62\n 74\n Creatinine\n 2.5\n TCO2\n 17\n 15\n 16\n 16\n 18\n 19\n Glucose\n 182\n 126\n 149\n 149\n 138\n Other labs: PT / PTT / INR:17.2/32.9/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:62/152, Alk-Phos / T bili:152/1.3, Amylase /\n Lipase:/10, Differential-Neuts:90.0 %, Band:2.0 %, Lymph:6.0 %,\n Mono:2.0 %, Eos:0.0 %, Fibrinogen:238 mg/dL, Lactic Acid:3.2 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.3 mg/dL, Mg:1.6 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN)\n Assessment and Plan: Septic shock with multi-organ failure\n Neurologic: midaz/fentanyl for sedation/analgesia. Wake up today\n Cardiovascular: requiring 3 pressors (neo, levo, vasopressin); will\n wean as tolerated; FLUSH R GROIN SHEATH 60CC NS EVERY HOUR. Place \n monitpor\n Pulmonary: ventilated, , Low TV and PES\n Gastrointestinal / Abdomen: NPO\n Nutrition: Start TF\n Renal: acute renal failure; mucomyst and bicarb given prior to angio;\n will follow creatinine\n Hematology: Hct 13 from 26; given 7U PRBCs, 2U FFP, 2U plt, 1U cryo on\n floor prior to angio; now s/p angio with coils x10, will follow serial\n Hct and coags. Start SC heparin.\n Endocrine: Check random cortisol. Blood sugar well controlled.\n Infectious Disease: empiric coverage for osteomyelitis with\n vanc/zosyn/flagyl\n Lines / Tubes / Drains: ETT, CVL, aline, L hip JP\n Wounds: L hip, clean/intact\n Imaging: CXR\n Fluids: KVO\n Consults: gyn, ortho\n Billing Diagnosis: acute osteomyelitis of left pelvis\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 08:00 AM\n Arterial Line - 02:26 AM\n Prophylaxis:\n DVT:\n Stress ulcer: Famotadine\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: SICU\n Total time spent: >1 hour\n" }, { "category": "Respiratory ", "chartdate": "2199-10-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488828, "text": "Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n :\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "General", "chartdate": "2199-10-03 00:00:00.000", "description": "ICU Event Note", "row_id": 488460, "text": "Clinician: Attending\n Critical Care\n Discussion with son about her recent decline with worsening pulm edema\n despite diuresis of > 5L. Discussed potential need for intubation. He\n believes a short intubation is consistent with her wishes but if her\n heart failure cannot be managed medically to a better level of function\n he believes she would prefer comfort. Plan is to diurese aggressively,\n intubate if necessary with either improvement or reduced level of care.\n Total time spent: 45 minutes\n Patient is critically ill.\n ------ Protected Section------\n Entered in error on wrong patient\n ------ Protected Section Error Entered By: , MD\n on: 08:29 ------\n" }, { "category": "Nursing", "chartdate": "2199-10-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488462, "text": "Pre-op Narrative Note:\n Pt arrived from at approx 1900 -> Alert, and oriented, denying\n pain, HR sinus 130\ns, SBP 100\ns, temp. 96.4, RR 30\nlow 40\ns, c/o of\n mild shortness of breath, ls were clear bilaterally. Pt was seen by\n Ortho attending, surgery planned for am. Decision to electively\n intubate was then made by MICU. Several unsuccessful attempts at\n a-line were made prior to intubation. Anesthesia at bedside to\n perform intubation. Intubation was difficult initially, pt became\n hypotensive to 60\ns with intermittent periods of hypoxia. Skin became\n mottled in the hips/thighs and there was much difficulty obtaining a\n blood pressure with automatic cuff at this time. Levo and Neo were\n added to Vasopressin which was already running. Pt received total of 3\n liters LR fluid boluses for hypotension during this time.\n Fentynal/versed gtt\ns started for sedation. MICU attending at the\n bedside after intubation, femoral a-line attempted unsuccessfully.\n Carotid pulse was lost very briefly, but returned immediately just as\n compressions were initiated. Pt received total 30meq potassium over\n 1.5 hours, 1 amp sodium bicarbonate given, 1 unit of platelets given.\n 22:00 dose of flagyl given, 22:00 dose of zosyn sent to o.r. with\n patient to be given with anesthesia, cipro also sent to the o.r. to be\n given by anesthesia. Pt sent to o.r. at 2330. Mother and father\n arrived shortly after, MICU resident and attending spoke with family.\n Nursing supervisor notified and with family to offer additional\n support.\n Post-oper Narrative Note:\n Pt arrived from o.r, intubated and mechanically ventilated on\n vasopressin, neo and levophed. JP open (not to suction), small amount\n sanguinous fluid drained in jp bulb. Initial hct obtained 13 and was\n verified at 12. Dr. notified, pt received 6 units prbc, 2\n units ffp, 2units platelets and 1 unit cryo while preparing for angio.\n Pt remained hemodynamically stable and was sent to angio at ~ 0500\n for embolization. Pt arrived back from angio at ~ 0630 with right\n groin sheath in place. Post-op dressing is c/d/I, jp currently to bulb\n suction and draining a small amounts sang. fluid.\n Plan: Esophogeal balloon, monitoring, cortisol stim. test, wean\n pressors and tolerated, kvo fluids, daily wake-up to asses neuro\n status, monitor hct and labs, social work consult for family support.\n" }, { "category": "Physician ", "chartdate": "2199-10-04 00:00:00.000", "description": "Intensivist Note", "row_id": 488811, "text": "SICU\n HPI:\n 55 y.o. Male w/ extensive medical history including severe\n CAD/mult stents/last LAD , DM, CKD III (creat 1.5), PAD,\n known brainstem meningioma, chronic hyponatremia, h/o congential\n pulm stenosis s/p valvuloplasty, Afib s/p ablation on coumadin\n Reccent admission for tooth extraction noted to have 1.1 x 1cm C1/C2\n spinal mass causing severe spinal narrowing and cord compression. .\n He has also had issue with lower extremity cellulitis that has\n been noted to poorly heal due to pt's poor peripheral vascular\n disease. On evaluation by the medicine team the RLE particularly\n the right heel showed concerns of an infection.\n for anterior fusion of c4/c5. Procedure unremarkable, but\n required awake FOI secondary to cervical mass. Decision to come to\n SICU remaining intubated in anticipation of return to OR following day\n to address C1 compression and possible C56 posterior fusion\n Chief complaint:\n upper extremity weakness\n PMHx:\n All: PCN/keflex\n .\n PMH\n (1) Type 2 diabetes mellitus, requiring insulin, and the\n complications from years of poor glycemic control:\n -hypertension\n -severe peripheral vascular disease\n -peripheral neuropathy\n -pressure, venous stasis, and neuropathic ulcers on his right\n and left lower extremities\n -stage 3 diabetic nephropathy\n -renal insufficiency (baseline creatinine 1.5 to 1.7)\n (2) Atrial fibrillation status post ablation and , on\n coumadin\n (3) Congenital pulmonic valve stenosis status post two childhood\n surgeries\n -history of RV failure\n -history of peripheral edema and anasarca\n (4) Chronic hyponatremia\n (5) Chronic low back pain status post car accident\n (6) Spinal cord meningioma compressing his spinal cord at C1/C2\n (7) COPD\n (8) Coronary artery disease status post stenting (bare\n metal stent by Dr. ()) and repeat\n stenting at in (bare metal stent - see d/c summary\n )\n (9) MI in \n .\n : Docusate Sodium,Furosemide, Ascorbic Acid, Pantoprazole,\n metoprolol, trazodone, APAP, Petrolatum Ointment, Methocarbamol,\n Albuterol, Actuation, Hydromorphone, Simvastatin, Senna, Hydroxyzine,\n Polyethylene Glycol, Bisacodyl, ativan, Ketoconazole, Glycerin supp,\n vicodin, Heparin drip.\n Current medications:\n . 2. Albuterol Inhaler 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Clonazepam 5. Famotidine\n 6. Gentamicin 7. HYDROmorphone (Dilaudid) 8. HydrOXYzine 9.\n Hydrocodone-Acetaminophen 10. Influenza Virus Vaccine\n 11. Insulin 12. Ketoconazole 2% 13. Metoprolol Tartrate 14.\n Methocarbamol 15. Metoprolol Tartrate\n 16. Propofol 17. Sodium Chloride 0.9% Flush 18. Vancomycin\n 24 Hour Events:\n No major events overnight. To OR this AM\n CORDIS/INTRODUCER - START 08:00 AM\n ARTERIAL LINE - START 08:00 AM\n Sheath/aline from angiography suite. flushes easily with good blood\n return.\n ARTERIAL LINE - START 11:30 AM\n ultrasound guided placement of left axillary aline\n ARTERIAL LINE - STOP 05:26 PM\n MULTI LUMEN - START 06:30 PM\n Line placed previous shift confirmed by xray outgoing RN.\n CORDIS/INTRODUCER - STOP 06:35 PM\n MULTI LUMEN - STOP 06:38 PM\n Line placed previous shift confirmed by xray outgoing RN.\n Post operative day:\n POD#1 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Vancomycin - 09:48 AM\n Metronidazole - 01:00 AM\n Piperacillin - 05:37 AM\n Clindamycin - 06:16 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 2 mg/hour\n Norepinephrine - 0.16 mcg/Kg/min\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 PM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.2\nC (98.9\n HR: 93 (89 - 113) bpm\n BP: 97/68(80) {85/50(63) - 131/86(103)} mmHg\n RR: 0 (0 - 29) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 111.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 23 (14 - 323) mmHg\n Total In:\n 13,772 mL\n 1,824 mL\n PO:\n Tube feeding:\n 240 mL\n 9 mL\n IV Fluid:\n 7,838 mL\n 731 mL\n Blood products:\n 5,574 mL\n 1,084 mL\n Total out:\n 1,411 mL\n 85 mL\n Urine:\n 611 mL\n 85 mL\n NG:\n Stool:\n Drains:\n 150 mL\n Balance:\n 12,361 mL\n 1,739 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 32 cmH2O\n Compliance: 21.9 cmH2O/mL\n SPO2: 97%\n ABG: 7.34/40/101/21/-3\n Ve: 9.9 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 3+), (Pulse - Dorsalis pedis: Diminished),\n (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 3+), (Pulse - Dorsalis pedis: Diminished),\n (Pulse - Posterior tibial: Diminished)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 59 K/uL\n 10.1 g/dL\n 134 mg/dL\n 2.6 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 39 mg/dL\n 107 mEq/L\n 139 mEq/L\n 28.4 %\n 14.3 K/uL\n [image002.jpg]\n 07:06 AM\n 09:44 AM\n 10:56 AM\n 03:12 PM\n 03:45 PM\n 05:02 PM\n 09:47 PM\n 10:05 PM\n 02:02 AM\n 02:29 AM\n WBC\n 18.4\n 12.1\n 14.3\n Hct\n 22.2\n 29.0\n 23.7\n 28.4\n Plt\n 33\n 47\n 26\n 59\n Creatinine\n 2.4\n 2.5\n 2.6\n TCO2\n 19\n 22\n 22\n 22\n 23\n Glucose\n 145\n 145\n 144\n 134\n Other labs: PT / PTT / INR:14.2/24.9/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:96/145, Alk-Phos / T bili:96/1.3, Amylase /\n Lipase:/10, Differential-Neuts:85.3 %, Band:2.0 %, Lymph:11.2 %,\n Mono:1.5 %, Eos:1.6 %, Fibrinogen:286 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.9 mg/dL, Mg:2.1 mg/dL, PO4:3.4\n mg/dL\n Imaging: CT Cervical Spine - Post surgical changes with subcutaneous\n emphysema, and new interval placement of anterior fusion hardware at\n C5-C6 level, with no definite evidence of immidiate complication.\n - Stable mass, likely meningeoma at C1 level, with associated canal\n compression, as described in more details on recent MRI of the C-spine.\n Assessment and Plan\n ALTERATION IN NUTRITION, INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Neuro: C1/C2 meningioma: Pt has known meningioma\n impinging the\n spinal cord at the level of C1/C2, which may cause some of pt's\n neurological symptoms and debilitation. Periodic wakeup tests over\n course of evening to assess neuro fx. Cervical CT. Propofol for\n sedation, diluadid pain. Return to OR in AM for posterior fusion and\n removal of meningioma.\n CVS: h/o of Afib and HTN, continuing home meds including PRN IV\n metoprolol\n Pulm: Difficult intubation secondary to cervical compression. Keep\n intubated overnight in anticipation of returning to OR in AM\n GI/FEN: GI propylaxis, IVF\n Renal: CRF\n Endo: DMII, checking BS, insulin SS. Vascular consulted for lower ext\n mottling. Recommending plavix and compression. Holding plavix in\n context of procedure.\n ID: perioperative vancomycin/gentamycin - levels to be obtained\n Wounds/injuries:\n Consults: Vascular, needs medical consult\n Code: Full\n Neurologic:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent: 36\n" }, { "category": "Physician ", "chartdate": "2199-10-03 00:00:00.000", "description": "Intensivist Note", "row_id": 488440, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At patient evaluated by OB gyn and a Vaginal US was\n performed which did not show retained products. Refused bimanual\n exam. Pt now on three pressors, increasing renal failure,\n increased WBC in 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. She has been started empirically on Vanco and Zosyn.\n Chief complaint:\n Buttock pain\n PMHx:\n G1P1\n Current medications:\n 1. 1000 mL LR\n Continuous at 125 ml/hr Order date: @ 0229\n 12. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 0223\n 2. Acetylcysteine 20% 600 mg PO/NG Q4H Duration: 4 Doses\n Two doses prior to angio, two doses after. Order date: @ 0418\n 13. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP >65 Order\n date: @ 0223\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 0223\n 14. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 0659\n 4. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses Order date: @\n 0223\n 15. Potassium Chloride Replacement (Oncology) IV Sliding Scale Order\n date: @ 0223\n 5. Epinephrine HCl 0.01-0.14 mcg/kg/min IV DRIP TITRATE TO MAP > 60\n Order date: @ 0223\n 16. Potassium Chloride 20 mEq / 50 ml SW IV X3 Order date: @\n 0223\n 6. Fentanyl Citrate 25-100 mcg/hr IV DRIP TITRATE TO sedation Order\n date: @ 0223\n 17. Senna 1 TAB PO BID:PRN Constipation Order date: @ 0223\n 7. Magnesium Sulfate Replacement (Oncology) IV Sliding Scale Order\n date: @ 0223\n 18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0223\n 8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n day 1= Order date: @ 0223\n 19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0223\n 9. Midazolam 1 mg IV ONCE Duration: 1 Doses Order date: @ 0223\n 20. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP >65 Order date:\n @ 0223\n 10. Midazolam 0.5-2 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0223\n 21. Vancomycin 1000 mg IV Q48H\n ID Approval will be required for this order in 55 hours. Order date:\n @ 0223\n 11. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP>65\n Order date: @ 0223\n 24 Hour Events:\n transferred to MICU with hypotension, increasing kidney failure; 3\n pressors, intubated; taken to OR with ortho for washout / debridement\n of L hip; postop Hct 13, given massive transfusion and taken back to\n angio for bleeding, coils placed x10\n MULTI LUMEN - START 08:00 AM\n Line placed previous shift confirmed by xray outgoing RN.\n ULTRASOUND - At 08:29 AM\n bedside vaginal ultrasound\n ULTRASOUND - At 08:30 AM\n internal vaginal ultrasoud tolerated well\n ULTRASOUND - At 08:50 AM\n abdominal ultrasound.\n URINE CULTURE - At 09:06 AM\n TRANSTHORACIC ECHO - At 10:07 AM\n INTUBATION - At 09:15 PM\n INVASIVE VENTILATION - START 09:20 PM\n OR SENT - At 11:24 PM\n INVASIVE VENTILATION - STOP 11:25 PM\n OR RECEIVED - At 02:10 AM\n INVASIVE VENTILATION - START 02:16 AM\n ARTERIAL LINE - START 02:26 AM\n Post operative day:\n POD#0 - I & D Lt ileum and Sacroiliac joint debridement\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 12:00 PM\n Metronidazole - 10:29 PM\n Ciprofloxacin - 11:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:45 PM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Norepinephrine - 0.15 mcg/Kg/min\n Vasopressin - 1.2 units/hour\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Morphine Sulfate - 08:14 AM\n Midazolam (Versed) - 08:57 PM\n Sodium Bicarbonate 8.4% (Amp) - 10:52 PM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.7\nC (98.1\n T current: 35.7\nC (96.3\n HR: 104 (98 - 136) bpm\n BP: 101/55(73) {31/20(-7) - 137/78(356)} mmHg\n RR: 25 (19 - 46) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n CVP: 23 (5 - 268) mmHg\n Total In:\n 20,216 mL\n 9,115 mL\n PO:\n 900 mL\n Tube feeding:\n IV Fluid:\n 9,792 mL\n 5,267 mL\n Blood products:\n 174 mL\n 3,848 mL\n Total out:\n 2,454 mL\n 933 mL\n Urine:\n 949 mL\n 273 mL\n NG:\n 675 mL\n Stool:\n Drains:\n 10 mL\n Balance:\n 17,762 mL\n 8,182 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 47 cmH2O\n Plateau: 38 cmH2O\n Compliance: 16.7 cmH2O/mL\n SPO2: 99%\n ABG: 7.34/34/255/16/-6\n Ve: 11.5 L/min\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact), L hip / leg ecchymoses, JP\n serosanguinous\n Neurologic: Sedated\n Labs / Radiology\n 74 K/uL\n 4.2 g/dL\n 138 mg/dL\n 2.5 mg/dL\n 16 mEq/L\n 4.0 mEq/L\n 38 mg/dL\n 110 mEq/L\n 135 mEq/L\n 30\n 30.5 K/uL\n [image002.jpg]\n 12:40 AM\n 01:00 AM\n 01:28 AM\n 02:16 AM\n 02:22 AM\n 03:04 AM\n 03:17 AM\n 04:55 AM\n 05:06 AM\n 07:06 AM\n WBC\n 30.6\n 30.5\n Hct\n 24\n 24\n 13.8\n 12.7\n 12\n 30\n Plt\n 40\n 83\n 62\n 74\n Creatinine\n 2.5\n TCO2\n 17\n 15\n 16\n 16\n 18\n 19\n Glucose\n 182\n 126\n 149\n 149\n 138\n Other labs: PT / PTT / INR:17.2/32.9/1.5, CK / CK-MB / Troponin\n T:374//, ALT / AST:62/152, Alk-Phos / T bili:152/1.3, Amylase /\n Lipase:/10, Differential-Neuts:90.0 %, Band:2.0 %, Lymph:6.0 %,\n Mono:2.0 %, Eos:0.0 %, Fibrinogen:238 mg/dL, Lactic Acid:3.2 mmol/L,\n Albumin:1.6 g/dL, LDH:326 IU/L, Ca:7.3 mg/dL, Mg:1.6 mg/dL, PO4:4.0\n mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE PAIN,\n CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: midaz/fentanyl for sedation/analgesia\n Cardiovascular: requiring 3 pressors (neo, levo, vasopressin); will\n wean as tolerated; FLUSH R GROIN SHEATH 60CC NS EVERY HOUR\n Pulmonary: ventilated, wean to pressure support as tolerated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: acute renal failure; mucomyst and bicarb given prior to angio;\n will follow creatinine\n Hematology: Hct 13 from 26; given 7U PRBCs, 2U FFP, 2U plt, 1U cryo on\n floor prior to angio; now s/p angio with coils x10, will follow serial\n Hct and coags\n Endocrine: no issues\n Infectious Disease: empiric coverage for osteomyelitis with\n vanc/zosyn/flagyl\n Lines / Tubes / Drains: ETT, CVL, aline, L hip JP\n Wounds: L hip, clean/intact\n Imaging:\n Fluids: LR@125\n Consults: gyn, ortho\n Billing Diagnosis: acute osteomyelitis of left pelvis\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:00 AM\n 18 Gauge - 08:00 AM\n Arterial Line - 02:26 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: SICU\n Total time spent: >1 hour\n" }, { "category": "Respiratory ", "chartdate": "2199-10-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488421, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: resp failure\n Tube Type\n ETT:\n Position: 22cm at teeth\n Route: oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n 19 yo F post partum 11d, readmitted to hosp for sepsis. Pt orally\n intubated for pending resp failure, then quickly decompensated. Pt\n required multiple pressors, fluids, and blood products. Emergently\n taken to OR to have\nwash out\n L hip. Pt returned to ICU, HCT=12, then emergently taken to IR. ABG\n poor, airway pressures high (peak48/plat38), and\n Pt remains critical. See flowsheet for further pt data. Will follow,\n maintain vent support.\n 06:55\n" }, { "category": "Nursing", "chartdate": "2199-10-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488808, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received this am intubated/sedated on multiple pressors\n Levo @ .16mcgs/kg Vasopressin 1.2 units/hr\n ABP/ART lines transduced with approx point difference\n but with correlating MAP and diastolic BP\n attached but not working properly ABP wave form\n HR 90-100\ns NSR no noted ectopySBP 90-100\ns/70\ns MAP 61-71\n SVR 550-700\ns C/O 6.23 this am via thermodilution index 3.\n Echo done this am by SICU team. Echo showing pt was\n adequately volume resuscitated but with some LV dysfunction r/t sepsis\n Left hip op site oozing blood\n Pt\ns Creatinine cont to climb\n HCT prior to OR 27 platelets decreased to 40\n Action:\n Cont to maintain SBP goal of >90 MAP >65\n Pt given 1 unit of platelets prior to OR\n Pt sent to OR for washout and D&C approx 1345\n Response:\n Plan:\n Cont supportive care to pt and family\n ? possible starting dobutamine\n ? possible dialysis line placement for ? CRRT\n Cont to monitor hemodynamics closely\n Monitor CBC especially Hct and platelets and treat as\n indicated\n" }, { "category": "Nursing", "chartdate": "2199-10-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488295, "text": "19yo femaile, PSH tonsillectomy. PMH: 11 postpartum after delivery of\n regular, vaginal birth without complications. No other hx.\n Presents to ED after tx from Center ED where she\n initially presented with hypotension. She was sent to by\n Urgent Care where she went to be seen for 1d hx of buttock/low\n back pain and general weakness and fatigue since delivery. In\n addition, reports N/D for 5 days pta accompanied by intermittent\n abdominal pain. Denies sob, cough, fever, cp, cardiac related\n symptoms.\n She reports minimal bleeding since delivery, no significant discharge,\n no clots.\n Transferred from on dopa gtt which was dc\nd in ED, TLC\n placed and confirmed. Started on levophed gtt. Remained hypotensive\n and started on neo gtt as well. OB saw pt for consult for eval of\n possible endomyetritis or other etiology of infection. U/S reported to\n be without evidence of any retained parts. No evidence of\n endomyometritis or other to explain sepsis and pain. Approx total\n fluid pta arrival to 10L.\n Tx\nd to for management.\n Events: Vaginal and abdominal ultrasounds and cardiac echo performed at\n bedside. CT of pelvis abdomen showed air in the ileacus muscle, sacral\n iliac joint and ileus and large, bilateral pleural effusions.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt pale and lethargic this am and able to converse appropriately. She\n sleeps in short naps and follows simple commands. WBC was 46 with\n lactate of 3.4. Pt was afebrile, tachpnic with respiratory rate\n ranging from 29-50 on 4Lnc stating her breathing felt\nfine\n. Lungs\n were clear and decreased at the bases. Uo was 5-20cc/hr of amber\n sludge with a BUN of 41 and CR of 2.9. BP was supported by neo gtt\n at 2mcg/kg/min, levophed at .25mcg/kg/min and vasopressin at 2.4\n units/hr with a MAP 72-83. HR was sinus in the mid 90\ns with a rare pvc\n and CVP ranged 13-14. HR gradually increased to 120-130 range in later\n afternoon and early evening with 02 sat dropping to 87-90 range. VBG\n showed metabolic acidosis with Venous PH of 7.18. Pain at left flank\n was at rest.\n Action:\n LR at 150cc/hr with 1Liter bolus of same. Bicarb gtt initated at 150/hr\n as well as antibiotic coverage for gram negative rod bacteremia.\n Morphine 1mg given IVP for left flank pain. Consults and imaging per\n orders and reports.\n Response:\n Neo and Levo gtts weaned to off and left flank pain resolved. WBC down\n to 11.2 and BUN/CR stable at 43/2.9 with Urine output 45-80cc/hr clear\n yellow with sediment. Venous PH improved to 7.28 but 02 requirement had\n increased to maintain 02 sat > 93% with pt currently on 4Lnc and 50%\n cool face tent. Current 02 sat 96%.\n Plan:\n Pt and family provided with information from MICU service re: sepsis\n and ortho service for pending surgery for probable infection of ileac\n bone and ileacus muscle. Pt to transfer to the via ACLS\n ambulance and nurse.\n" }, { "category": "Respiratory ", "chartdate": "2199-10-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488608, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: esophageal balloon placed this shist ansd PEEP\n increased to 15 based on findings, and Vt kept low for lung protective\n protocol. plan to revaluate in AM rounds. ABG's and oxygenation well\n adjusted\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2199-10-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 488667, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 59\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 350x28/+15/.4\n Visual assessment of breathing pattern: Accessory muscle use when awake\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory) when awake\n Dysynchrony assessment:paradoxical breathing when awake\n Comments: Attempt to wean rr tol poorly with vent dysynchrony\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol and protective lung\n strategy; PIP36/plat 32\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI held d/t peep level\n Comments: will wean vent as tol per abg\n" }, { "category": "Nursing", "chartdate": "2199-10-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 488869, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received this am intubated/sedated on multiple pressors\n Levo @ .16mcgs/kg Vasopressin 1.2 units/hr\n ABP/ART lines transduced with approx point difference\n but with correlating MAP and diastolic BP\n attached but not working properly ABP wave form\n HR 90-100\ns NSR no noted ectopySBP 90-100\ns/70\ns MAP 61-71\n SVR 550-700\ns C/O 6.23 this am via thermodilution index 3.\n Echo done this am by SICU team. Echo showing pt was\n adequately volume resuscitated but with some LV dysfunction r/t sepsis\n Left hip op site oozing blood\n Pt\ns Creatinine cont to climb\n HCT prior to OR 27 platelets decreased to 40\n Resp: Remains on A/C 350X28 w/15 peep .40% Fi02 with\n adequate gas exchange\n Action:\n Cont to maintain SBP goal of >90 MAP >65\n Pt given 1 unit of platelets prior to OR\n Pt sent to OR for washout and D&C approx 1345\n Lungs clear to diminished at the bases\n No changes to vent settings d/t OR today re-eval ABG post OR\n Response:\n Tolerating OR procedure well\n Per Ortho bone looked clean\n D&C done some clot removal sent for path but nothing\n abnormal in procedure\n Pt post op able to wean pressors\n Tolerating rotation\n Pt to start dobutamine for LV dysfunction noted on previous\n echo\n Re-eval tomorrow for CRRT\n Vent setting remain unchanged\n Sats Adequate\n Plan:\n Cont supportive care to pt and family\n ? possible starting dobutamine\n ? possible dialysis line placement for ? CRRT\n Cont to monitor hemodynamics closely\n Monitor CBC especially Hct and platelets and treat as\n indicated\n Wean pressors as tolerated\n F/U on pending BC\n" }, { "category": "Radiology", "chartdate": "2199-10-21 00:00:00.000", "description": "CT PELVIS ORTHO W/O C", "row_id": 1103302, "text": " 10:03 AM\n CT PELVIS ORTHO W/O C Clip # \n Reason: assess post-op changes\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman s/p I+D Left SI joint and \n REASON FOR THIS EXAMINATION:\n assess post-op changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 19-year-old female status post I&D of the left SI joint on\n , and .\n\n STUDY: CT of the pelvis without contrast was performed. Coronal and sagittal\n reformatted images were generated.\n\n COMPARISON STUDY: .\n\n FINDINGS: There is a surgical defect in the left iliac bone with round high\n density pellets which is consistent with the previously described I&D, and\n subsequent antibiotic pellet placement. Patchy hypodensities are seen in the\n left sacrum just medial to the left SI joint (400B; 36, 38). Additionally, a\n linear lucency is seen in the left sacral ala (38; 27). High-density material\n projecting in the distribution of the left superior gluteal artery is\n consistent with catheter embolization material. Postoperative changes\n consistent with a left lateral inguinal approach are seen including a 6 cm x 6\n cm x 9 cm fluid collection in the left inguinal subcutaneous soft tissue,\n likely postoperative simple fluid/ seroma. There is also a small amount of\n free fluid in the pelvis. Skin staple line is also seen projecting over this\n area.\n\n A small locule of air within the bladder likely represents recent\n catheterization; mild enlargement of the uterus likely represents recent\n postpartum state.\n\n IMPRESSION:\n 1. New left sacral small hypodense foci may represent focal areas of\n osteopenia versus new areas osteomyelitis; close attention on followup is\n recommended.\n 2. Left sacral linear lucency may represent developing insufficiency\n fracture; again close attention on followup imaging is recommended.\n 3. Expected post surgical changes in left iliac bone and soft tissues.\n\n" }, { "category": "Radiology", "chartdate": "2199-10-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100919, "text": " 2:27 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with septic shock, intubated, desats\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:52 P.M. ON \n\n HISTORY: Septic shock. Intubated. Desaturating.\n\n IMPRESSION: AP chest compared to 6:04 a.m.:\n\n The radiodensity of consolidation at the lung bases has increased, but whether\n this represents real progression of disease would depend upon ventilator\n settings. ET tube and right jugular line are in standard placements. Mild\n cardiomegaly, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-21 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 1103297, "text": " 9:43 AM\n PELVIS (AP ONLY) Clip # \n Reason: assess pelvic stability\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with left iliac debridement done and . She is OK to\n be 50% WB on each leg for Xray only. Otherwise, she is TDWB on left. This must\n be a standing AP Pelvis Xray\n REASON FOR THIS EXAMINATION:\n assess pelvic stability\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MH MON 11:09 AM\n AP weightbearing view of the spine shows asymmetry of the acetabular roofs\n approximately 8 mm higher on the left. Spinal scoliosis, embolization coils\n and skin staples on the weightbearing view.\n ______________________________________________________________________________\n FINAL REPORT\n Single AP view of the pelvis obtained weightbearing. There is asymmetry of\n the acetabular roofs, approximately 8 mm higher on the left. However, overall\n the pelvis appears symmetric and congruent. Slight left convex rotary\n scoliosis suggested in the lower lumbar spine. Embolization coils and skin\n staples again noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-21 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 1103298, "text": ", E. MED CC7A 9:43 AM\n PELVIS (AP ONLY) Clip # \n Reason: assess pelvic stability\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with left iliac debridement done and . She is OK to\n be 50% WB on each leg for Xray only. Otherwise, she is TDWB on left. This must\n be a standing AP Pelvis Xray\n REASON FOR THIS EXAMINATION:\n assess pelvic stability\n ______________________________________________________________________________\n PFI REPORT\n AP weightbearing view of the spine shows asymmetry of the acetabular roofs\n approximately 8 mm higher on the left. Spinal scoliosis, embolization coils\n and skin staples on the weightbearing view.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1101039, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with ARDS, septic shock, intubated\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: ARDS, septic shock, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is minimal decrease\n in the peripheral portion of the pre-existing parenchymal opacities.\n Otherwise, there is no relevant change. Moderate cardiomegaly, unchanged\n course and position of the monitoring and support devices.\n\n\n" }, { "category": "Radiology", "chartdate": "2199-10-09 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1101421, "text": " 10:51 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please eval for pleural effusion, abd fluid collection, L hi\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old woman with septic shock, L septic hip s/p drainage now spiking\n temperatures\n REASON FOR THIS EXAMINATION:\n please eval for pleural effusion, abd fluid collection, L hip collection\n CONTRAINDICATIONS for IV CONTRAST:\n ARF - creatinine 3.1\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, ABDOMEN AND PELVIS\n\n HISTORY: Septic shock. Status post drainage of septic left hip, now with\n spiking fevers.\n\n COMPARISON: CT abdomen and pelvis performed , aortic\n angiogram and right upper quadrant ultrasound .\n\n CT CHEST\n\n 64-row MDCT was performed from the thoracic inlet to the base of the lung.\n Intravenous contrast was not administered.\n\n The tip of the endotracheal tube is in good position, 3.8 cm above the carina.\n There are diffuse patchy pulmonary opacities throughout both lungs somewhat\n sparring the left upper lobe. Findings are consistent with diffuse multifocal\n pneumonia and/or superimposed ARDS. Compared to the prior study, there is a\n stable moderate-sized right pleural effusion and a moderate-sized left pleural\n effusion. The left effusion has increased slightly in size since the prior\n study. There is dense consolidation in both lung bases with air bronchograms.\n Superimposed aspiration should be considered.\n\n CT ABDOMEN\n\n 64-row MDCT was performed from the base of the lung to the iliac crest. Oral\n and intravenous contrasts were not administered.\n\n The liver is unremarkable. There is high-density material in the dependent\n portion of the gallbladder consistent with vicarious excretion likely from the\n prior angiogram of . The spleen is enlarged along the\n cephalocaudad axis measuring 18.5 cm. However, the transverse diameter of the\n spleen is relatively measuring 4.4 cm. The size of the spleen is\n unchanged since the prior study.\n\n The right adrenal gland is unremarkable.\n\n There is punctate calcification within the left adrenal gland which was stable\n from the prior CT scan. This may represent the sequelae of prior adrenal\n (Over)\n\n 10:51 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please eval for pleural effusion, abd fluid collection, L hi\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hemorrhage. Correlation with any relevant past medical history is\n recommended.\n\n The abdominal aorta is normal in caliber. There is a small-to-moderate amount\n of ascites lateral to the liver which measures an average of 8.7 Hounsfield\n units consistent with simple fluid.\n\n Both kidneys are grossly abnormal. The right kidney measures 9.9 cm in the\n sagittal axis and the left measures 12.0 cm in the sagittal axis. There is\n linear density involving the renal cortices bilaterally. The renal cortices\n measure up to an average of 85 Hounsfield units. The overall attenuation of\n the kidneys is decreased and there is an appearance of striated\n corticomedullary junction. These findings would be consistent with possible\n ATN and delayed enhancement of the renal cortex secondary to IV contrast\n administration on . Reportedly, the patient is making urine, but has\n an elevated creatinine of approximately 3.\n\n In the upper pole of the right kidney is a 19 mm relatively low-attenuation\n area which is poorly defined. This is best appreciated on series 300B, image\n 43. This was not present on the prior study or at least was not evident.\n This may represent focal inflammatory or infectious region within the right\n kidney. However, there is no surrounding perinephric fat stranding making the\n possibility of infectious or inflammatory lesion less likely. Clinical\n correlation is advised.\n\n CT PELVIS\n\n 64-row MDCT was performed from the iliac crest to the symphysis pubis. Oral\n and intravenous contrasts were not administered.\n\n There is high-density material within the colon, likely from prior ingested\n oral contrast on . There is a surgical defect in the left iliac\n bone with high-density rounded material. This is consistent with recent\n debridement and placement of antibiotic capsules. Metallic densities are also\n noted in the distribution of the left superior gluteal artery related to\n recent catheter embolization. There is no evidence of a pelvic abscess.\n There is diffuse anasarca. Specifically, there is no evidence of a drainable\n fluid collection around the left hip.\n\n The uterus is slightly enlarged consistent with postpartum state. A Foley\n catheter is noted in the dependent portion of the bladder. There is air in\n the anterior aspect of the bladder.\n\n BONE WINDOWS: There are no lytic or blastic lesions.\n\n (Over)\n\n 10:51 AM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: please eval for pleural effusion, abd fluid collection, L hi\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n MULTIPLANAR REFORMATTED IMAGES. Coronal and sagittal multiplanar reformatted\n images were performed.\n\n IMPRESSION:\n 1. Diffuse bilateral pulmonary opacities with bilateral pleural effusions.\n Findings could be consistent with multifocal pneumonia or ARDS. Underlying\n aspiration should also be considered.\n\n 2. Enlarged spleen in the craniocaudad dimension of unclear clinical\n significance.\n\n 3. Diffusely abnormal kidneys. The kidneys are normal in size. However,\n there is a rim of high density attenuation surrounding both kidneys. This may\n be related to vicarious excretion of contrast and delayed nephrogram from IV\n contrast administration approximately one week ago in the setting of acute\n renal failure.\n\n 4. Low-attenuation lesion measuring approximately 2 cm in the upper pole of\n the right kidney which is poorly defined. In the proper clinical setting,\n this may represent a focal abscess or inflammatory focus. However, there is\n no surrounding perinephric fat stranding which would often be associated with\n an infectious or inflammatory etiology.\n\n 5. Ascites and anasarca.\n\n 6. Vicarious excretion of contrast in the gallbladder.\n\n 7. Postoperative and post-embolical changes in the left iliac bone and\n distribution of the left superior gluteal artery.\n\n 8. Compared to the prior study, the attenuation of the liver has increased and\n now measures approximately 48 Hounsfield units, previously measuring 43 to 44\n Hounsfield units. The spleen measures 40 Hounsfield units.\n\n" }, { "category": "Rehab Services", "chartdate": "2199-10-17 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 491972, "text": "Subjective:\n \"I'm okay\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NT\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n T\n Sit to Stand:\n\n\n\n\n T\n Ambulation:\n NT\n\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 110\n 160/90\n 18\n 96 on 5L\n Activity\n Sit\n 118\n 163/105\n 24\n 88-93 on RA\n Recovery\n Sit\n 100\n 148/57\n 24\n 95 on 5L\n Total distance walked:\n Minutes:\n Gait: Transfer: Stand-pivot transfer bed to chair with mod-max A\n Balance: S to sit EOB.\n Education / Communication: Pt. edu re: Role of Pt, , L LE: TDWB; RN\n comm re: Pt. status, method of transfer\n Other: A&O to self, \"\", \"\". Flat affect.\n Follows 100% of simple commands\n Assessment: Pt. is 19 y.o. F with sepsis from GU sources, SIJ\n osteomyelitis that improvement in mobility since initial eval,\n however continues to be functioning far below baseline. At this time\n recommend rehab placement, but will continue to f/u as appropriate to\n progress mobility.\n Anticipated Discharge: Rehab\n Plan: bed mobility, transfers, gait-training, balance re-ed, endurance\n training\n Face time: 14:38-15:02\n Nsg recs: Stand-pivot bed to chair with 2 assist to R side, or \n OOB to chair\n" }, { "category": "Nursing", "chartdate": "2199-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 492272, "text": "19 y/o femtale, G1P1 was Post partum 11 days NSVD with episotomy when\n she presented to urgent care center in NH with buttock/back pain found\n to be hypotensive with low plt count. Seen at with\n WBC 10.8 with 29 bands and plt of 21. Cr of 3.8. Given fluids and\n started on a Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n resp. failure ARDS, intubated, inc WBC to 48.1, plt 59. FDP products\n increased.\n Now off pressors with improving renal and pulmonary function.\n I&D left hip\n Washout of Left hip and D&C done by OB\n Chief complaint:\n Septic shock resolved\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n S/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 4 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, Pt incontinent of stool at times.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to cycled feeding\n overnoc 6pm to 6am (impact with fiber at 70cc\ns/hr). Urine output is\n adequate, elevated creatinine is resolving. Pt can get oob with\n touchdown weight-bearing on the left and full weight-bearing on the\n right. Seen by p.t. on . Left hip incision is c/d/I, staples in\n place, small amounts serosanguinous/brownish drainage noted from\n incision.\n Action:\n Right single lumen PICC line placed . Coughing/deep breathing and\n incentive spirometry encouraged.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Needs encouragement with po intake\n Plan:\n Enourage po intake, D/c ngt if po intake is adequate, continue p.t. and\n oob to chair, continue to encourage coughing and deep breathing and\n incentive spirometry.\n" }, { "category": "Physician ", "chartdate": "2199-10-16 00:00:00.000", "description": "Intensivist Note", "row_id": 491678, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n resolving septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n Ciprofloxacin 10. Clonidine Patch 0.2 mg/24 hr 11. DiphenhydrAMINE 12.\n Enoxaparin Sodium 13. Famotidine 14. Fentanyl Patch 15. Fentanyl\n Citrate 16. Haloperidol 17. Insulin 18. Ipratropium Bromide Neb 19.\n Lorazepam 20. Lorazepam 21. Magnesium Sulfate 22. MetRONIDAZOLE\n (FLagyl) 23. Methadone 24. Ondansetron\n 24 Hour Events:\n Did well over course of day. Balance net negative. Sedation\n appropriate with no evidence of withdrawl\n EKG - At 11:52 AM\n Post operative day:\n POD#13 - I & D Lt ileum and Sacroiliac joint debridement\n POD#12 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Ciprofloxacin - 10:18 PM\n Metronidazole - 02:10 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:54 AM\n Other medications:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 105 (99 - 118) bpm\n BP: 144/95(118) {130/80(100) - 154/100(123)} mmHg\n RR: 31 (20 - 38) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.1 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 19 (8 - 23) mmHg\n Total In:\n 2,693 mL\n 771 mL\n PO:\n Tube feeding:\n 1,689 mL\n 618 mL\n IV Fluid:\n 944 mL\n 153 mL\n Blood products:\n Total out:\n 4,350 mL\n 1,375 mL\n Urine:\n 4,350 mL\n 1,375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,657 mL\n -604 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.46/43/81./30/5\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Erythema)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 411 K/uL\n 7.4 g/dL\n 105 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 4.5 mEq/L\n 40 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.0 %\n 6.9 K/uL\n [image002.jpg]\n 05:06 AM\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n WBC\n 7.1\n 6.3\n 6.9\n Hct\n 22.4\n 22.4\n 23.0\n Plt\n 348\n 363\n 411\n Creatinine\n 1.3\n 1.2\n 1.3\n TCO2\n 27\n 25\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL, PO4:4.1\n mg/dL\n Imaging: : Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n : Vaginal US: 8mm endometrial stripe, no retained products\n seen\n : CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n : CXR - Apparent improvement probably due to increased ventilator\n pressures. No new consolidation or pneumothorax.\n Liver U/S Stable appearance of nonspecific gallbladder wall\n thickening which is likely to be related to third spacing. The\n appearance is not suggestive of acute cholecystitis, and furthermore\n the stability of gallbladder volume would also argue against acute\n cholecystitis.\n CXR - There is multifocal airspace opacity in both lungs. This\n could represent ARDS or severe pulmonary edema. The appearance has not\n significantly changed.\n Microbiology: - Outside hospital BCx GNR, species pending.\n - BCx - NGTD\n - Wound Cx (OR) - GNR ( samples)\n - UCx - negative\n - BCx - pending\n - BCx - pending\n - Sputum negative\n .\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned.\n .\n Neuro: Scheduled ativan PRN, clonidine,for sedation/analgesia. On\n haldol and clonidine. Titrating down sedation. Decreasing methadone TID\n dose and on fentanyl patch with drip wean.\n CV: Stable.\n Resp:Self extubated, stable.\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, c-diff (neg x 1). Consider repeating\n CDiff if she re-spikes\n Renal: ARF, creatinine trending down. Follow UOP, goal kg negative\n today.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with goal\n transfuse PRBCs prn. SQH and boots.\n ID: On flagyl, cipro, s/p clinda. ID following. rash resolved.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. No purulent d/c. Ortho may consider removing\n staples. Continue wound care for episiotomy\n Prophylaxis: Lovenox, SCDs, H2B\n TLD: will eventually need PICC. aline, subclavian\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Communication: Ortho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 06:28 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: boots, LMWH\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n Total time spent:\n" }, { "category": "Rehab Services", "chartdate": "2199-10-16 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 491681, "text": "Subjective:\n I feel better today\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: no new imaging\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n X2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 108\n 150/95\n 17\n 93% on 5L NC\n Activity\n Sit\n 120\n 144/87\n 20\n 94% on 5L NC\n Recovery\n 104\n 150/100\n 20\n 95% on 5L NC\n Total distance walked: 0\n Minutes:\n Gait: able to stand, able to maintain TDWB once standing with mod\n verbal cues. No c/o pain.\n Balance: Maintains static sitting at edge of bed with S, dynamic\n activities with CG. STatic standing with mod-max A x2, tolerated\n standing x10 sec.\n Education / Communication: Reviewed PT , safety and d/c planning.\n Communicated with nsg re: status.\n Other: Follows 100% of commands\n dysarthric speech but increasingly verbal compared to yesterday\n improved anxiety\n Seated therex at edge of bed x5 reps ea, hip flexion, knee ext, DF/PF\n total assist slide transfer to stretcher chair.\n Assessment: 19 yo F with sepsis making good progress in PT with\n mobility and endurance, continues to be limited by general\n deconditioning a/w prolonged hospitalization/bedrest. She continues to\n be well below her baseline, and would recommend rehab at this time\n however will continue to try to progress toward home as she has strong\n family support and could possibly go home at w/c level.\n Anticipated Discharge: Rehab vs. home\n Plan: continue with \n" }, { "category": "Physician ", "chartdate": "2199-10-16 00:00:00.000", "description": "Intensivist Note", "row_id": 491690, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n resolving septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n Ciprofloxacin 10. Clonidine Patch 0.2 mg/24 hr 11. DiphenhydrAMINE 12.\n Enoxaparin Sodium 13. Famotidine 14. Fentanyl Patch 15. Fentanyl\n Citrate 16. Haloperidol 17. Insulin 18. Ipratropium Bromide Neb 19.\n Lorazepam 20. Lorazepam 21. Magnesium Sulfate 22. MetRONIDAZOLE\n (FLagyl) 23. Methadone 24. Ondansetron\n 24 Hour Events:\n Did well over course of day. Balance net negative. Sedation\n appropriate with no evidence of withdrawl\n EKG - At 11:52 AM\n Post operative day:\n POD#13 - I & D Lt ileum and Sacroiliac joint debridement\n POD#12 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Ciprofloxacin - 10:18 PM\n Metronidazole - 02:10 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:54 AM\n Other medications:\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 105 (99 - 118) bpm\n BP: 144/95(118) {130/80(100) - 154/100(123)} mmHg\n RR: 31 (20 - 38) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 111.1 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 19 (8 - 23) mmHg\n Total In:\n 2,693 mL\n 771 mL\n PO:\n Tube feeding:\n 1,689 mL\n 618 mL\n IV Fluid:\n 944 mL\n 153 mL\n Blood products:\n Total out:\n 4,350 mL\n 1,375 mL\n Urine:\n 4,350 mL\n 1,375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,657 mL\n -604 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: 7.46/43/81/30/5\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Erythema)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, Sedated\n Labs / Radiology\n 411 K/uL\n 7.4 g/dL\n 105 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 4.5 mEq/L\n 40 mg/dL\n 108 mEq/L\n 143 mEq/L\n 23.0 %\n 6.9 K/uL\n [image002.jpg]\n 05:06 AM\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n WBC\n 7.1\n 6.3\n 6.9\n Hct\n 22.4\n 22.4\n 23.0\n Plt\n 348\n 363\n 411\n Creatinine\n 1.3\n 1.2\n 1.3\n TCO2\n 27\n 25\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.4 mg/dL, Mg:2.1 mg/dL, PO4:4.1\n mg/dL\n Imaging: : Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n : Vaginal US: 8mm endometrial stripe, no retained products\n seen\n : CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n : CXR - Apparent improvement probably due to increased ventilator\n pressures. No new consolidation or pneumothorax.\n Liver U/S Stable appearance of nonspecific gallbladder wall\n thickening which is likely to be related to third spacing. The\n appearance is not suggestive of acute cholecystitis, and furthermore\n the stability of gallbladder volume would also argue against acute\n cholecystitis.\n CXR - There is multifocal airspace opacity in both lungs. This\n could represent ARDS or severe pulmonary edema. The appearance has not\n significantly changed.\n Microbiology: - Outside hospital BCx GNR, species pending.\n - BCx - NGTD\n - Wound Cx (OR) - GNR ( samples)\n - UCx - negative\n - BCx - pending\n - BCx - pending\n - Sputum negative\n .\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned.\n .\n Neuro: D/C ativan and haldol; Cont clonidine. Titrating down sedation\n and narcotics.\n CV: Stable.\n Resp:Self extubated, but ventilating well and did not require\n reintubation.\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, c-diff (neg x 1).\n Renal: ARF, creatinine trending down. Follow UOP, goal kg negative\n today.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia. SQH and\n boots.\n ID: On flagyl, cipro, s/p clinda. ID following. rash resolved.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. No purulent d/c. Ortho may consider removing\n staples. Continue wound care for episiotomy\n Prophylaxis: Lovenox, SCDs, H2B\n TLD: will eventually need PICC. aline, subclavian\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Communication: Ortho\n Billing Diagnosis: Respiratory insuff, post-op\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 06:28 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: boots, LMWH\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 32\n" }, { "category": "Nutrition", "chartdate": "2199-10-16 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 491692, "text": "Subjective: Patient would like to try sips.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 95.5 kg\n 109.4 kg ( )\n 33.9\n Pertinent medications: Fentanyl, ABx, pepcid, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 105 mg/dL\n 03:40 AM\n Glucose Finger Stick\n 138\n 10:00 AM\n BUN\n 40 mg/dL\n 03:40 AM\n Creatinine\n 1.3 mg/dL\n 03:40 AM\n Sodium\n 143 mEq/L\n 03:40 AM\n Potassium\n 4.5 mEq/L\n 03:40 AM\n Chloride\n 108 mEq/L\n 03:40 AM\n TCO2\n 30 mEq/L\n 03:40 AM\n PO2 (arterial)\n 81. mm Hg\n 03:30 AM\n PO2 (venous)\n 63 mm Hg\n 12:00 AM\n PCO2 (arterial)\n 43 mm Hg\n 03:30 AM\n PCO2 (venous)\n 50 mm Hg\n 12:00 AM\n pH (arterial)\n 7.46 units\n 03:30 AM\n pH (venous)\n 7.10 units\n 12:00 AM\n pH (urine)\n 5.5 units\n 07:28 AM\n CO2 (Calc) arterial\n 32 mEq/L\n 03:30 AM\n CO2 (Calc) venous\n 16 mEq/L\n 12:00 AM\n Albumin\n 2.9 g/dL\n 03:40 AM\n Calcium non-ionized\n 8.4 mg/dL\n 03:40 AM\n Phosphorus\n 4.1 mg/dL\n 03:40 AM\n Ionized Calcium\n 1.15 mmol/L\n 03:30 AM\n Magnesium\n 2.1 mg/dL\n 03:40 AM\n ALT\n 9 IU/L\n 03:40 AM\n Alkaline Phosphate\n 103 IU/L\n 03:40 AM\n AST\n 13 IU/L\n 03:40 AM\n Total Bilirubin\n 1.1 mg/dL\n 03:40 AM\n WBC\n 6.9 K/uL\n 03:40 AM\n Hgb\n 7.4 g/dL\n 03:40 AM\n Hematocrit\n 23.0 %\n 03:40 AM\n Current diet order / nutrition support: Diet: NPO\n Tube Feeds: Impact with Fiber @ 70ml/hr (1680kcals, 94g protein)\n GI: NGT in place, abd soft, bowel sounds present\n Assessment of Nutritional Status\n 19 y.o. Female post partum complicated by w/septic shock, ARDS,\n multiorgan failure with improving clinical course. Patient\n self-extubated and remains extubated, doing well. Tube feeds are\n running at goal, which meet 100% of estimated needs. Now that patient\n is extubated, recommend trialing sips and recommend a swallow\n evaluation if there is question of aspiration.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with Tube Feed at goal.\n Recommend advancing diet versus swallow evaluation.\n Montior hydration and lytes.\n Following - #\n" }, { "category": "Nursing", "chartdate": "2199-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491651, "text": "Anxiety\n Assessment:\n Pt alert and awake most of night\n Noted to have several short naps\n Pt noted to be very anxious when awoken\n Asking for her mother\n Action:\n Pt reoriented to place and time\n Emotional support for pt\n need for haldol or ativan\n Response:\n Pt easily redirected\n Plan:\n Cont with emotional support for pt and family\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues on fentanyl gtt at 50mcg/hr\n Methadone 15mg TID\n Moaning vs auto peep all night\n Action:\n Repositioned and back rub for comfort\n Response:\n Denies pain over night\n Plan:\n Attempt to wean pain meds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds- rhonchi through out\n O2 at 5l via N/C\n Action:\n Pulmonary toileting\n Response:\n O2 sats >95%\n ABG acceptable\n Plan:\n Cont with pulmonary toilet\n" }, { "category": "Nursing", "chartdate": "2199-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491852, "text": "Anxiety\n Assessment:\n Pt calm and relaxed throughout shift\n Slept well throughout shift\n Action:\n No Ativan or haldol given\n Emotional support given to pt\n Clonidine patch\n Response:\n No change in pt\ns condition\n Plan:\n Continue to provide pt with emotional support\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n LS clear to coarse, diminished at bases\n Pt able to cough and raise small amounts of sputum in which\n the pt then swallows\n Pt denies SOB\n O2 sat 95-98% on 5L n/c\n Action:\n Turn and reposition pt Q2-3hrs\n Encourage pt to C&DB\n Wean O2 as needed\n Response:\n No change in pt\ns condition\n Plan:\n Continue with pulm toileting\n Continue wean O2 as tolerated\n Turn and reposition Q2-3hrs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt denies pain at rest\n C/O back pain when turning and repositioning\n Action:\n Fent patch\n Methadone 15mg po TID\n Response:\n No change in pt\ns condition\n Plan:\n Continue with meds as ordered\n ? wean methadone\n Provide pt with emotional support\n" }, { "category": "Nursing", "chartdate": "2199-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491853, "text": "Anxiety\n Assessment:\n Pt calm and relaxed throughout shift\n Slept well throughout shift\n Action:\n No Ativan or haldol given\n Emotional support given to pt\n Clonidine patch\n Response:\n No change in pt\ns condition\n Plan:\n Continue to provide pt with emotional support\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n LS clear to coarse, diminished at bases\n Pt able to cough and raise small amounts of sputum in which\n the pt then swallows\n Pt denies SOB\n O2 sat 95-98% on 5L n/c\n Action:\n Turn and reposition pt Q2-3hrs\n Encourage pt to C&DB\n Wean O2 as needed\n Response:\n No change in pt\ns condition\n Plan:\n Continue with pulm toileting\n Continue wean O2 as tolerated\n Turn and reposition Q2-3hrs\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt denies pain at rest\n C/O back pain when turning and repositioning\n Action:\n Fent patch\n Methadone 15mg po TID\n Response:\n No change in pt\ns condition\n Plan:\n Continue with meds as ordered\n ? wean methadone\n Provide pt with emotional support\n" }, { "category": "Nursing", "chartdate": "2199-10-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 492052, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n S/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 5 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, rectal tube draining liquid stool.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to feeding (impact\n with fiber at 70cc\ns/hr). Urine output is adequate, elevated\n creatinine is resolving. Pt can get oob with touchdown weight-bearing\n on the left and full weight-bearing on the right. Seen by p.t. on\n . Left hip incision is c/d/I, staples in place, small amounts\n serosanguinous/brownish drainage noted from incision.\n Action:\n Right PICC line placed this morning, cvl to be d/c\nd after picc line is\n confirmed. Rectal tube d/c\nd. Coughing/deep breathing and incentive\n spirometry encouraged. Tube feeds now cycled, so off during the day\n and on at night.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Plan:\n Enourage po intake, cycled tube feeds, continue p.t. and oob to chair,\n continue to encourage coughing and deep breathing and incentive\n spirometry, continue to monitor nutritional status.\n" }, { "category": "Nursing", "chartdate": "2199-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491763, "text": "Anxiety\n Assessment:\n Alert and oriented x3\n Pt appears calm and at times apprehensive\n Action:\n Emotional support given\n Response:\n Pt stable,\n No doses of Ativan or haldol required\n Plan:\n Continue to offer emotional support\n Explain all procedures\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Breath sounds coarse and slightly diminished in bases\n Nasal cannula at 5 liters with sats 94-98%\n Action:\n Oob to chair for 3 hours\n Pulmonary toilet encouraged\n Response:\n Improved resp status\n Minimal secretions\n Plan:\n Encourage pt to cough and deep breath\n Wean o2 as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n On Fentanyl gtt at 50,\n Fentanyl patch applied \n Continues on methadone\n Pt denies pain\n Action:\n Fentanyl gtt discontinued\n Response:\n Pt continues to deny pain\n Plan:\n ? wean methadone tomorrow\n Continue to assess for pain\n" }, { "category": "Nursing", "chartdate": "2199-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490733, "text": "Anxiety\n Assessment:\n Pt off all sedative cont gtts\n PRN Dilaudid and midaz for pain/sedation\n Pt increasingly tachycardic and tachypnic when awake\n Pt with RR at times as hight as 50 SBP up to 170\n Pt requiring much reassurance and emotional support\n Action:\n Pt requiring increased doses of midaz and Dilaudid\n Pt cont to be very anxious/scared\n Midaz d/c\nd Ativan added for longer acting since versed only\n lasting approx 20-40 min\n Response:\n Pt still very anxious and scared\n Weepy at times\n Attempting to mouth words seems very frustrated\n Plan:\n Emotional support to pt\n med regimine ? switching to prop or precedex\n until ready to extubate\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CPAP 12X8\n Pt cont to be tachpnic\n Lungs Rhonchi and diminished at the bases\n + strong cough\n Sxn for mod amts of secretions\n Action:\n Turn and repositioned Q2 and PRN\n Pulmonary toilet as tolerated\n Pt with episode of desats to 88-90% most likely anxiety\n related ABG sent\n Placed on A/C for approx 15 min to open up airway with\n higher set TV and see if pt more comfortable\n Response:\n Pt only on A/C for short time\n Lungs clearer after placed on A/C and given puffers\n ABG when pt\ns sat 88-90 adequate Pa02 in 120 range\n No additional weaning do to pt\ns episodes of increased\n tachycardia and tachypnea most like not directly pulmonary related but\n felt that sedation needs to be more undercontrol to facilitate\n successful vent wean and extubation.\n Plan:\n Cont supportive care to pt and family\n Pulmonary toilet as tolerated\n Cont with current plan of care\n" }, { "category": "Respiratory ", "chartdate": "2199-10-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490735, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n ETT:\n Position: 22cm at teeth\n Route: po\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n Pt remains intubated, vent supported. No vent changes made overnight.\n Of note, pt continues to have episodes of agitation with hypertension,\n tachypnea and diaphoresis. RSBI=143. See flowsheet for further pt\n data. Will follow.\n 05:56\n" }, { "category": "Physician ", "chartdate": "2199-10-13 00:00:00.000", "description": "Intensivist Note", "row_id": 490960, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer, started empirically on Vanco and Zosyn.\n Chief complaint:\n Septic shock\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n .\n : None\n All: NKDA\n .\n Current medications:\n . Acetaminophen (Liquid) 4. Albuterol Inhaler 9. Ciprofloxacin 10.\n Clindamycin 11. Clonidine Patch 0.2 mg/24 hr\n 12. CloniDINE 13. DiphenhydrAMINE 14. Enoxaparin Sodium 15. Famotidine\n 16. Fentanyl Citrate 17. Insulin\n 18. Lorazepam 121. MetRONIDAZOLE (FLagyl) 22. Methadone 23.\n Ondansetron Propofol 27. Senna\n 24 Hour Events:\n Started on methadone, clonidine. Intolerate of sedation schedule; with\n increased respiratory effort and need to transiently increase\n ventilatory settings. Febrile. Intermittently on propofol. Started\n on standing ativan and fentanyl drip.\n FEVER - 101.9\nF - 11:00 AM\n Post operative day:\n POD#10 - I & D Lt ileum and Sacroiliac joint debridement\n POD#9 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Meropenem - 04:00 AM\n Metronidazole - 06:00 PM\n Ciprofloxacin - 10:49 PM\n Clindamycin - 03:54 AM\n Infusions:\n Propofol - 15 mcg/Kg/min\n Fentanyl - 300 mcg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 06:45 AM\n Fentanyl - 11:10 AM\n Lorazepam (Ativan) - 10:49 PM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.9\n T current: 37.8\nC (100\n HR: 110 (91 - 137) bpm\n BP: 111/67(85) {89/40(56) - 154/94(117)} mmHg\n RR: 26 (15 - 41) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 11 (6 - 16) mmHg\n Total In:\n 3,177 mL\n 643 mL\n PO:\n Tube feeding:\n 1,682 mL\n 372 mL\n IV Fluid:\n 1,495 mL\n 271 mL\n Blood products:\n Total out:\n 2,860 mL\n 925 mL\n Urine:\n 2,860 mL\n 925 mL\n NG:\n Stool:\n Drains:\n Balance:\n 317 mL\n -282 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (317 - 427) mL\n PS : 12 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Agitated\n PIP: 19 cmH2O\n SPO2: 98%\n ABG: 7.41/42/125/23/2\n Ve: 10.3 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Skin: Rash:\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 173 K/uL\n 8.1 g/dL\n 107 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 50 mg/dL\n 109 mEq/L\n 143 mEq/L\n 24.5 %\n 8.3 K/uL\n [image002.jpg]\n 10:01 AM\n 12:10 AM\n 02:18 AM\n 02:57 AM\n 12:14 PM\n 02:12 PM\n 09:20 PM\n 02:47 AM\n 02:48 AM\n 03:11 AM\n WBC\n 8.3\n Hct\n 25.0\n 24.5\n Plt\n 173\n Creatinine\n 2.0\n 1.8\n TCO2\n 23\n 26\n 27\n 25\n 26\n 28\n 28\n Glucose\n 102\n 104\n 98\n 110\n 107\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:78.9 %, Band:2.0 %, Lymph:15.2 %,\n Mono:2.6 %, Eos:2.7 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:1.6 mg/dL, PO4:3.6\n mg/dL\n Imaging: : Upright CXR: no free air, some haziness in right chest\n appears to be volume overload\n : Vaginal US: 8mm endometrial stripe, no retained products\n seen\n : CT abd/pelvis: Small phlegmonous density anterior to the left\n sacroiliac joint and possibly continuous with the joint space, with\n pockets of gas within the left iliacus, piriformis and gluteus minimus\n muscles with associated rarefaction of the posterior left iliac bone,\n highly suspicious for septic arthritis of the left sacroiliac joint and\n associated osteomyelitis.\n : CXR - decreased haziness, no carddiomegaly\n : CXR - Improved moderate-severe pulmonary edema since\n : ARDS unlikely. Marked distension of the stomach despite NGT\n : CXR - Severe infiltrative pulmonary abnormality has not\n improved. Vascular engorgement in the mediastinum and at least a small\n to moderate right pleural effusion suggests volume overload, and heart\n is mildly enlarged though partially obscured by parenchymal abnormality\n in the left lung.\n : CXR - Apparent improvement probably due to increased ventilator\n pressures. No new consolidation or pneumothorax.\n Liver U/S Stable appearance of nonspecific gallbladder wall\n thickening which is likely to be related to third spacing. The\n appearance is not suggestive of acute cholecystitis, and furthermore\n the stability of gallbladder volume would also argue against acute\n cholecystitis.\n CXR - There is multifocal airspace opacity in both lungs. This\n could represent ARDS or severe pulmonary edema. The appearance has not\n significantly changed.\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n .\n Neuro: Scheduled ativan q6 and PRN, fentanyl drip, clonidine, methadone\n for sedation/analgesia\n CV: Off all pressors.\n Resp: PEEP down to 12/5, will wean slowly, ARDS protocol, daily CXR.\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1). Esophageal\n balloon removed.\n Renal: ARF, creatinine trending down.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with goal\n transfuse PRBCs prn. SQH and boots.\n ID: cipro/clinda/flagyl for fusobacteria, bacillis sp. ID following.\n D/c' rash.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation. Wound care for episiotomy\n Prophylaxis: Lovenox, boots, H2B\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n Billing Diagnosis:\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:41 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H@B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2199-10-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490896, "text": "Anxiety\n Assessment:\n Pt increasingly more anxious and agitated throughout the day,\n tachycardic as high as 150\ns, tachypnic as high as 6o\ns, sbp as high as\n 170\ns. Pt desaturated to 89. Temp was 101.9 when patient was most\n agitated.\n Action:\n Emotional/resassuranc, po methadone, po clonidine and patch, ativan iv\n push and fentynal iv push all unsuccessful in attempt to control\n anxiety. Pt then started on ppf as temporizing , fentyanl gtt\n started and ativan started around the clock in addition to prn dosing.\n Pt placed on cooling blanket and given tylenol.\n Response:\n Temp. returned to 97.5 and agitation considerably improved. Pt less\n anxious, able to nod appropriately and follow some commands. Of note,\n level of agitation seemed to correspond with fever.\n Plan:\n Fentynal gtt, ativan around the clock, methadone, clonidine, wean\n fentynal daily, monitor temp. -> prn tylenol and cooling blanket.\n" }, { "category": "Nursing", "chartdate": "2199-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490971, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt initially sleeping quietly at start of shift but escalated in\n agitation and restlessness over the course of the shift. Pt started\n having increasing periods when her respiratory rate was into 50s, and\n tachycardia into 120s. During periods of agitation the pt was\n constantly shifting in bed, very restless. Pt nodding head\n pain. Pt given IV scheduled Ativan and PRN dosing Ativan with only\n brief, short term effects.\n Action:\n Pt required low dose propofol to ultimately decrease\n restlessness/agitation and lower HR/RR.\n Response:\n Pt RR back into 28-30s after propofol started at 15 mcg/kg/min. Pt calm\n and resting quietly in bed\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491910, "text": "19 y/o femtale, G1P1 was Post partum 11 days NSVD with episotomy when\n she presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n resp. failure ARDS, intubated, inc WBC to 48.1, plt 59. FDP products\n increased.\n Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n Septic shock resolved\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n S/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 5 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, rectal tube draining liquid stool.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to feeding (impact\n with fiber at 70cc\ns/hr). Urine output is adequate, elevated\n creatinine is resolving. Pt can get oob with touchdown weight-bearing\n on the left and full weight-bearing on the right. Seen by p.t. on\n . Left hip incision is c/d/I, staples in place, small amounts\n serosanguinous/brownish drainage noted from incision.\n Action:\n Right PICC line placed this morning, cvl to be d/c\nd after picc line is\n confirmed. Rectal tube d/c\nd. Coughing/deep breathing and incentive\n spirometry encouraged.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Plan:\n Enourage po intake, D/c ngt if po intake is adequate, continue p.t. and\n oob to chair, continue to encourage coughing and deep breathing and\n incentive spirometry.\n" }, { "category": "Nursing", "chartdate": "2199-10-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491104, "text": "Anxiety\n Assessment:\n Anxiety and agitation overall improved throughout the course of the\n day. Tachy to 110\ns, rr 20\ns-30\n Action:\n Haldol initiated and ativan increased to 6mg iv q 6 horus. Clonidine\n po and patch continues, fentynal gtt remains at 300, methadone\n continues tid. Ppf initiated this morning for some intermittent\n agitation, ppf since weaned off.\n Response:\n Pt has remained fairly calm since ppf weaned off. with intermittent\n bouts of agitation that resolve with re-assurance and emotional\n support. Pt able to nod appropriately and follow commands. Pt denies\n pain.\n Plan:\n Continue po bid haldol, continue fentynal gtt\n ? start to wean, po\n methadone, clonidine patch, around the clock ativan, provide emotional\n support and re-assurance.\n" }, { "category": "Nursing", "chartdate": "2199-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491736, "text": "Anxiety\n Assessment:\n Alert and oriented x3\n Pt appears calm and at times apprehensive\n Action:\n Emotional support given\n Response:\n Pt stable,\n No doses of Ativan or haldol required\n Plan:\n Continue to offer emotional support\n Explain all procedures\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Breath sounds coarse and slightly diminished in bases\n Nasal cannula at 5 liters with sats 94-98%\n Action:\n Oob to chair for 3 hours\n Pulmonary toilet encouraged\n Response:\n Improved resp status\n Minimal secretions\n Plan:\n Encourage pt to cough and deep breath\n Wean o2 as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n On Fentanyl gtt at 50,\n Fentanyl patch applied \n Continues on methadone\n Pt denies pain\n Action:\n Fentanyl gtt discontinued\n Response:\n Pt continues to deny pain\n Plan:\n ? wean methadone tomorrow\n Continue to assess for pain\n" }, { "category": "Nursing", "chartdate": "2199-10-17 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 491908, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n s/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 5 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, rectal tube draining liquid stool.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to feeding (impact\n with fiber at 70cc\ns/hr). Pt can get oob with touchdown weight-bearing\n on the left and full weight-bearing on the right. Seen by p.t. on\n . Left hip incision is c/d/I, staples in place, small amounts\n serosanguinous/brownish drainage noted from incision.\n Action:\n Right PICC line placed this morning, cvl to be d/c\nd after picc line is\n confirmed. Rectal tube d/c\nd. Coughing/deep breathing and incentive\n spirometry encouraged.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Plan:\n Enourage po intake, D/c ngt if po intake is adequate, continue p.t. and\n oob to chair, continue to encourage coughing and deep breathing and\n incentive spirometry.\n" }, { "category": "Respiratory ", "chartdate": "2199-10-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490957, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 11\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2199-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 492107, "text": "19 y/o femtale, G1P1 was Post partum 11 days NSVD with episotomy when\n she presented to urgent care center in NH with buttock/back pain found\n to be hypotensive with low plt count. Seen at with\n WBC 10.8 with 29 bands and plt of 21. Cr of 3.8. Given fluids and\n started on a Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n resp. failure ARDS, intubated, inc WBC to 48.1, plt 59. FDP products\n increased.\n Now off pressors with improving renal and pulmonary function.\n I&D left hip\n Washout of Left hip and D&C done by OB\n Chief complaint:\n Septic shock resolved\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n S/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 4 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, Pt incontinent of stool at times.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to cycled feeding\n overnoc 6pm to 6am (impact with fiber at 70cc\ns/hr). Urine output is\n adequate, elevated creatinine is resolving. Pt can get oob with\n touchdown weight-bearing on the left and full weight-bearing on the\n right. Seen by p.t. on . Left hip incision is c/d/I, staples in\n place, small amounts serosanguinous/brownish drainage noted from\n incision.\n Action:\n Right single lumen PICC line placed . Coughing/deep breathing and\n incentive spirometry encouraged.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Plan:\n Enourage po intake, D/c ngt if po intake is adequate, continue p.t. and\n oob to chair, continue to encourage coughing and deep breathing and\n incentive spirometry.\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491155, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt had longer periods when she was in a calm restful state but\n continues to wake very agitated, restless. Pt able to move all\n extremities, follows commands and will occasionally nod head to simple\n questions. When agitated, pt\ns RR up into 50-60s and HR tachy into\n 120s-130s\n Action:\n -re-oriented pt frequently when pt awake\n -ativan 6mg every 6 hours ATC\n -standing haldol dosing of 2mg \n -pt with clonidine patch\n -fentanyl drip continues and dosing titrated down\n -standing methadone dose\n Response:\n Pt able to have longer rest periods between periods of agitation\n Plan:\n Continue current med regime, wean fentanyl down as tolerated\n" }, { "category": "Physician ", "chartdate": "2199-10-15 00:00:00.000", "description": "Intensivist Note", "row_id": 491462, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a dopamine gtt and\n transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per records, patient\n has receieved a total of 9-10L of fluid before transfer. Now off\n pressors with improving renal and pulmonary function.\n Chief complaint:\n Buttock pain\n PMHx:\n G1P1\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1557\n 18. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 1425\n 19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing Order date:\n @ 0120\n 3. Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN fever Start: \n Order date: @ 1157\n 20. Lorazepam 1-2 mg IV Q4H:PRN agitation Order date: @ 1157\n 4. Albuterol Inhaler PUFF IH Q2H:PRN wheezing Order date: @\n 2227\n 21. Lorazepam 6 mg IV Q6H Order date: @ 0859\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 0120\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1023\n 6. Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date:\n @ 0429\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0815\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 1557\n 24. Methadone 20 mg PO TID Order date: @ 0657\n 8. Calcium Gluconate IV Sliding Scale Order date: @ 1557\n 25. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n 26. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n 10. Ciprofloxacin 400 mg IV Q12H Order date: @ 1039\n 27. Potassium Chloride IV Sliding Scale Order date: @ 0657\n 11. Clindamycin 600 mg IV Q8H Order date: @ 0835\n 28. Propofol 0-50 mcg/kg/min IV DRIP TITRATE TO agitation Order date:\n @ 0136\n 12. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT Order date: @\n 0657\n 29. Senna 1 TAB PO/NG :PRN Constipation Start: Order date:\n @ 1156\n 13. DiphenhydrAMINE 50 mg IV Q8H:PRN rash Order date: @ 0702\n 15. Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n 14. Enoxaparin Sodium 40 mg SC DAILY Order date: @ 0915\n 16. Fentanyl Citrate 300 mcg/hr IV DRIP INFUSION Order date: @\n 1157\n 17. Haloperidol 1-2 mg IV Q2H:PRN agitation Order date: @ 0641\n 24 Hour Events:\n Self-extubated overnight, O2 sats 99% on face tent. OOB to chair,\n speaking occasionally, appropriate.\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 06:56 PM\n Post operative day:\n POD#12 - I & D Lt ileum and Sacroiliac joint debridement\n POD#11 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 10:51 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 12:30 AM\n Fentanyl - 04:30 AM\n Haloperidol (Haldol) - 05:00 AM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.1\nC (97\n HR: 106 (88 - 130) bpm\n BP: 140/89(112) {114/68(87) - 166/99(125)} mmHg\n RR: 35 (18 - 35) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (6 - 28) mmHg\n Total In:\n 2,673 mL\n 618 mL\n PO:\n Tube feeding:\n 1,679 mL\n 403 mL\n IV Fluid:\n 994 mL\n 185 mL\n Blood products:\n Total out:\n 4,280 mL\n 1,010 mL\n Urine:\n 4,280 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,607 mL\n -392 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 380 (340 - 420) mL\n PS : 10 cmH2O\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.41/43/184/29/2\n Ve: 9.3 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 363 K/uL\n 7.2 g/dL\n 104 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 41 mg/dL\n 109 mEq/L\n 143 mEq/L\n 22.4 %\n 6.3 K/uL\n [image002.jpg]\n 02:47 AM\n 02:48 AM\n 03:11 AM\n 02:20 AM\n 05:06 AM\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n WBC\n 6.8\n 7.1\n 6.3\n Hct\n 24.5\n 23.5\n 22.4\n 22.4\n Plt\n 349\n 348\n 363\n Creatinine\n 1.8\n 1.6\n 1.3\n TCO2\n 28\n 27\n 25\n 28\n 28\n Glucose\n 107\n 113\n 104\n Other labs: PT / PTT / INR:15.2/43.6/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:105/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:1.8 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Scheduled Methadone\n begin to wean today. Fentanyl drip\n weaning\n transition to patch, clonidine, for sedation/analgesia.\n Haldol for agitation PRN. Somnolent but arousable and appropriate.\n Cardiovascular: Off all pressors and maintaining normal pressure.\n Pulmonary: Self-extubated overnight, ABG satisfactory, but remains\n tachypneic, O2 sats >98% on face tent. AM CXR.\n Gastrointestinal / Abdomen: NGT in place. Tube feeds; high output loose\n stool -- flexiseal, c-diff (neg x 1). Consider repeating CDiff if she\n re-spikes.\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition\n Renal: ARF, creatinine trending down\n cont to maintain negative fluid\n balance QD.\n Hematology: Hx of SGA bleed s/p coiling in IR. Mild anemia unchanged.\n Lovenox and boots for DVT prophylaxis\n Endocrine: RISS.\n Infectious Disease: On flagyl, cipro, clinda. ID following. rash\n resolving. Consider d/c clinda today.\n Lines / Tubes / Drains: , , NGT\n Wounds: L hip clean / dry / intact\n Imaging: AM CXR\n Fluids: HLIV\n Consults: ortho, ID\n Billing Diagnosis: Respiratory failure; Sepsis.\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:04 AM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 33 min\n" }, { "category": "Nursing", "chartdate": "2199-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491619, "text": "Anxiety\n Assessment:\n Pt alert and awake most of night\n Noted to have several short naps\n Pt noted to be very anxious when awoken\n Asking for her mother\n Action:\n Pt reoriented to place and time\n Emotional support for pt\n need for haldol or ativan\n Response:\n Pt easily redirected\n Plan:\n Cont with emotional support for pt and family\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues on fentanyl gtt at 50mcg/hr\n Methadone 15mg TID\n Moaning vs auto peep all night\n Action:\n Repositioned and back rub for comfort\n Response:\n Denies pain over night\n Plan:\n Attempt to wean pain meds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds- rhonchi through out\n O2 at 5l via N/C\n Action:\n Pulmonary toileting\n Response:\n O2 sats >95%\n ABG acceptable\n Plan:\n Cont with pulmonary toilet\n" }, { "category": "Physician ", "chartdate": "2199-10-17 00:00:00.000", "description": "Intensivist Note", "row_id": 491897, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n Septic shock resolved\n PMHx:\n Current medications:\n Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Albuterol 0.083% Neb\n Soln 6. Artificial Tears\n 7. Bisacodyl 8. Calcium Gluconate 9. Ciprofloxacin 10. Clonidine Patch\n 0.2 mg/24 hr 11. DiphenhydrAMINE\n 12. Enoxaparin Sodium 13. Famotidine 14. Fentanyl Patch 15. Haloperidol\n 16. 17. Insulin 18. Ipratropium Bromide Neb\n 19. Lorazepam 20. Lorazepam 21. Magnesium Sulfate 22. MetRONIDAZOLE\n (FLagyl) 23. Methadone 24. Ondansetron\n 25. Potassium Phosphate 26. Potassium Chloride 27. Senna\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:28 PM\n ultrasound guided placement of left axillary aline\n Post operative day:\n POD#14 - I & D Lt ileum and Sacroiliac joint debridement\n POD#13 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Ciprofloxacin - 10:45 PM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:54 AM\n Enoxaparin (Lovenox) - 08:00 PM\n Other medications:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.2\nC (97.1\n HR: 87 (83 - 114) bpm\n BP: 149/84(99) {129/77(89) - 149/84(99)} mmHg\n RR: 24 (18 - 35) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.4 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 11 (6 - 17) mmHg\n Total In:\n 2,514 mL\n 626 mL\n PO:\n Tube feeding:\n 1,684 mL\n 463 mL\n IV Fluid:\n 831 mL\n 133 mL\n Blood products:\n Total out:\n 4,635 mL\n 1,165 mL\n Urine:\n 4,635 mL\n 965 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -2,121 mL\n -539 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 356 K/uL\n 7.9 g/dL\n 127 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.4 mEq/L\n 38 mg/dL\n 107 mEq/L\n 142 mEq/L\n 23.7 %\n 7.3 K/uL\n [image002.jpg]\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n 02:46 AM\n WBC\n 7.1\n 6.3\n 6.9\n 7.3\n Hct\n 22.4\n 22.4\n 23.0\n 23.7\n Plt\n 348\n 363\n 411\n 356\n Creatinine\n 1.3\n 1.2\n 1.3\n 1.2\n TCO2\n 25\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n 127\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned.\n Neurologic: Clonidine,for sedation/analgesia. Decrease methadoneQOD.\n Cont fentanyl patch, Fent gtt now off.\n Cardiovascular: Stable. d/cd aline\n Pulmonary: Self extubated, stable.\n Gastrointestinal / Abdomen: On TF, will passed speech & swallow eval\n Nutrition: Tube feeding\n Renal: ARF, creatinine trending down. Follow UOP, goal kg negative\n today.\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemi.\n Lovenox and boots.\n Endocrine: RISS\n Infectious Disease: On flagyl & cipro, ID following. rash\n resolved.\n Lines / Tubes / Drains: PICC placed, D/C CVL later today.\n Wounds: Dry dressings\n Imaging: none\n Fluids: KVO\n Consults: Ortho, Medicine consult today for floor managment\n Billing Diagnosis: Respiratory insuff, post-op\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 11:37 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, Lovenox SQ\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor with tele.\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491152, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt initially sleeping quietly at start of shift but escalated in\n agitation and restlessness over the course of the shift. Pt started\n having increasing periods when her respiratory rate was into 50s, and\n tachycardia into 120s. During periods of agitation the pt was\n constantly shifting in bed, very restless. Pt nodding head\n pain. Pt given IV scheduled Ativan and PRN dosing Ativan with only\n brief, short term effects.\n Action:\n Pt required low dose propofol to ultimately decrease\n restlessness/agitation and lower HR/RR.\n Response:\n Pt RR back into 28-30s after propofol started at 15 mcg/kg/min. Pt calm\n and resting quietly in bed\n Plan:\n Wean propofol as if tolerated. AtivanATC. Methadone PO and clonidine\n patch initiated already. Await further plan from SICU team\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491153, "text": "Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491154, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491359, "text": "Anxiety\n Assessment:\n Pt received this am on CPAP .50% Fi02\n Pt still very restless at times with episodes of increased\n anxiety\n Pt appears very scared and frustrated. Attempting to mouth\n words\n Pt MAE\n Action:\n Haldol increased to IV Q2hrs PRN\n Pt OOB to chair via lift\n Family in today and at bedside\n Fent weaned to 100mcg\n Methadone cont at 20mg 3x daily\n IPS weaned to 10 this am\n Response:\n Pt with adequate response from PRN haldol\n Pt not requiring ativan Haldol more effective\n Pt tolerating IPS of 10 well pt did appear more tired and\n breathing appearing more labored after Pt hoyered back into bed. Resp\n is aware\n Pt mental status cont to improve pt nodding appropriately to\n questions and following commands\n Plan:\n Cont haldol ? possible transition to PO seraquel tomorrow\n per pharmacy rec\n Cont to wean IPS as tolerated\n Pt requiring much emotional support\n Possible extubation tomorrow\n Cont with current plan of care\n ------ Protected Section ------\n At approx 1855 pt wiggled herself done in bed and was pulling on base\n of ET tubing. Pt was restrained at this time and restraints where\n appropriatel still tied to the bed. Pt at this time was found also to\n be very scared and tachycardic and tachypnic. A C02 detector was\n placed on ETT and noted for good color changed but pt with very audible\n cuff leak and starting to desat. The decision was then made by\n Respiratory, nursing and ICU resident that pt was extubated and to pull\n out ET tube. Tube was removed and facetent with 100% oxygen placed on\n pt. Once extubated but stated she was scared and emotional support\n given. Once 02 applied and much emotional reassurance given Pt with\n sats >95%. HR and SBP decreased and pt appearing comfortable.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:27 ------\n" }, { "category": "Rehab Services", "chartdate": "2199-10-15 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 491480, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: sepsis / 038.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 19 yo F admitted\n with hypotension and weakness following 5 days of n/v/d, found to\n have prominent bandemia/thrombocytopenia and developed ARF with 3\n pressor requirement, sepsis presumed to be from GU source. CT showed L\n retroperitoneal abscess with air c/w SI osteomyelitis, went to the OR\n for I&D on , post-op course c/b L superior gluteal artery bleed\n requiring IR intervention, post-op remained intubated and sedated.\n Subsequent I&D on \n Past Medical / Surgical History: 11 days post partum on admission,\n vaginal delivery with episiotomy\n Medications: flagyl, ciprofloxacin, lorazepam, haloperidol, lorazepam,\n fentanyl, methadone\n Radiology: CXR - Bilateral pleural effusions are increased.\n Extensive bilateral parenchymal opacities\n Labs:\n 22.4\n 7.2\n 363\n 6.3\n [image002.jpg]\n Other labs:\n Activity Orders: ok for OOB per sicu team, NWB LLE per ortho PA, ROM as\n tolerated\n Social / Occupational History: lives with her parents, brother,\n boyfriend, and daughter\n Environment: unknown\n Prior Functional Status / Activity Level: I pta\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented to\n self only, follows most simple commands. Minimally verbal, moaning and\n calling for \"mom\"\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 104\n 133/86\n 12\n 99% on FT\n Sit\n /\n Activity\n 116\n 139/70\n 16\n 93% on FT\n Stand\n /\n Recovery\n 100\n 124/76\n 13\n 98% on FT\n Total distance walked: 0\n Minutes:\n Pulmonary Status: shallow breathing, no cough noted, diminished BS at\n bases. On 100% FiO2 via face tent.\n Integumentary / Vascular: R IJ multi-lumen, R axillary a-line, foley,\n rectal tube, tele. 3+ peripheral edema\n Sensory Integrity: intact to light touch\n Pain / Limiting Symptoms: c/o L hip/thigh pain when at edge of bed\n Posture: obese\n Range of Motion\n Muscle Performance\n B LE's WNL\n grossly 2 to 2+/5 B LE's\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: not assessed, transfer OOB\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: able to maintain static sitting at edge of bed once\n positioned, able to weight shift minimally. Standing balance not\n assessed.\n Education / Communication: Reviewed PT and encouraged OOB.\n COmmunicated with nsg re: status. Spoke with ortho PA re: WB\n restrictions.\n Intervention:\n Other:\n Diagnosis:\n Clinical impression / Prognosis:\n Goals\n Time frame: 1 week\n 1.\n Min A bed mobility, assess transfers\n 2.\n S static/dynamic sitting balance, assess standing\n 3.\n Tolerate OOB >/= 3 hours/day\n 4.\n Tolerate daily strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, ambulation, balance, strengthening, education,\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2199-10-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491561, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n fentanyl gtt infusing at 50mcg\n pt moaning continuosly\n denies pain when asked\n Action:\n fentanyl patch added\n methadone decreased to 15mg tid\n emotional support given\n Response:\n continues to deny pain\n continues to moan\n Plan:\n administer methadone as ordered\n ? decrease fentanyl gtt in am\n continue to assess frequently for pain\n Anxiety\n Assessment:\n moaning continuosly\n states she is frightened especially when turning in bed or when in\n lift\n Action:\n emotional support given\n family at bedside most of shift\n Response:\n pt has not required any haldol or ativan this shift\n Plan:\n emotional support as needed\n medicate with ativan or haldol only if needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt self-extubated last evening\n received on 100% open face tent\n continues to desat to low 90\ns when O2 off\n bs rhonchi throughout and diminished in bases\n Action:\n pulmonary toilet encouraged\n oob to chair for 3hrs\n dangeled at side of bed with PT\n changed to nasal cannula at 5 liters\n Response:\n O2 sats 95-97%\n tolerated being oob\n coughing but not raising\n Plan:\n pulmonary toilet\n monitor sats\n increase activity as tolerated\n" }, { "category": "Nursing", "chartdate": "2199-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 492100, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt is alert and oriented\n 5LNC sats 97-98%\n Lungs clear to diminished at the bases\n Pt with very flat affect\n Pt fluid status: cont to be negative\n Action:\n Pulmonary hygiene as tolerated\n + productive cough\n 02 requirement decreased overnoc to 4L\n Response:\n Tolerating pulmonary hygiene well\n IS at bedside\n Pt does require encouragement to move\n Sats remain 94-96% on 4L\n No additional diuretic requirements overnoc\n Plan:\n Re-eval resp status this am Tnf to floor under medicine\n service\n" }, { "category": "Nursing", "chartdate": "2199-10-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491215, "text": "19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n Pt found to have infected left hip and had-I and D left ileum and\n sacroiliac joint on admission to . s/p washout of left hip and D &\n C done\n Anxiety\n Assessment:\n Pt had longer periods when she was in a calm restful state but\n continues to wake very agitated, restless. Pt able to move all\n extremities, follows commands and will occasionally nod head to simple\n questions. When agitated, pt\ns RR up into 50-60s and HR tachy into\n 120s-130s\n Action:\n -re-oriented pt frequently when pt awake\n -ativan 6mg every 6 hours ATC\n -standing haldol dosing of 2mg \n -pt with clonidine patch\n -fentanyl drip continues and dosing titrated down\n -standing methadone dose\n Response:\n Pt able to have longer rest periods between periods of agitation\n Plan:\n Continue current med regime, wean fentanyl down as tolerated\n Addendum: Pt with prolonged period of restlessness and agitation this\n AM where HR up into 140s and RR up into 50s. Pox dropping 88-90% and\n only elevating to 92% when pt was less restless. ABG drawn and Poa2\n down to 66. fio2 increased to 50% and pox subsequently improved. Hct\n 23.5 this AM, will recheck at 0800 per Dr. .\n" }, { "category": "Nursing", "chartdate": "2199-10-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491413, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt self extubated prior to change of shift.\n Chest xray s/p.\n Open face tent mask 15L @ 100% Fio2.\n ABG within desired parameters.\n Lungs with Rhonchi to exp wheezing overnight.\n O2 SATs 99-100%.\n On RA DeSats to 80%.\n Action:\n Bilateral Chest PT.\n Encouraging C&DB.\n PRN Neb Tx\ns ordered and administered.\n Response:\n Congested, non-productive cough.\n ABG\ns remain WNL.\n Plan:\n Monitor respiratory status closely.\n Chest PT Q2 hours when awake.\n Cont open face tent for moisture and adequate oxygenation.\n Pt OOB to chair.\n ABGs PRN.\n Pain control (acute pain, chronic pain)/ Anxiety\n Assessment:\n Fentanyl gtt continued @ 50mcg/hr with intermittent boluses for\n turning/procedures.\n Pt with periods of agitation and moaning.\n At times with tachypena.\n Action:\n PRN Haldol as ordered.\n Scheduled Ativan.\n Emotional support and quiet/calm environment provided.\n Nsg activities grouped to promote longer periods of uninterrupted rest.\n Response:\n With medication and quiet environment, pt resting and sleeping for \n hour periods.\n Plan:\n Continue current pain and anti-anxiety regime.\n Start PT/OT.\n Pt OOB to chair.\n" }, { "category": "Physician ", "chartdate": "2199-10-15 00:00:00.000", "description": "Intensivist Note", "row_id": 491414, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a dopamine gtt and\n transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per records, patient\n has receieved a total of 9-10L of fluid before transfer. Now off\n pressors with improving renal and pulmonary function.\n Chief complaint:\n Buttock pain\n PMHx:\n G1P1\n Current medications:\n 1. IV access: Temporary central access (ICU) Order date: @ 1557\n 18. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n 2. IV access: Temporary central access (ICU) Location: Right Internal\n Jugular, Date inserted: Order date: @ 1425\n 19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing Order date:\n @ 0120\n 3. Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN fever Start: \n Order date: @ 1157\n 20. Lorazepam 1-2 mg IV Q4H:PRN agitation Order date: @ 1157\n 4. Albuterol Inhaler PUFF IH Q2H:PRN wheezing Order date: @\n 2227\n 21. Lorazepam 6 mg IV Q6H Order date: @ 0859\n 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Order date:\n @ 0120\n 22. Magnesium Sulfate IV Sliding Scale Order date: @ 1023\n 6. Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date:\n @ 0429\n 23. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0815\n 7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @\n 1557\n 24. Methadone 20 mg PO TID Order date: @ 0657\n 8. Calcium Gluconate IV Sliding Scale Order date: @ 1557\n 25. Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n 26. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n 10. Ciprofloxacin 400 mg IV Q12H Order date: @ 1039\n 27. Potassium Chloride IV Sliding Scale Order date: @ 0657\n 11. Clindamycin 600 mg IV Q8H Order date: @ 0835\n 28. Propofol 0-50 mcg/kg/min IV DRIP TITRATE TO agitation Order date:\n @ 0136\n 12. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSAT Order date: @\n 0657\n 29. Senna 1 TAB PO/NG :PRN Constipation Start: Order date:\n @ 1156\n 13. DiphenhydrAMINE 50 mg IV Q8H:PRN rash Order date: @ 0702\n 30. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 14. Enoxaparin Sodium 40 mg SC DAILY Order date: @ 0915\n 31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 15. Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n 32. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1557\n 16. Fentanyl Citrate 300 mcg/hr IV DRIP INFUSION Order date: @\n 1157\n 33. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1425\n 17. Haloperidol 1-2 mg IV Q2H:PRN agitation Order date: @ 0641\n 24 Hour Events:\n Self-extubated overnight, O2 sats 99% on face tent. OOB to chair,\n speaking occasionally, appropriate.\n UNPLANNED EXTUBATION (PATIENT-INITIATED) - At 06:56 PM\n Post operative day:\n POD#12 - I & D Lt ileum and Sacroiliac joint debridement\n POD#11 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 10:51 PM\n Metronidazole - 02:00 AM\n Clindamycin - 04:00 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 12:30 AM\n Fentanyl - 04:30 AM\n Haloperidol (Haldol) - 05:00 AM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.1\nC (97\n HR: 106 (88 - 130) bpm\n BP: 140/89(112) {114/68(87) - 166/99(125)} mmHg\n RR: 35 (18 - 35) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 17 (6 - 28) mmHg\n Total In:\n 2,673 mL\n 618 mL\n PO:\n Tube feeding:\n 1,679 mL\n 403 mL\n IV Fluid:\n 994 mL\n 185 mL\n Blood products:\n Total out:\n 4,280 mL\n 1,010 mL\n Urine:\n 4,280 mL\n 1,010 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,607 mL\n -392 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 380 (340 - 420) mL\n PS : 10 cmH2O\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 16 cmH2O\n SPO2: 99%\n ABG: 7.41/43/184/29/2\n Ve: 9.3 L/min\n PaO2 / FiO2: 368\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 363 K/uL\n 7.2 g/dL\n 104 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 41 mg/dL\n 109 mEq/L\n 143 mEq/L\n 22.4 %\n 6.3 K/uL\n [image002.jpg]\n 02:47 AM\n 02:48 AM\n 03:11 AM\n 02:20 AM\n 05:06 AM\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n WBC\n 6.8\n 7.1\n 6.3\n Hct\n 24.5\n 23.5\n 22.4\n 22.4\n Plt\n 349\n 348\n 363\n Creatinine\n 1.8\n 1.6\n 1.3\n TCO2\n 28\n 27\n 25\n 28\n 28\n Glucose\n 107\n 113\n 104\n Other labs: PT / PTT / INR:15.2/43.6/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:105/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.0 mg/dL, Mg:1.8 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Scheduled ativan q4h and PRN, fentanyl drip weaning,\n clonidine, for sedation/analgesia. Haldol for agitation. Alert and\n appropriate though intermittently somnolent.\n Cardiovascular: Off all pressors.\n Pulmonary: Self-extubated overnight, ABG stable, O2 sats >98% on face\n tent. AM CXR.\n Gastrointestinal / Abdomen: NGT in place. Tube feeds; high output loose\n stool -- flexiseal, c-diff (neg x 1). Consider repeating CDiff if she\n re-spikes.\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition\n Renal: ARF, creatinine trending down\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS.\n Infectious Disease: On flagyl, cipro, clinda. ID following. rash\n resolving. Consider d/c clinda today.\n Lines / Tubes / Drains: , , R femoral , NGT\n Wounds: L hip clean / dry / intact\n Imaging: AM CXR\n Fluids: HLIV\n Consults: ortho, ID\n Billing Diagnosis: septic shock acute osteomyelitis of left hip\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 02:04 AM 70 mL/hour\n Glycemic Control: RISS\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2199-10-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 491618, "text": "Anxiety\n Assessment:\n Pt alert and awake most of night\n Noted to have several short naps\n Pt noted to be very anxious when awoken\n Asking for her mother\n Action:\n Pt reoriented to place and time\n Emotional support for pt\n need for haldol or ativan\n Response:\n Pt easily redirected\n Plan:\n Cont with emotional support for pt and family\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues on fentanyl gtt at 50mcg/hr\n Moaning vs auto peep all night\n Action:\n Repositioned and back rub for comfort\n Response:\n Denies pain over night\n Plan:\n Attempt to wean pain meds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds- rhonchi through out\n O2 at 5l via N/C\n Action:\n Pulmonary toileting\n Response:\n O2 sats >95%\n Plan:\n Cont with pulmonary toilet\n" }, { "category": "Nursing", "chartdate": "2199-10-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 492315, "text": "19 y/o femtale, G1P1 was Post partum 11 days NSVD with episotomy when\n she presented to urgent care center in NH with buttock/back pain found\n to be hypotensive with low plt count. Seen at with\n WBC 10.8 with 29 bands and plt of 21. Cr of 3.8. Given fluids and\n started on a Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n resp. failure ARDS, intubated, inc WBC to 48.1, plt 59. FDP products\n increased.\n Now off pressors with improving renal and pulmonary function.\n I&D left hip\n Washout of Left hip and D&C done by OB\n Chief complaint:\n Septic shock resolved\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n S/p sepis from left hip infection, ARDS and renal failure, now\n resolving. Alert and oriented x\ns 3, cooperative with care. Denies\n pain. Pt was on long term fentynal while intubated, narcotics now\n being weaned with methadone, fentynal patch and clonidine patch. LS\n clear and diminished, able to cough and raise sputum. 02 sat 94-97% on\n 4 liters n.c. HR sinus 90\ns-100\ns, no ecotpy. Sbp 120\ns -150\n A-febrile. Abd. soft, nontender, Pt incontinent of stool at times.\n Pt cleared by speech and swallow for thin liquids and solids, currently\n tolerating small amounts solids and water. NGT to cycled feeding\n overnoc 6pm to 6am (impact with fiber at 70cc\ns/hr). Urine output is\n adequate, elevated creatinine is resolving. Pt can get oob with\n touchdown weight-bearing on the left and full weight-bearing on the\n right. Seen by p.t. on . Left hip incision is c/d/I, staples in\n place, small amounts serosanguinous/brownish drainage noted from\n incision.\n Action:\n Right single lumen PICC line placed . Coughing/deep breathing and\n incentive spirometry encouraged.\n Response:\n No pain. Tolerating po\ns thus far. Resp. status stable.\n Plan:\n Enourage po intake, D/c ngt if po intake is adequate, continue p.t. and\n oob to chair, continue to encourage coughing and deep breathing and\n incentive spirometry.\n Demographics\n Attending MD:\n K.\n Admit diagnosis:\n HYPOTENSION\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 95.5 kg\n Daily weight:\n 109.4 kg\n Allergies/Reactions:\n Meropenem\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: s/p regular vag delivery 11 days ago..\n Surgery / Procedure and date: 11 day post partum. Regular,\n uncomplicated vaginal delivery without epidural. (delievery took 3\n hours). Pt has had no clots, no abd pain and no significant discharge\n since delivery. tonsillectomy\n OR for I&D of ileam and sacralileac joint debridement\n Washout of sacralileac joint and D&C\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:85\n Temperature:\n 97.6\n Arterial BP:\n S:127\n D:75\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,675 mL\n 24h total out:\n 3,740 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:46 AM\n Potassium:\n 4.6 mEq/L\n 03:46 AM\n Chloride:\n 102 mEq/L\n 03:46 AM\n CO2:\n 28 mEq/L\n 03:46 AM\n BUN:\n 36 mg/dL\n 03:46 AM\n Creatinine:\n 1.1 mg/dL\n 03:46 AM\n Glucose:\n 108 mg/dL\n 03:46 AM\n Hematocrit:\n 24.8 %\n 03:46 AM\n Finger Stick Glucose:\n 116\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: CC7\n Date & time of Transfer: \n" }, { "category": "Rehab Services", "chartdate": "2199-10-16 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 491711, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 19 year old female G1P1 11 days\npost partum who initially presented to OSH on with\nhypotension. Patient reported that she had an uncomplicated\npregnancy without hypertension or DM, delivered vaginally in 3.5\nhours with episiotomy, denies spinal anesthesia or any other\nspinal block. Patient reported 5 days of increased watery,\nnon-bloody diarrhea, dizziness with standing, and extreme\nfatigue.\nAt OSH, BPs dropped and patient was med-flighted to .\nPatient was tachypneic on arrival and developed severe crampy\npelvic pain and was intubated. Patient was found with refractory\nshock and multiorgan dysfunction, with likely unifying dx as\nabdominal sepsis from GU or GI source. On and \npatient was taken to the OR and underwent irrigation and\ndebridement, aggressive bone curettage to left sacroiliac joint\nand ilium and dilation and curettage, removal of redundant\nsuture material from the perineum (). Patient\nself-extubated on . We were consulted to evaluate\npatient's oral and pharyngeal swallowing function and r/o\naspiration while eating and drinking.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the chair on the SICU.\nCognition, language, speech, voice: Patient was awake and alert,\noriented, able to follow commands. Speech was fluent and\ndeliberate and unintelligible for long utterances. Voice was low\nin volume.\nTeeth: intact dentition\nSecretions: mild secretions removed via oral care\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual strength,\nROM, and buccal tone. Palatal elevation was symmetrical. Gag\ndeferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids via tsp/straw, bites\nof puree, ground solids, and a bite of cracker. Oral\nphase was slow, however grossly wfl with normal oral residue\nremaining. Laryngeal elevation felt mildly reduced to palpation.\nNo overt change in vocal quality. No throat clearing, coughing,\nor choking noted. O2 sats remained stable at 100%. Patient denied\nthe sensation of food or liquid stuck in her throat or going down\nthe wrong way.\nSUMMARY / IMPRESSION:\nMs. presents with generalized weakness and appeared to\ntolerate today's PO trials without overt s/sx of aspiration noted\nat the bedside. Recommend initiating a PO diet of thin liquids\nand regular solids, encouraging soft solids initially. Please\nprovide supervision to assist with feeding (family or staff).\nSilent aspiration cannot be r/o at the bedside. If there are\nconcerns for aspiration on this diet, we will be happy to perform\na video swallow.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of level 6 out of 7.\nRECOMMENDATIONS:\n1. PO diet of thin liquids and regular solids, encourage soft\nsolids initially.\n2. Pills may be taken whole with water or puree.\n3. Supervision to assist with feeding.\n4. Q6 oral care.\n5. If there are concerns for aspiration on this diet, we will be\nhappy to perform a video swallow.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1110-1120\nTotal time: 45 minutes\n" }, { "category": "Physician ", "chartdate": "2199-10-17 00:00:00.000", "description": "Intensivist Note", "row_id": 491873, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n Septic shock resolved\n PMHx:\n Current medications:\n Acetaminophen (Liquid) 4. Albuterol Inhaler 5. Albuterol 0.083% Neb\n Soln 6. Artificial Tears\n 7. Bisacodyl 8. Calcium Gluconate 9. Ciprofloxacin 10. Clonidine Patch\n 0.2 mg/24 hr 11. DiphenhydrAMINE\n 12. Enoxaparin Sodium 13. Famotidine 14. Fentanyl Patch 15. Haloperidol\n 16. 17. Insulin 18. Ipratropium Bromide Neb\n 19. Lorazepam 20. Lorazepam 21. Magnesium Sulfate 22. MetRONIDAZOLE\n (FLagyl) 23. Methadone 24. Ondansetron\n 25. Potassium Phosphate 26. Potassium Chloride 27. Senna\n 24 Hour Events:\n ARTERIAL LINE - STOP 01:28 PM\n ultrasound guided placement of left axillary aline\n Post operative day:\n POD#14 - I & D Lt ileum and Sacroiliac joint debridement\n POD#13 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Clindamycin - 04:00 AM\n Ciprofloxacin - 10:45 PM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:54 AM\n Enoxaparin (Lovenox) - 08:00 PM\n Other medications:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.2\nC (97.1\n HR: 87 (83 - 114) bpm\n BP: 149/84(99) {129/77(89) - 149/84(99)} mmHg\n RR: 24 (18 - 35) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 109.4 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 11 (6 - 17) mmHg\n Total In:\n 2,514 mL\n 626 mL\n PO:\n Tube feeding:\n 1,684 mL\n 463 mL\n IV Fluid:\n 831 mL\n 133 mL\n Blood products:\n Total out:\n 4,635 mL\n 1,165 mL\n Urine:\n 4,635 mL\n 965 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -2,121 mL\n -539 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 356 K/uL\n 7.9 g/dL\n 127 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.4 mEq/L\n 38 mg/dL\n 107 mEq/L\n 142 mEq/L\n 23.7 %\n 7.3 K/uL\n [image002.jpg]\n 06:36 AM\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n 02:46 AM\n WBC\n 7.1\n 6.3\n 6.9\n 7.3\n Hct\n 22.4\n 22.4\n 23.0\n 23.7\n Plt\n 348\n 363\n 411\n 356\n Creatinine\n 1.3\n 1.2\n 1.3\n 1.2\n TCO2\n 25\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n 127\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n ANXIETY, ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY\n DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA,\n PYREXIA, NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION,\n INEFFECTIVE COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage. Now experiencing agitation\n when turned.\n Neurologic: Scheduled ativan PRN, clonidine,for sedation/analgesia. On\n clonidine. Decrease methadone. Cont fentanyl patch, stop fentanyl gtt.\n Cardiovascular: Stable. d/cd aline, PICC PND\n Pulmonary: Self extubated, stable.\n Gastrointestinal / Abdomen: On TF, will passed speech & swallow eval\n Nutrition: Tube feeding\n Renal: ARF, creatinine trending down. Follow UOP, goal kg negative\n today.\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS\n Infectious Disease: On flagyl & cipro, ID following. rash\n resolved.\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Ortho\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 11:37 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2199-10-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490284, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n - Received patient on FiO2 .50; Vt 350 X f 28 X PEEP 14 on maximum\n cisatracurium, TOF with 20 mA. Lung sounds rhonchorous all around\n with small amount of thick white secretions. Tolerating rotating bed.\n Action:\n - Shut cisatracurium off. Repeat ABG showed improved oxygenation to PO2\n 147 from 109 on AM labs. PEEP weaned to 12, midaz gtt weaned to 4.\n Response:\n - Repeat ABG 153-39-7.36, FiO2 decreased to 40. Tol midaz wean so midaz\n gtt off\n getting PRN boluses of midaz 2-4 mg Q 2. Lung sounds clear\n compared to this morning, remains rhonchorous in RUL.\n - Pt opening eyes to voice and command, flexing all extremities to\n pain, moving head spontaneously.\n Plan:\n - Overnight, no further vent changes. Wean fent if tolerated. Cont to\n wean tomorrow as tolerated.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n - Remains hemodynamically stable in sinus/sinus tach 94-118, no ectopy\n noted. Mean BPs 60-90 without support. Urine output >50/hour. T max\n this shift 99.9. Cont to have blanchable red rash throughout body.\n Action:\n - Cooling blanket removed. Cipro discontinued as probable cause of body\n rash. Antibiotics admin as ordered. Cdiff number 2 sent. IV flagyl\n added.\n Response:\n - T current 99.6. Cr cont to trend down, currently 2.6\n Plan:\n - Cont antibiotic admin; f/u cultures.\n - Episiotomy\n 1 suture with slight tear. OB assessed. Plan is it will\n heal on its own or it can be repaired once her edema decreases. Blood\n from area\n keep clean, use hygiene pads PRN\n" }, { "category": "Physician ", "chartdate": "2199-10-18 00:00:00.000", "description": "Intensivist Note", "row_id": 492185, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n Septic shock resolved\n PMHx:\n G1P1\n Current medications:\n Acetaminophen (Liquid) 5. Albuterol Inhaler 6. Albuterol 0.083% Neb\n Soln 7. Artificial Tears\n 8. Bisacodyl 9. Calcium Gluconate 10. Ciprofloxacin 11. Clonidine Patch\n 0.2 mg/24 hr 12. DiphenhydrAMINE\n 13. Enoxaparin Sodium 14. Famotidine 15. Fentanyl Patch 16. Furosemide\n 17. Heparin Flush (10 units/ml)\n 18. 19. Insulin 20. Ipratropium Bromide Neb 21. Magnesium Sulfate 22.\n MetRONIDAZOLE (FLagyl) 23. Methadone\n 24. Ondansetron 25. Potassium Phosphate 26. Potassium Chloride 27.\n Senna\n 24 Hour Events:\n PICC LINE - START 08:41 AM\n MULTI LUMEN - STOP 01:05 PM\n Post operative day:\n POD#15 - I & D Lt ileum and Sacroiliac joint debridement\n POD#14 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 03:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:22 AM\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.6\nC (97.9\n HR: 105 (87 - 112) bpm\n BP: 137/79(94) {121/56(72) - 160/104(113)} mmHg\n RR: 18 (18 - 39) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109.4 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 0 (0 - 7) mmHg\n Total In:\n 3,229 mL\n 764 mL\n PO:\n 960 mL\n Tube feeding:\n 1,329 mL\n 573 mL\n IV Fluid:\n 820 mL\n 191 mL\n Blood products:\n Total out:\n 6,530 mL\n 1,370 mL\n Urine:\n 6,265 mL\n 1,370 mL\n NG:\n 265 mL\n Stool:\n Drains:\n Balance:\n -3,301 mL\n -605 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished:\n bases)\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 345 K/uL\n 8.3 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 102 mEq/L\n 139 mEq/L\n 24.8 %\n 9.3 K/uL\n [image002.jpg]\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n 02:46 AM\n 03:46 AM\n WBC\n 7.1\n 6.3\n 6.9\n 7.3\n 9.3\n Hct\n 22.4\n 22.4\n 23.0\n 23.7\n 24.8\n Plt\n 348\n 363\n 411\n 356\n 345\n Creatinine\n 1.3\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n 127\n 108\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.6 mg/dL, Mg:1.6 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n ANXIETY, ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY,\n ), INEFFECTIVE COPING\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course.\n Neurologic: Ativan PRN, clonidine,for sedation/analgesia. On clonidine.\n Weaning methadone. Cont fentanyl patch s/p fentanyl gtt.\n Cardiovascular: Stable. d/cd aline, PICC\n Pulmonary: Self extubated, stable.\n Gastrointestinal / Abdomen: On TF, cycling overnight. Passed speech &\n swallow eval. Calorie count to remove NG tube.\n Nutrition:\n Renal: resolving ARF, creatinine trending down. Follow UOP\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS\n Infectious Disease: On flagyl & cipro, ID following. rash\n resolved.\n Lines / Tubes / Drains: PICC for IV abx. d/c axillary aline/subclavian\n Wounds: Left hip incision. No purulent d/c. Continue wound care for\n episiotomy\n Imaging:\n Fluids:\n Consults: Ortho\n Billing Diagnosis: Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:18 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:41 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Fondaparinux Sodium)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2199-10-18 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 492187, "text": "Subjective:\n I feel good\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for therapeutic exercise , patient education\n Updated medical status: Pelvis XR - Status post antibiotic bead\n placement; CXR - Small right pleural effusion\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 100\n 130/73\n 22\n 97% on 5L NC\n Activity\n Sit\n 120\n 143/80\n 30\n 88% on RA\n Recovery\n Sit\n 98\n 136/81\n 26\n 98% on 5L NC\n Total distance walked: 0\n Minutes:\n Gait: able to stand and pivot RLE minimally, mod verbal and tactile\n cues to maintain TDWB LLE. Mildy impulsive.\n Balance: S static sitting, Min A static standing, mod A dynamic\n standing balance. Poor eccentric control with stand-to-sit. No gross\n LOB.\n Education / Communication: Reviewed PT , reviewed WB restrictions\n and encouraged AROM LLE during the day. Communicated with nsg re:\n status.\n Other: Denies pain\n AAROM L Hip/knee, ROM WNL\n interacting appropriately, flat affect\n Assessment: 19 yo F with sepsis making good progress in PT with\n mobility and strength, continues to be limited by general weakness a/w\n hospitalization and is below her baseline status. Would continue to\n recommend rehab at this time, however she may be able to progress to\n home if she remains inpatient for a longer period of time. PT to\n continue to progress as able.\n Anticipated Discharge: Rehab\n Plan: continue with \n" }, { "category": "Physician ", "chartdate": "2199-10-18 00:00:00.000", "description": "Intensivist Note", "row_id": 492188, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per\n records, patient has receieved a total of 9-10L of fluid before\n transfer. Now off pressors with improving renal and pulmonary function.\n Chief complaint:\n Septic shock resolved\n PMHx:\n G1P1\n Current medications:\n Acetaminophen (Liquid) 5. Albuterol Inhaler 6. Albuterol 0.083% Neb\n Soln 7. Artificial Tears\n 8. Bisacodyl 9. Calcium Gluconate 10. Ciprofloxacin 11. Clonidine Patch\n 0.2 mg/24 hr 12. DiphenhydrAMINE\n 13. Enoxaparin Sodium 14. Famotidine 15. Fentanyl Patch 16. Furosemide\n 17. Heparin Flush (10 units/ml)\n 18. 19. Insulin 20. Ipratropium Bromide Neb 21. Magnesium Sulfate 22.\n MetRONIDAZOLE (FLagyl) 23. Methadone\n 24. Ondansetron 25. Potassium Phosphate 26. Potassium Chloride 27.\n Senna\n 24 Hour Events:\n PICC LINE - START 08:41 AM\n MULTI LUMEN - STOP 01:05 PM\n Post operative day:\n POD#15 - I & D Lt ileum and Sacroiliac joint debridement\n POD#14 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 03:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:22 AM\n Other medications:\n Flowsheet Data as of 08:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.6\nC (97.9\n HR: 105 (87 - 112) bpm\n BP: 137/79(94) {121/56(72) - 160/104(113)} mmHg\n RR: 18 (18 - 39) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109.4 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 0 (0 - 7) mmHg\n Total In:\n 3,229 mL\n 764 mL\n PO:\n 960 mL\n Tube feeding:\n 1,329 mL\n 573 mL\n IV Fluid:\n 820 mL\n 191 mL\n Blood products:\n Total out:\n 6,530 mL\n 1,370 mL\n Urine:\n 6,265 mL\n 1,370 mL\n NG:\n 265 mL\n Stool:\n Drains:\n Balance:\n -3,301 mL\n -605 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished:\n bases)\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 345 K/uL\n 8.3 g/dL\n 108 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.6 mEq/L\n 36 mg/dL\n 102 mEq/L\n 139 mEq/L\n 24.8 %\n 9.3 K/uL\n [image002.jpg]\n 10:19 AM\n 08:08 PM\n 04:04 AM\n 04:24 AM\n 03:37 PM\n 04:59 PM\n 03:30 AM\n 03:40 AM\n 02:46 AM\n 03:46 AM\n WBC\n 7.1\n 6.3\n 6.9\n 7.3\n 9.3\n Hct\n 22.4\n 22.4\n 23.0\n 23.7\n 24.8\n Plt\n 348\n 363\n 411\n 356\n 345\n Creatinine\n 1.3\n 1.2\n 1.3\n 1.2\n 1.1\n TCO2\n 28\n 28\n 29\n 32\n Glucose\n 104\n 115\n 125\n 105\n 127\n 108\n Other labs: PT / PTT / INR:14.7/43.7/1.3, CK / CK-MB / Troponin\n T:374//, ALT / AST:, Alk-Phos / T bili:103/1.1, Amylase /\n Lipase:/10, Differential-Neuts:67.5 %, Band:2.0 %, Lymph:23.8 %,\n Mono:4.4 %, Eos:3.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.3 mmol/L,\n Albumin:2.9 g/dL, LDH:326 IU/L, Ca:8.6 mg/dL, Mg:1.6 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n ANXIETY, ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY,\n ), INEFFECTIVE COPING\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course.\n Neurologic: Wean clonidine to 0.1mg today; Weaning methadone. D/C\n fentanyl patch and start Roxicet PRN.\n Cardiovascular: Stable. d/cd aline\n Pulmonary: Remains extubated with improving respiratory status\n Gastrointestinal / Abdomen: On TF, cycling overnight. Passed speech &\n swallow eval. Calorie count to remove NG tube. Cont bowel regimen.\n Nutrition: Cycled TF with regular diet (cont calorie counts and\n consider d/c TF if adequate)\n Renal: resolving ARF, creatinine trending down. Follow UOP\n lasix\n given x1 yesterday with improved respiratory status.\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS\n Infectious Disease: On flagyl & cipro, ID following. rash\n resolved.\n Lines / Tubes / Drains: PICC for IV abx. d/c axillary aline/subclavian\n Wounds: Left hip incision. No purulent d/c. Continue wound care for\n episiotomy\n Imaging: None\n Fluids: KVO\n Consults: Ortho, Medicine\n Billing Diagnosis: Respiratory failure; Post-op complication; Post-op\n hypotension.\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 04:18 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 08:41 AM\n Prophylaxis:\n DVT: Boots (Systemic anticoagulation: Fondaparinux Sodium)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 10\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2199-10-11 00:00:00.000", "description": "Intensivist Note", "row_id": 490407, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent\n care center in NH with buttock/back pain found to be hypotensive\n with low plt count. Seen at with WBC 10.8 with\n 29 bands and plt of 21. Cr of 3.8. Given fluids and started on a\n Dopamine gtt and transferred to .\n PMHx:\n PMHx: G1P1\n PShx: Tonsillectomy, episotomy\n Current medications:\n Acetaminophen (Liquid)\n Albuterol Inhaler\n Bisacodyl\n Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse\n DiphenhydrAMINE\n Famotidine\n Fentanyl Citrate\n Heparin\n Insulin\n Magnesium Sulfate Replacement\n Meropenem\n MetRONIDAZOLE (FLagyl)\n Midazolam\n Ondansetron\n Potassium Chloride Replacement\n Potassium Phosphate\n Senna\n Vancomycin\n 24 Hour Events:\n cont to wean PEEP\n d/c cisatricurium\n d/c cipro\n started flagyl\n Post operative day:\n POD#8 - I & D Lt ileum and Sacroiliac joint debridement\n POD#7 - S/P washout of left hip and D&C\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 02:30 PM\n Vancomycin - 08:20 AM\n Metronidazole - 01:06 AM\n Meropenem - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 36.9\nC (98.5\n HR: 117 (96 - 122) bpm\n BP: 113/69(87) {91/47(64) - 135/85(106)} mmHg\n RR: 28 (14 - 30) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 16 (11 - 22) mmHg\n Total In:\n 3,296 mL\n 695 mL\n PO:\n Tube feeding:\n 1,680 mL\n 395 mL\n IV Fluid:\n 1,556 mL\n 301 mL\n Blood products:\n Total out:\n 2,965 mL\n 415 mL\n Urine:\n 2,365 mL\n 415 mL\n NG:\n Stool:\n 600 mL\n Drains:\n Balance:\n 331 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 25 cmH2O\n Plateau: 30 cmH2O\n Compliance: 17.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/45/124/24/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General Appearance: Anxious, Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous : b/l)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: minimal drainage R hip incision\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 118 K/uL\n 8.7 g/dL\n 93 mg/dL\n 2.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 107 mEq/L\n 140 mEq/L\n 26.6 %\n 9.5 K/uL\n [image002.jpg]\n 02:05 PM\n 03:57 PM\n 01:51 AM\n 01:57 AM\n 09:34 AM\n 11:46 AM\n 02:26 PM\n 06:25 PM\n 02:37 AM\n 02:45 AM\n WBC\n 7.2\n 8.4\n 9.5\n Hct\n 26.9\n 25.1\n 24.5\n 26.6\n Plt\n 81\n 92\n 118\n Creatinine\n 3.0\n 2.9\n 2.6\n 2.5\n TCO2\n 25\n 25\n 24\n 23\n 25\n 26\n Glucose\n 108\n 99\n 100\n 104\n 96\n 93\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:84.9 %, Band:2.0 %, Lymph:11.3 %,\n Mono:1.6 %, Eos:1.9 %, Fibrinogen:578 mg/dL, Lactic Acid:1.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:8.1 mg/dL, Mg:1.8 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 19F post partum complicated by w/septic shock,\n ARDS, multiorgan failure with improving clinical course. Pt continues\n to spike temps despite broad abx coverage.\n .\n Neuro: Midaz prn/fentanyl for sedation/analgesia.\n CV: Off all pressors; monitoring.\n Resp: PEEP down to 8, will wean slowly, ARDS protocol, daily CXR.\n FEN/GI: NGT in place. TF Impact w/ fiber at 70mL/hr per nutrition; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1)\n Renal: ARF, creatinine trending down.\n Endo: RISS.\n Heme: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with goal\n transfuse PRBCs prn. SQH and boots.\n ID: Vanc//flagyl for fusobacteria. ID following. Monitor vanco\n level adjust as needed Pharm recs 1250 q 48hrs. D/c'd cipro \n rash. Start flagyl empirically for cdiff.\n Ortho: S/p Washout ; no plans for return to OR at this time.\n Wound: Left hip incision. Now with area of erythema. No purulent d/c.\n Area marked for observation.\n Prophylaxis: SQH, boots, H2B\n Code status: FULL\n Consults: ortho, IR, ID; gyn signed off \n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 01:43 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2199-10-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 490573, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 59 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean PS as tol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2199-10-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 490564, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Received on CMV 350 X 28 X PEEP 8. Sedated on fent gtt and midaz PRN.\n LS rhonchorous, diminished in bases. Sxn sm amt of white/yellow\n secretions.\n Action:\n Switched patient to PSV 12/8. Turned off fent gtt and started\n administering PRN dilaudid and continued to admin. PRN midaz. Admin\n lasix X 1 with goal 1 L negative today.\n Response:\n ABG on PSV 169-39-7.37. Agitated off fent gtt\n awake, looks anxious,\n scared, tachycardic and tachypneic to 50s. Correct conversion of 400\n mcg fent per hour is 6 mg of dilaudid, so PRN dose increased.\n Administering 2-4 mg/hour with good effect.\n Plan:\n PSV, cont PRN dilaudid and midaz.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt spiked to 102.5 oral at 0730, with accompanying tachycardia to 145.\n Pattern noticed of patient spiking and rash worsening after meropenem\n doses\n at least last 3 doses.\n Action:\n Pan cultured. Acetaminophen; cooling blanket; ice packs to underarms\n and near groin. Meropenem D/Ced. Clinda and Cipro added.\n Response:\n T decreased to 99.4 after above interventions, T current 100.6. Prelim\n cultures: sputum gram stain neg, UA neg.\n Plan:\n Cont to monitor, follow up cultures.\n" }, { "category": "Physician ", "chartdate": "2199-10-12 00:00:00.000", "description": "Intensivist Note", "row_id": 490763, "text": "SICU\n HPI:\n 19F G1P1 PP 11 days NSVD with episotomy presented to urgent care center\n in NH with buttock/back pain found to be hypotensive with low plt\n count. Seen at with WBC 10.8 with 29 bands and plt of\n 21. Cr of 3.8. Given fluids and started on a Dopamine gtt and\n transferred to .\n At eval by OB gyn and Vaginal US did not show retained products.\n Refused bimanual exam. Pt placed on three pressors, inc renal failure,\n inc WBC to 48.1, plt 59. FDP products increased. Per records, patient\n has receieved a total of 9-10L of fluid before transfer, started\n empirically on Vanco and Zosyn.\n Chief complaint:\n buttock pain\n PMHx:\n G1P1, otherwise negative\n Current medications:\n Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1455\n HYDROmorphone (Dilaudid) 1-5 mg IV Q1H:PRN pain Order date: @\n 1247\n Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN fever Start: Order\n date: @ 1157\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0705\n Albuterol Inhaler PUFF IH Q2H:PRN wheezing Order date: @\n 2227\n Lorazepam 1-2 mg IV Q1H:PRN agitation Order date: @ 0054\n Artificial Tears 1-2 DROP BOTH EYES PRN lubrication Order date: \n @ 0429\n Magnesium Sulfate IV Sliding Scale Order date: @ 1023\n Bisacodyl 10 mg PO/PR DAILY:PRN Constipation Order date: @ 1557\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0815\n Calcium Gluconate IV Sliding Scale Order date: @ 1557\n Ondansetron 4 mg IV Q8H:PRN nausea Order date: @ 1557\n Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL oral care\n Order date: @ 1557\n Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 1557\n Ciprofloxacin 400 mg IV ONCE Duration: 1 Doses Order date: @ 0835\n Senna 1 TAB PO/NG :PRN Constipation Start: Order date:\n @ 1156\n Ciprofloxacin 400 mg IV Q12H Order date: @ 1039\n Enoxaparin Sodium 40 mg SC DAILY Order date: @ 0915\n Clindamycin 600 mg IV Q8H Order date: @ 0835\n Famotidine 20 mg PO/NG Q24H Order date: @ 0705\n DiphenhydrAMINE 25 mg IV Q8H:PRN rash Order date: @ 2201\n 24 Hour Events:\n C diff neg x 1; diffuse rash, likely meropenem; d/c'd and\n cipro/clinda started; vanc d/c'd. D/c'd fentanyl and started PRN\n dilaudid; pt anxious overnight, requiring high doses of dilaudid and\n ativan.\n FEVER - 102.5\nF - 08:00 AM\n Post operative day:\n POD#9 - I & D Lt ileum and Sacroiliac joint debridement\n POD#8 - S/P washout of left hip and D&C\n Allergies:\n Meropenem\n Rash; Fever/\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Meropenem - 04:00 AM\n Clindamycin - 08:00 PM\n Ciprofloxacin - 09:43 PM\n Metronidazole - 02:14 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:02 AM\n Heparin Sodium (Prophylaxis) - 08:02 AM\n Furosemide (Lasix) - 04:00 PM\n Midazolam (Versed) - 11:10 PM\n Lorazepam (Ativan) - 04:10 AM\n Hydromorphone (Dilaudid) - 05:10 AM\n Other medications:\n Flowsheet Data as of 05:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 37.5\nC (99.5\n HR: 128 (112 - 140) bpm\n BP: 149/96(117) {94/55(70) - 149/96(117)} mmHg\n RR: 13 (0 - 35) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 104.3 kg (admission): 95.5 kg\n Height: 66 Inch\n CVP: 13 (7 - 14) mmHg\n Total In:\n 3,006 mL\n 502 mL\n PO:\n Tube feeding:\n 1,680 mL\n 375 mL\n IV Fluid:\n 1,177 mL\n 127 mL\n Blood products:\n Total out:\n 3,545 mL\n 360 mL\n Urine:\n 3,445 mL\n 360 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n -539 mL\n 142 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 355 (355 - 704) mL\n PS : 12 cmH2O\n RR (Spontaneous): 32\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 143\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: 7.42/40/112/24/0\n Ve: 11.5 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General Appearance: Anxious, intermittently agitated\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: Rash: chest / arms / legs, (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 173 K/uL\n 8.1 g/dL\n 98 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 53 mg/dL\n 109 mEq/L\n 141 mEq/L\n 25.0 %\n 8.3 K/uL\n [image002.jpg]\n 11:46 AM\n 02:26 PM\n 06:25 PM\n 02:37 AM\n 02:45 AM\n 06:22 AM\n 10:01 AM\n 12:10 AM\n 02:18 AM\n 02:57 AM\n WBC\n 8.4\n 9.5\n 8.3\n Hct\n 24.5\n 26.6\n 25.0\n Plt\n 92\n 118\n 173\n Creatinine\n 2.6\n 2.5\n 2.0\n TCO2\n 23\n 25\n 26\n 26\n 23\n 26\n 27\n Glucose\n 104\n 96\n 93\n 102\n 104\n 98\n Other labs: PT / PTT / INR:14.3/37.1/1.2, CK / CK-MB / Troponin\n T:374//, ALT / AST:14/27, Alk-Phos / T bili:172/3.0, Amylase /\n Lipase:/10, Differential-Neuts:78.9 %, Band:2.0 %, Lymph:15.2 %,\n Mono:2.6 %, Eos:2.7 %, Fibrinogen:578 mg/dL, Lactic Acid:0.8 mmol/L,\n Albumin:2.8 g/dL, LDH:326 IU/L, Ca:7.7 mg/dL, Mg:1.7 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA), ACUTE RESPIRATORY DISTRESS\n SYNDROME (ARDS, ACUTE LUNG INJURY, ), FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), ALTERATION IN NUTRITION, INEFFECTIVE\n COPING, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Ativan PRN for agitation/anxiety, fentanyl prn for\n analgesia. Start methadone, clonidine\n Cardiovascular: off all pressors, stable; sinus tach\n Pulmonary: PEEP continuing to wean slowly, ARDS protocol\n Gastrointestinal / Abdomen: NGT in place, tube feeds at goal; high\n output loose stool -- flexiseal, f/u c-diff (neg x 1). Esophageal\n balloon removed.\n Nutrition: TF Impact w/ fiber at 70mL/hr per nutrition\n Renal: ARF, creatinine trending down\n Hematology: Hx of SGA bleed s/p coiling in IR. Stable mild anemia with\n goal transfuse PRBCs prn. SQH and boots.\n Endocrine: RISS.\n Infectious Disease: No new culture data; cipro/clinda/flagyl for\n fusobacteria, bacillis sp. ID following. D/c' rash.\n Lines / Tubes / Drains:\n Wounds: L hip clean / dry / intact Benadryl for rash\n Imaging: none\n Fluids: HLIV\n Consults: orthopaedic surgery\n Billing Diagnosis: septic shock resp failure\n ICU Care\n Nutrition:\n Impact with Fiber (Full) - 12:12 AM 70 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 AM\n Multi Lumen - 02:21 PM\n Prophylaxis:\n DVT: SQH, boots\n Stress ulcer: H2B\n VAP bundle: +\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 min\n" } ]

[ { "category": "Echo", "chartdate": "2118-01-26 00:00:00.000", "description": "Report", "row_id": 87212, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 277\nBSA (m2): 2.40 m2\nBP (mm Hg): 91/59\nHR (bpm): 129\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. .\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus. Suboptimal image\nquality - ventilator. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\nThere is mild regional left ventricular systolic dysfunction with inferior\nhypokinesis. No masses or thrombi are seen in the left ventricle. There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2118-01-26 00:00:00.000", "description": "Report", "row_id": 86402, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 70\nWeight (lb): 277\nBSA (m2): 2.40 m2\nBP (mm Hg): 77/45\nHR (bpm): 150\nStatus: Inpatient\nDate/Time: at 05:44\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. The patient appears to be in sinus\nrhythm. Resting tachycardia (HR>100bpm). Emergency study. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nOverall left ventricular systolic function is severely depressed (LVEF=10%).\nLeft ventricular wall thicknesses are normal. Right ventricular chamber size\nand free wall motion are normal. The mitral valve leaflets are structurally\nnormal. No mitral regurgitation is seen. The pulmonary artery systolic\npressure could not be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality, but there is severe global left\nventricular dysfunction (EF=10%). Right ventricular systolic function appears\nto be normal.\n\nDr. was notified in person of the results on at 05:45 AM.\n\n\n" }, { "category": "Physician ", "chartdate": "2118-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 553845, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : d/c diuretics as 7L neg yesterday; VAC changed to W->D;\n continuing to wean vent as tolerated; changed fentanyl to dilaudid prn\n and pt. doing well\n .\n MEDICAL: pneumonia\n 24 Hour Events:\n FEVER - 102.1\nF - 12:00 AM\n Post operative day:\n POD#9 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 05:29 PM\n Fentanyl - 06:02 PM\n Famotidine (Pepcid) - 08:00 PM\n Metoprolol - 04:03 AM\n Hydromorphone (Dilaudid) - 04:03 AM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Lorazepam 0.5-2 mg IV\n Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN, Magnesium Sulfate IV\n Sliding Scale, Albuterol Inhaler PUFF IH Q4H:PRN, Metoprolol\n Tartrate 5 mg IV Q6H, Metoclopramide 10 mg IV Q6H, Bisacodyl 10 mg\n PO/PR DAILY, Metoprolol Tartrate 5 mg IV Q4H, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine\n Gluconate 0.12% Oral Rinse 15 ml ORAL , Potassium Chloride IV\n Sliding Scale, Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID,\n HYDROmorphone, Heparin 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg\n IV Q 12H\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 38.3\nC (101\n HR: 100 (91 - 121) bpm\n BP: 132/67(84) {97/52(65) - 143/80(95)} mmHg\n RR: 35 (18 - 35) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 10 (3 - 14) mmHg\n Total In:\n 3,218 mL\n 814 mL\n PO:\n Tube feeding:\n 175 mL\n 65 mL\n IV Fluid:\n 1,508 mL\n 142 mL\n Blood products:\n Total out:\n 9,505 mL\n 1,130 mL\n Urine:\n 7,995 mL\n 805 mL\n NG:\n Stool:\n 300 mL\n Drains:\n 10 mL\n 25 mL\n Balance:\n -6,287 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 660 (572 - 808) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 69\n PIP: 24 cmH2O\n SPO2: 96%\n ABG: 7.47/40/162/26/5\n Ve: 14 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), slightly tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: slightly diminished at bases)\n Abdominal: Soft, midline abdominal wound with wet to dry dressing; no\n abdominal sounds; diffuse ttp\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: erythema on torso much decreased\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 375 K/uL\n 9.4 g/dL\n 136 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.6 %\n 13.5 K/uL\n [image002.jpg]\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n WBC\n 8.2\n 12.4\n 13.5\n Hct\n 28.3\n 32.9\n 27.6\n Plt\n \n Creatinine\n 0.6\n 0.8\n 1.0\n 0.9\n TCO2\n 31\n 32\n 31\n 27\n 28\n 30\n Glucose\n 160\n 128\n 138\n 134\n 136\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:71/81, Alk-Phos / T bili:98/2.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.3 mg/dL, Mg:2.3\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR same day for perforation, now s/p partial ileum\n and ascending colon resection w mesh removal and primary closure of\n wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: Held diuresis after am dose of ethacrinic acid -> as\n was 6L neg, no diuresis today, Lopressor for BP and HR control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS 10, continue to decrease support\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n Hold for CT abd today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today to rule out abscess\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT, place piv\n WOUNDS: abd wound w/ W-> dressings - change \n IMAGING: am CXR\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete (Full) - 12:10 PM 10 mL/hour\n TPN without Lipids - 05:00 PM 91. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 553849, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : d/c diuretics as 7L neg yesterday; VAC changed to W->D;\n continuing to wean vent as tolerated; changed fentanyl to dilaudid prn\n and pt. doing well\n .\n MEDICAL: pneumonia\n 24 Hour Events:\n FEVER - 102.1\nF - 12:00 AM\n Post operative day:\n POD#9 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 05:29 PM\n Fentanyl - 06:02 PM\n Famotidine (Pepcid) - 08:00 PM\n Metoprolol - 04:03 AM\n Hydromorphone (Dilaudid) - 04:03 AM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Lorazepam 0.5-2 mg IV\n Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN, Magnesium Sulfate IV\n Sliding Scale, Albuterol Inhaler PUFF IH Q4H:PRN, Metoprolol\n Tartrate 5 mg IV Q6H, Metoclopramide 10 mg IV Q6H, Bisacodyl 10 mg\n PO/PR DAILY, Metoprolol Tartrate 5 mg IV Q4H, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine\n Gluconate 0.12% Oral Rinse 15 ml ORAL , Potassium Chloride IV\n Sliding Scale, Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID,\n HYDROmorphone, Heparin 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg\n IV Q 12H\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 38.3\nC (101\n HR: 100 (91 - 121) bpm\n BP: 132/67(84) {97/52(65) - 143/80(95)} mmHg\n RR: 35 (18 - 35) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 10 (3 - 14) mmHg\n Total In:\n 3,218 mL\n 814 mL\n PO:\n Tube feeding:\n 175 mL\n 65 mL\n IV Fluid:\n 1,508 mL\n 142 mL\n Blood products:\n Total out:\n 9,505 mL\n 1,130 mL\n Urine:\n 7,995 mL\n 805 mL\n NG:\n Stool:\n 300 mL\n Drains:\n 10 mL\n 25 mL\n Balance:\n -6,287 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 660 (572 - 808) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 69\n PIP: 24 cmH2O\n SPO2: 96%\n ABG: 7.47/40/162/26/5\n Ve: 14 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), slightly tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: slightly diminished at bases)\n Abdominal: Soft, midline abdominal wound with wet to dry dressing; no\n abdominal sounds; diffuse ttp\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: erythema on torso much decreased\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 375 K/uL\n 9.4 g/dL\n 136 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.6 %\n 13.5 K/uL\n [image002.jpg]\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n WBC\n 8.2\n 12.4\n 13.5\n Hct\n 28.3\n 32.9\n 27.6\n Plt\n \n Creatinine\n 0.6\n 0.8\n 1.0\n 0.9\n TCO2\n 31\n 32\n 31\n 27\n 28\n 30\n Glucose\n 160\n 128\n 138\n 134\n 136\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:71/81, Alk-Phos / T bili:98/2.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.3 mg/dL, Mg:2.3\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR same day for perforation, now s/p partial ileum\n and ascending colon resection w mesh removal and primary closure of\n wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: Held diuresis after am dose of ethacrinic acid -> as\n was 6L neg, no diuresis today, Lopressor for BP and HR control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS 10, continue to decrease support\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n Hold for CT abd today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0. Hold\n diuresis for CT Abd today.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today to rule out abscess\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT, place piv\n WOUNDS: abd wound w/ W-> dressings - change \n IMAGING: am CXR; Abd CT\n FLUIDS: Bicarb infusion x 1 liter for CT, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete (Full) - 12:10 PM 10 mL/hour\n TPN without Lipids - 05:00 PM 91. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 554189, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Insulin SC Sliding Scale,Ipratropium Bromide MDI 2\n PUFF IH Q4H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN, Lorazepam 0.5-2 mg\n IV Q6H:PRN agitation, Albuterol Inhaler PUFF IH Q4H:PRN, Magnesium\n Sulfate IV Sliding Scale,Metoclopramide 10 mg IV Q6H, Bisacodyl 10 mg\n PO/PR DAILY, Metoprolol Tartrate 10 mg IV Q4H, Calcium Gluconate IV\n Sliding Scale, MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Potassium\n Chloride IV Sliding Scale, Ciprofloxacin 400 mg IV Q12H, Potassium\n Phosphate IV Sliding Scale, Famotidine 20 mg IV Q12H, HYDROmorphone\n (Dilaudid) 2 mg IV Q2H:PRN, Heparin 5000 UNIT SC TID.\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today. Aim to keep phos> 3. Monitoring LFTs and INR.\n Received 10mg SC vit K.\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; Ultrasound RUQ -> prelim read\n negative\n : Lasix dc'd due to rash. Started on ethacrynic acid- huge diuresis\n overnight. Lopressor started instead of labetolol. Continue day 2 of\n TPN. Trophic tube feeds started but residuals> 100cc so held briefly\n overnight. Switched to pressure support. Sputum, stool and UC sent. Ct\n head performed due to sluggish dilated right pupil-no acute pathology.\n Fluconazole dc'd due to rising bilirubin. Spiked a temp overnight- BC\n sent.\n : d/c diuretics as 7L neg yesterday; VAC changed to W->D;\n continuing to wean vent as tolerated; changed fentanyl to dilaudid prn\n and pt. doing well\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source.\n 24 HOUR EVENTS:\n :Extubated, appears confused. SC from positive for\n Enterobacter cloacae- switched to cipro and flagyl. Further diuresis\n witheld today. Had Upper and Lower ext US- no DVT, but small non\n occluding clot left cephalic vein.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: cipro/flagyl started \n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n : SC-25 PMNs and <10 epithelial cells/100X field. ENTEROBACTER\n CLOACAE.SPARSE GROWTH.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n : Upper and lower ext US: no DVT\n .\n 24 Hour Events:\n ULTRASOUND - At 11:06 AM\n upper and lower ext.\n INVASIVE VENTILATION - STOP 12:34 PM\n FEVER - 101.6\nF - 03:00 PM\n Post operative day:\n POD#11 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 11:06 AM\n Ciprofloxacin - 05:00 PM\n Metronidazole - 11:49 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:16 AM\n Famotidine (Pepcid) - 08:33 PM\n Metoprolol - 08:56 PM\n Hydromorphone (Dilaudid) - 03:45 AM\n Lorazepam (Ativan) - 05:05 AM\n Haloperidol (Haldol) - 05:08 AM\n Other medications:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.3\nC (100.9\n HR: 118 (94 - 132) bpm\n BP: 161/79(106) {134/58(80) - 178/94(122)} mmHg\n RR: 32 (20 - 40) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 7 (2 - 15) mmHg\n Total In:\n 5,123 mL\n 687 mL\n PO:\n Tube feeding:\n 1,646 mL\n 62 mL\n IV Fluid:\n 1,270 mL\n 31 mL\n Blood products:\n Total out:\n 3,075 mL\n 1,070 mL\n Urine:\n 2,035 mL\n 545 mL\n NG:\n 120 mL\n 55 mL\n Stool:\n 900 mL\n 450 mL\n Drains:\n 20 mL\n 20 mL\n Balance:\n 2,048 mL\n -383 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 762 (475 - 762) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 96%\n ABG: 7.47/30/121/23/0\n Ve: 19.1 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Agitated\n Labs / Radiology\n 532 K/uL\n 8.9 g/dL\n 132 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 26.2 %\n 12.7 K/uL\n [image002.jpg]\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n 09:17 AM\n 02:43 AM\n 03:04 AM\n WBC\n 13.5\n 15.0\n 12.7\n Hct\n 27.6\n 26.2\n 26.2\n Plt\n 375\n 410\n 532\n Creatinine\n 1.0\n 0.9\n 0.7\n 0.6\n TCO2\n 28\n 30\n 27\n 26\n 22\n Glucose\n 134\n 136\n 134\n 142\n 132\n Other labs: PT / PTT / INR:14.8/22.8/1.3, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:54/53, Alk-Phos / T bili:129/1.5,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.0 mmol/L, Albumin:2.5 g/dL, LDH:234 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation. Monitor confusion.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis and allowing to autodiurese, continue\n to monitor net fluid balance. Lopressor for BP and HR control.\n PULMONARY: Extubated- appears stable.\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n Replete with Fiber (Full) - 01:06 PM 10 mL/hour\n TPN w/ Lipids - 05:51 PM 91. mL/hour\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: Stable\n ENDOCRINE: RISS\n ID: Started on Cipro/flagyl for Enterobacter Cloacae\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n WOUNDS: abd wound w/ W->D gauze dressings - change .\n IMAGING: none pending\n FLUIDS: KVO, replete K and phosphate as needed.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis:\n ICU Care\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553760, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Acute Pain\n Assessment:\n Pt resting. Will grimace when turned or abd palpated. Pt HR ST.\n Action:\n Wound Vac Dressing changed today. Dressing replaced with wet/dry\n dressing. Large opening noted once wound vac removed. Strong odor from\n wound. Dusky color to tissue. Pt given fentanyl 150mcg for pain control\n with dressing change.\n Response:\n Pt tolerated dressing change well. Surgical service informed they need\n to call and give the RN notification prior to dressing change.\n Plan:\n Surgical service to come back by to change dressing again tonight. CT\n scan of abd tomorrow\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains orally intubated and on vent settings as charted. Increasingly\n Tachypneic when more alert.\n Action:\n Weaned pressure support as tolerated. Medicated with ativan and\n fentanyl when patient appeared restless/agitated. Pt on 18 of PS at\n this time. Will try to wean down PS as tolerated. PCXR better this\n morning from last PCXR.\n Response:\n Pt tolerating ps of 16 at this time. RR 20-30\ns. Pt given ativan and\n fentanyl as needed prn.\n Plan:\n Continue to wean pt PS as tolerated. Plan for slow wean. Repeat ABG in\n am. PCXR in am.\n" }, { "category": "Nursing", "chartdate": "2118-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553948, "text": "47 yo male s/p ventral hernia with repair and subsequent ileocolostomy.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented on CPAP/PS 10/5, 40% FiO2. Lung sounds clear in the\n upper lobes, diminished at the bases bilaterally. Pt has strong,\n productive cough, requires suctioning Q1-2 hrs for frothy, white\n secretions. RR <30 when comfortable, pt often becomes tachypneic with\n coughing/activity/repositioning.\n Action:\n No vent changes made throughout the day. Pt not diuresed today, seems\n to be auto-diuresing. 1mg Dilaudid IVP made pt\ns breathing less\n tachypneic, pt seemed more comfortable, denied pain.\n Response:\n Pt continues to autodiurese, negative one liter for the day.\n Plan:\n Diurese pt tomorrow, wean vent to Extubation tomorrow. Continue to\n support pt and family. Continue to suction as needed.\n Hernia, ventral / incisional\n Assessment:\n Pt has large abdominal incision (fascia closed, skin/tissue open). Vac\n previously removed, currently site with wet to dry dressing changes\n . Abdomen is draining large amount of serous fluid. JP drain to\n blub suction intact, draining scant amount of serous fluid. Pt spiking\n fevers- Tmax 101.8, WBC 13.\n Action:\n CT torso with contrast done to assess for possible abcess. Pt pan\n cultured at 16:00 with Tmax. Abdominal dressing requiring multiple\n changes/reinforcement d/t heavy serous drainage.\n Response:\n Abdomen continues to drain large amount of serous fluid despite\n multiple dressing changes. Pt experiencing pain with abdominal\n dressing changes as evidenced by nonverbal cues/grimacing.\n Plan:\n Follow up with CT scan results, gold surgery doing all full dressing\n changes? VAC replacement tomorrow? Debridement? Continue to provide\n pain medication to pt for dressing changes. Continue to support pt and\n family. Follow up with pan cultures sent 16:00.\n" }, { "category": "Physician ", "chartdate": "2118-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 554003, "text": "TSICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,\n Lorazepam 0.5-2 mg IV Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN,\n Magnesium Sulfate IV Sliding Scale, Albuterol Inhaler PUFF IH\n Q4H:PRN, Metoprolol Tartrate 10 mg IV Q4H, Metoclopramide 10 mg IV Q6H,\n Bisacodyl 10 mg PO/PR DAILY, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine Gluconate 0.12%\n Oral Rinse 15 ml ORAL , Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID, HYDROmorphone, Heparin\n 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:30 PM\n blood culture #1 from central line\n blood culture #2 from new PIV\n SPUTUM CULTURE - At 04:30 PM\n endotracheal\n URINE CULTURE - At 04:30 PM\n catheter\n STOOL CULTURE - At 04:30 PM\n c diff\n FEVER - 101.8\nF - 04:00 PM\n Post operative day:\n POD#10 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:11 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Lorazepam (Ativan) - 03:38 AM\n Metoprolol - 04:16 AM\n Hydromorphone (Dilaudid) - 06:59 AM\n Other medications:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 38.2\nC (100.8\n HR: 114 (94 - 121) bpm\n BP: 161/76(101) {120/55(74) - 179/76(101)} mmHg\n RR: 26 (20 - 34) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 12 (4 - 16) mmHg\n Total In:\n 4,633 mL\n 1,029 mL\n PO:\n Tube feeding:\n 180 mL\n 72 mL\n IV Fluid:\n 1,070 mL\n 234 mL\n Blood products:\n Total out:\n 3,300 mL\n 1,410 mL\n Urine:\n 2,765 mL\n 710 mL\n NG:\n 150 mL\n 90 mL\n Stool:\n 300 mL\n 600 mL\n Drains:\n 35 mL\n 10 mL\n Balance:\n 1,333 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 426 (426 - 899) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.44/38/158/24/2\n Ve: 11 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Labs / Radiology\n 410 K/uL\n 9.2 g/dL\n 142 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 111 mEq/L\n 141 mEq/L\n 26.2 %\n 15.0 K/uL\n [image002.jpg]\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n WBC\n 12.4\n 13.5\n 15.0\n Hct\n 32.9\n 27.6\n 26.2\n Plt\n 326\n 375\n 410\n Creatinine\n 0.8\n 1.0\n 0.9\n 0.7\n TCO2\n 31\n 27\n 28\n 30\n 27\n Glucose\n 128\n 138\n 134\n 136\n 134\n 142\n Other labs: PT / PTT / INR:15.7/22.8/1.4, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:59/59, Alk-Phos / T bili:105/1.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:286 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ACUTE\n PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis--monitor net fluid balance. Lopressor\n for BP and HR control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS.\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W-> dressings - change , possible\n further bedside debridement by primary team.\n IMAGING: am CXR\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n TPN without Lipids - 04:57 PM 91. mL/hour\n Replete with Fiber (Full) - 03:40 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2118-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552889, "text": "47 yo male admitted w/ incarcerated ventral hernia. s/p ex lap,\n VHR w/ mesh placement. Patient w/ dramatic hemodynamic decompensation,\n fecal drainage from drains in PACU post op, back to OR for repair of\n small bowel perforation. Patient to TSICU from OR w/ severe\n hemodynamic instability. After large volumes of fluid and high dose\n vasopressors ineffective to manage BP and CO, TTE revealed EF 10%,\n consistent w/ cardiogenic shock. See below for management since\n admission.\n Shock, cardiogenic\n Assessment:\n Initial cardiogenic shock picture in setting of SIRS/severe\n hypotension s/p small bowel perforation. s/p OR as above, milrinone and\n vasopressors very effective in optimizing CO and decreasing\n afterload. EF immediately improved w/ start of milrinone , up to\n 45% w/ f/u echo.\n Action:\n Weaned milrinone by half , VSS, vasopressin cont at set rate.\n Response:\n Able to wean levophed successfully throughout day and night,\n vasopressin continued. Periphery less mottled, CO remains stable. SVV\n WNL.\n Plan:\n Stop milrinone today, wean pressors carefully. ? f/u echo, slowly begin\n to wean sedation in coming days.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rising peep & fio2 requirements in setting of massive fluid\n resuscitation, cardiogenic shock. Abg reveals metabolic acidosis.\n Mild desaturations noted last night w/ turns w/ inability to recover\n after time. CXR worse from am.\n Action:\n Peep holding at 12, most recent abg w/ pao2 190s. weaned fio2\n overnight. Frequent oral care, ett care.\n Response:\n O2 sats when positioned on R side 94-96%, when on L side 92-94%. Team\n aware, acceptable. Minimal secretions present, clear, thin.\n Plan:\n f/u CXR today, maintain current settings in light of worsening pulm\n status, likely d/t third spacing, fluid mobilization.\n Hernia, ventral / incisional\n Assessment:\n s/p VHR, small bowel perf repair .\n Action:\n VAC dsg in place to midline abdomen, freq belly exams continue.\n Response:\n Foul, watery brown drainage from VAC, canister changed prn. No further\n rectal drainage noted, JP w/ mod amts serous output to LWS. Wound\n edges exposed under transparent VAC tegederm, areas beefy red.\n Plan:\n Cont to monitor belly exam, VAC drainage. VAC dsg due to be changed\n today .\n" }, { "category": "Physician ", "chartdate": "2118-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 554043, "text": "TSICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,\n Lorazepam 0.5-2 mg IV Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN,\n Magnesium Sulfate IV Sliding Scale, Albuterol Inhaler PUFF IH\n Q4H:PRN, Metoprolol Tartrate 10 mg IV Q4H, Metoclopramide 10 mg IV Q6H,\n Bisacodyl 10 mg PO/PR DAILY, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine Gluconate 0.12%\n Oral Rinse 15 ml ORAL , Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID, HYDROmorphone, Heparin\n 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source, tolerating minimal vent settings\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n BLOOD CULTURED - At 04:30 PM\n blood culture #1 from central line\n blood culture #2 from new PIV\n SPUTUM CULTURE - At 04:30 PM\n endotracheal\n URINE CULTURE - At 04:30 PM\n catheter\n STOOL CULTURE - At 04:30 PM\n c diff\n FEVER - 101.8\nF - 04:00 PM\n Post operative day:\n POD#10 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:11 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Lorazepam (Ativan) - 03:38 AM\n Metoprolol - 04:16 AM\n Hydromorphone (Dilaudid) - 06:59 AM\n Other medications:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 38.2\nC (100.8\n HR: 114 (94 - 121) bpm\n BP: 161/76(101) {120/55(74) - 179/76(101)} mmHg\n RR: 26 (20 - 34) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 12 (4 - 16) mmHg\n Total In:\n 4,633 mL\n 1,029 mL\n PO:\n Tube feeding:\n 180 mL\n 72 mL\n IV Fluid:\n 1,070 mL\n 234 mL\n Blood products:\n Total out:\n 3,300 mL\n 1,410 mL\n Urine:\n 2,765 mL\n 710 mL\n NG:\n 150 mL\n 90 mL\n Stool:\n 300 mL\n 600 mL\n Drains:\n 35 mL\n 10 mL\n Balance:\n 1,333 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 426 (426 - 899) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.44/38/158/24/2\n Ve: 11 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Labs / Radiology\n 410 K/uL\n 9.2 g/dL\n 142 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 111 mEq/L\n 141 mEq/L\n 26.2 %\n 15.0 K/uL\n [image002.jpg]\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n WBC\n 12.4\n 13.5\n 15.0\n Hct\n 32.9\n 27.6\n 26.2\n Plt\n 326\n 375\n 410\n Creatinine\n 0.8\n 1.0\n 0.9\n 0.7\n TCO2\n 31\n 27\n 28\n 30\n 27\n Glucose\n 128\n 138\n 134\n 136\n 134\n 142\n Other labs: PT / PTT / INR:15.7/22.8/1.4, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:59/59, Alk-Phos / T bili:105/1.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:286 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ACUTE\n PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis--monitor net fluid balance. Lopressor\n for BP and HR control.\n PULMONARY: consider extubation today\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W-> dressings - change , possible\n further bedside debridement by primary team.\n IMAGING:\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 04:57 PM 91. mL/hour\n Replete with Fiber (Full) - 03:40 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n Communication: Comments:\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2118-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 554046, "text": "TSICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,\n Lorazepam 0.5-2 mg IV Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN,\n Magnesium Sulfate IV Sliding Scale, Albuterol Inhaler PUFF IH\n Q4H:PRN, Metoprolol Tartrate 10 mg IV Q4H, Metoclopramide 10 mg IV Q6H,\n Bisacodyl 10 mg PO/PR DAILY, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine Gluconate 0.12%\n Oral Rinse 15 ml ORAL , Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID, HYDROmorphone, Heparin\n 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source, tolerating minimal vent settings\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n BLOOD CULTURED - At 04:30 PM\n blood culture #1 from central line\n blood culture #2 from new PIV\n SPUTUM CULTURE - At 04:30 PM\n endotracheal\n URINE CULTURE - At 04:30 PM\n catheter\n STOOL CULTURE - At 04:30 PM\n c diff\n FEVER - 101.8\nF - 04:00 PM\n Post operative day:\n POD#10 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:11 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Lorazepam (Ativan) - 03:38 AM\n Metoprolol - 04:16 AM\n Hydromorphone (Dilaudid) - 06:59 AM\n Other medications:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 38.2\nC (100.8\n HR: 114 (94 - 121) bpm\n BP: 161/76(101) {120/55(74) - 179/76(101)} mmHg\n RR: 26 (20 - 34) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 12 (4 - 16) mmHg\n Total In:\n 4,633 mL\n 1,029 mL\n PO:\n Tube feeding:\n 180 mL\n 72 mL\n IV Fluid:\n 1,070 mL\n 234 mL\n Blood products:\n Total out:\n 3,300 mL\n 1,410 mL\n Urine:\n 2,765 mL\n 710 mL\n NG:\n 150 mL\n 90 mL\n Stool:\n 300 mL\n 600 mL\n Drains:\n 35 mL\n 10 mL\n Balance:\n 1,333 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 426 (426 - 899) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.44/38/158/24/2\n Ve: 11 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Labs / Radiology\n 410 K/uL\n 9.2 g/dL\n 142 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 111 mEq/L\n 141 mEq/L\n 26.2 %\n 15.0 K/uL\n [image002.jpg]\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n WBC\n 12.4\n 13.5\n 15.0\n Hct\n 32.9\n 27.6\n 26.2\n Plt\n 326\n 375\n 410\n Creatinine\n 0.8\n 1.0\n 0.9\n 0.7\n TCO2\n 31\n 27\n 28\n 30\n 27\n Glucose\n 128\n 138\n 134\n 136\n 134\n 142\n Other labs: PT / PTT / INR:15.7/22.8/1.4, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:59/59, Alk-Phos / T bili:105/1.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:286 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ACUTE\n PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis--monitor net fluid balance. Lopressor\n for BP and HR control. Venous dopplers to r/o DVT\n PULMONARY: consider extubation today\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W-> dressings - change , possible\n further bedside debridement by primary team.\n IMAGING:\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 04:57 PM 91. mL/hour\n Replete with Fiber (Full) - 03:40 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n Communication: Comments:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2118-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553026, "text": "47 yo male admitted s/p ventral hernia. Pt c/o abdominal pain\n since , ongoing anorexia, pain, intermittent\n diarrhea/N/V. pt had ventral hernia repair with mesh placement;\n pt experienced tachycardia, abdominal pain, vomiting, decreasing UO and\n stool via NGT/JP drain in PACU. Pt brought back to OR for\n re-exploration, washout, removal of mesh, ileocolectomy and placement\n of VAC dressing. Pt remains in TSICU for care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented, settings at beginning of the shift: CMV TV 500/RR\n 25/50% FiO2/PEEP 12. ABG in AM WNL. Lung sounds rhonchorous\n throughout. Secretions increasing slightly throughout the day (white,\n thick, small-moderate). Pt has +/unproductive cough.\n Action:\n Vent settings changed: PEEP decreased to 10, FiO2 decreased to 40%.\n Response:\n Initially, pt tolerated changes well, ABG WNL. In afternoon, O2 sats\n decreased to 90-94% with repositioning and did not resolve with periods\n of rest. Subsequent ABG showing lower PaO2 (86 then 74). Per HO and\n RT FiO2 increased to 50%.\n Plan:\n Continue to assess respiratory function, wean vent as tolerated,\n continue to provide VAP care per protocol, pulmonary toilet. If pt off\n vasopressors/BP WNL tomorrow, consider diuresing pt? Repeat CXR in AM.\n Repeat ABG to be drawn before change of shift.\n Hernia, ventral / incisional\n Assessment:\n VAC dressing dry and intact: fascia closed, foam sponge not covering\n all of adipose tissue, moderate amount of serosanguinous drainage being\n collected. JP drain to wall suction in surgical site, draining\n serous/purulent drainage. Pt on 500mcg/hr fentanyl gtt and midazolam\n 8mg/hr for sedation/comfort.\n Action:\n VAC dressing changed at 18:00 by surgical team in room. Small amount\n of dead adipose tissue removed from site. Foul odor from site.\n Response:\n Pt appears comfortable, tolerated VAC dsg change well as well as ET\n tube.\n Plan:\n Monitor VAC output, continue to assess site, bladder pressures not\n needed per team at this time. Continue to monitor INR 2.9- consider\n enteral feedings in AM? Continue to support pt and family. Wean off\n vent and pressors, diurese pt when able.\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554105, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.4 this am. Recheck of temp 101.3 this afternoon.\n Action:\n Pt given Tylenol for temp. MD aware no new cultures ordered at this\n time\n Response:\n Pt temp down 100.7\n Plan:\n f/u on cx\ns that were sent on around 1600, cont to treat fever\n with Tylenol as ordered. D/C zosyn and vanco. Pt started on Cipro and\n flagyl.\n Altered mental status (not Delirium)\n Assessment:\n Pt extubated at 1200. Pt voice very weak at first. Stronger as the day\n went on. Pt confused. Not able to state correct place, date, reason for\n visit. Pt is able to state correct year and month. Pt stated\nleave me\n alone\nm having a bad week\n Action:\n Pt reoriented to location and plan of care. Pt OOb to chair for 2 hr\n today. Ativan given per orders.\n Response:\n No change in pt mental status. Pt to bed at 1630. Tolerated well.\n Ativan given and pt more calm.\n Plan:\n Continue to monitor pt neuro status and provide ativan as needed.\n Acute Pain\n Assessment:\n Pt grimaces with repositioning and dressing changes\n Action:\n Prn dilaudid given per orders\n Response:\n Changed prn order to 2mg q2 hours\n Plan:\n Cont to assess pain level, premedicate before turns and dressing\n changes.\n" }, { "category": "Nursing", "chartdate": "2118-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553809, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear, equal bilaterally. SPO2 >96% on vent settings. ABG\n normal. Intermittent tachypnea responds well to verbal coaching and\n pain meds.\n Action:\n Weaned ventilator to CPAP+PSV 10 with 5 PEEP 40% FiO2.\n Response:\n SPO2 remains >97% with normal work of breathing.\n Plan:\n Wean ventilator as tolerated, extubate when able.\n Acute Pain\n Assessment:\n Patient much more alert than in days past. Follows commands\n inconsistently, mouths words, appears delirious. Indicates no pain at\n rest but facial grimace and vital signs indicate pain with movement and\n turning.\n Action:\n Added Dilaudid 1mg q3 hrs prn for pain.\n Response:\n Tolerates care and invasive ventilation well.\n Plan:\n Provide adequate analgesia for surgical/wound pain and care.\n Hernia, ventral / incisional\n Assessment:\n Abdomen open to the fascia. Wound with serosanguenous drainage, foul\n smell. No granulation noted. Tunneled wound under soft tissue makes\n full assessment difficult. Green/dusky areas noted.\n Action:\n Wet to dry dressing changed with surgery resident.\n Response:\n Weeps serous fluid through the dressing.\n Plan:\n wet to dry dressing changes by nursing (clarify with entire\n surgical team on rounds, address need for VAC?).\n" }, { "category": "Nursing", "chartdate": "2118-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552804, "text": "Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen with no drainage on this shift. Vac dressing\n placed in incisional wound bed draining minimal serosanguinous fluid.\n BS absent. NG tube to suction with thick tan drainage. Bladder\n pressures 22 at beginning of shift. Adequate pain management.\n Action:\n Monitoring drainage color and amt. Bladder pressures discontinued.\n Fentanyl gtt in place for pain and midaz gtt for sedation.\n Response:\n Vac draining minimal fluid and skin surrounding wound bed shows\n ecchymosis\n Plan:\n Vac drsg to be changed tomorrow. ?JP removal\n Shock, cardiogenic\n Assessment:\n Pt tachycardic. Pt\ns requiring pressors for adequate BP. Cool, dusky\n lower extremities with pulses difficult to palpate. Pt\ns SVV and CO\n remain adequate, pt\ns successfully fluid resuscitated.\n Action:\n TTE performed by ICU fellow. Milrinone gtt decreased to .25 Levophed\n titrated down. Pt goal is MAP >60 Vigileo in place.\n Response:\n Pt\ns tachycardia decreased. With titration MAP still within goal range.\n SVV stable and wnl.\n Plan:\n Continue to wean Levophed and milrinone. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with Peep increased over night to 12 and FiO2 to 70% ABG with\n adequate PaO2 but still in metabolic acidosis. O2 sats low 90s. LS\n clear and diminished at bases. Minimal thin tan secretions.\n Action:\n Pt\ns FiO2 decreased to 60. VAP care performed. Chest xray taken.\n Response:\n O2 sats in mid 90s when pt place on right side and low 90s on left\n side. Team aware and satisfied with abg and O2 saturations. Chest xray\n shows worsening lungs.\n Plan:\n Continue to monitor ABG\ns, continue vent support. ?Bronch tomorrow\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs and\n afebrile. Tachycardia and hypotension. Pan culture performed on night\n shift. Electrolytes and lactate wnl. Bilirubin minimally increased.\n Action:\n Pt on Vanco, Fluconazole and Zosyn. Electrolytes and lactates\n monitored. Fan in place.\n Response:\n Low grade fever remains.\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n ICU consent done today. Son and Mother visited.\n" }, { "category": "Physician ", "chartdate": "2118-01-28 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 552880, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; levophed weaned; FiO2 down to 50%; output from Wound Vac foul\n smelling\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#3 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:27 AM\n Vancomycin - 09:17 PM\n Piperacillin/Tazobactam (Zosyn) - 02:30 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Milrinone - 0.25 mcg/Kg/min\n Norepinephrine - 0.14 mcg/Kg/min\n Midazolam (Versed) - 8 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:59 AM\n Midazolam (Versed) - 09:30 PM\n Famotidine (Pepcid) - 09:59 PM\n Fentanyl - 05:08 AM\n Other medications:\n Heparin 5000 UNIT SC TID,Insulin SC Sliding Scale,Ipratropium Bromide\n MDI 2 PUFF IH Q4H:PRN, Milrinone 0.5 mcg/kg/min IV DRIP, Midazolam \n mg/hr IV DRIP, Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Albuterol\n Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Famotidine 20 mg IV Q12H, Fentanyl Citrate 100-200 mcg IV Q1HR PRN\n pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP, Vasopressin 1.2-3.6\n UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200 mg IV Q24H\n Vancomycin 1000 mg IV Q 12H, milrinone gtt\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.4\nC (99.4\n HR: 108 (105 - 123) bpm\n BP: 104/51(66) {96/42(61) - 110/67(79)} mmHg\n RR: 22 (21 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 143 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (12 - 18)mmHg\n Bladder pressure: 21 (21 - 21) mmHg\n Total In:\n 9,374 mL\n 1,964 mL\n PO:\n TF:\n IVF:\n 9,354 mL\n 1,924 mL\n Blood products:\n Total out:\n 2,090 mL\n 520 mL\n Urine:\n 1,720 mL\n 370 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 120 mL\n 150 mL\n Balance:\n 7,284 mL\n 1,444 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n ABG: 7.34/36/194/23/-5\n Ve: 12 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, intubated and sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g; RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), coarse breath sounds bilaterally\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+, no c/c\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed, intubated and sedated\n Labs / Radiology\n 206 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.2 %\n 14.6 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n 08:49 AM\n 09:31 AM\n 02:35 PM\n 09:29 PM\n 03:09 AM\n WBC\n 17.2\n 17.0\n 15.2\n 14.6\n Hct\n 31.2\n 30.7\n 28.4\n 28.2\n Plt\n 275\n 256\n 224\n 206\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 20\n 22\n 21\n 21\n 20\n Glucose\n 140\n 120\n 128\n 101\n 85\n 101\n Other labs: PT / PTT / INR:28.6/42.5/2.9, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:21/32, Alk Phos / T Bili:57/2.4,\n Lactic Acid:2.3 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 65 - continue to\n wean as tolerated; LR @ 250cc/hr; milrinone weaned\n PULMONARY: Vent dep resp failure, continue to optomize resp status\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO\n RENAL: f/u creat and UO.\n HEMATOLOGY: f/u Hct - stable\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery. Await pending culture results.\n LINES/TUBES/DRAINS: RIJ, L fem a-line, JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, SQH\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Nutrition:\n General:\n ICU Care\n Nutrition: NPO presently\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2118-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553044, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2118-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 553208, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS:IV access: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Midazolam 1-10 mg/hr IV DRIP TITRATE TO sedation, Albuterol\n Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium Chloride IV Sliding\n Scale, Famotidine 20 mg IV Q12H, Potassium Phosphate IV Sliding Scale,\n Fentanyl Citrate 100-200 mcg IV Q1HR PRN, Fentanyl Citrate 100-500\n mcg/hr, Fluconazole 200 mg IV Q24H, Insulin SC (per Insulin\n Flowsheet)Sliding Scale, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF.\n 24 HOUR EVENTS:\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today, either NG feeds vs. TPN tomorrow. Aim to keep\n phos> 3. Monitoring LFTs and INR. Received 10mg SC vit K. .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn/fluc\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n 24 Hour Events:\n Post operative day:\n POD#5 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:17 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:30 PM\n Other medications:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.7\nC (99.8\n HR: 105 (98 - 108) bpm\n BP: 110/55(71) {90/51(64) - 116/62(77)} mmHg\n RR: 28 (22 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (11 - 19) mmHg\n Total In:\n 1,580 mL\n 364 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,580 mL\n 364 mL\n Blood products:\n Total out:\n 3,377 mL\n 935 mL\n Urine:\n 2,007 mL\n 435 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 1,170 mL\n 500 mL\n Balance:\n -1,797 mL\n -571 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 26 cmH2O\n SPO2: 98%\n ABG: 7.46/38/152/26/3\n Ve: 13.2 L/min\n PaO2 / FiO2: 380\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 193 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 9.1 K/uL\n [image002.jpg]\n 02:13 PM\n 02:36 PM\n 05:35 PM\n 07:20 PM\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n WBC\n 14.9\n 11.2\n 8.9\n 9.1\n Hct\n 29.9\n 30.3\n 29.5\n 28.7\n Plt\n 185\n 191\n 191\n 193\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 26\n 25\n 26\n 28\n 29\n 28\n Glucose\n 102\n 80\n 78\n 100\n 97\n Other labs: PT / PTT / INR:18.5/30.4/1.7, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:28/60, Alk-Phos / T bili:81/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L, Ca:8.5 mg/dL, Mg:2.2\n mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR on same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Off pressor medications. Start diuresis today.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO. Start TPN today vs TFs.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR.\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2118-01-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 552994, "text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 126 kg\n 143 kg ( 05:00 AM)\n +17 kg d/t fluid\n 39.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 167%\n 88\n Diagnosis: hernia\n PMH :\n Food allergies and intolerances: peanuts\n Pertinent medications: RISS, LR, pepcid, IV abx, KPhos, Ca Gluconate,\n others noted\n Labs:\n Value\n Date\n Glucose\n 102 mg/dL\n 02:13 PM\n Glucose Finger Stick\n 109\n 02:00 PM\n BUN\n 12 mg/dL\n 02:13 PM\n Creatinine\n 0.6 mg/dL\n 02:13 PM\n Sodium\n 135 mEq/L\n 02:13 PM\n Potassium\n 4.3 mEq/L\n 02:13 PM\n Chloride\n 104 mEq/L\n 02:13 PM\n TCO2\n 25 mEq/L\n 02:13 PM\n PO2 (arterial)\n 86 mm Hg\n 02:36 PM\n PCO2 (arterial)\n 42 mm Hg\n 02:36 PM\n pH (arterial)\n 7.38 units\n 02:36 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 02:36 PM\n Albumin\n 2.7 g/dL\n 03:02 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:13 PM\n Phosphorus\n 2.0 mg/dL\n 02:13 PM\n Ionized Calcium\n 1.22 mmol/L\n 10:35 AM\n Magnesium\n 2.2 mg/dL\n 02:13 PM\n ALT\n 21 IU/L\n 03:02 AM\n Alkaline Phosphate\n 57 IU/L\n 03:02 AM\n AST\n 32 IU/L\n 03:02 AM\n Total Bilirubin\n 2.4 mg/dL\n 03:02 AM\n WBC\n 14.9 K/uL\n 02:13 PM\n Hgb\n 10.3 g/dL\n 02:13 PM\n Hematocrit\n 29.9 %\n 02:13 PM\n Current diet order / nutrition support: NPO\n GI: soft, distended, -BS\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1760-2200 (BEE x or / 20-25 cal/kg)\n Protein: 106-132 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2118-01-28 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 552995, "text": "Subjective\n Intubated and sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 126 kg\n 143 kg ( 05:00 AM)\n +17 kg d/t fluid\n 39.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 167%\n 88 kg\n Diagnosis: hernia\n PMH : pna\n Food allergies and intolerances: peanuts\n Pertinent medications: RISS, LR, pepcid, IV abx, KPhos, Ca Gluconate,\n others noted\n Labs:\n Value\n Date\n Glucose\n 102 mg/dL\n 02:13 PM\n Glucose Finger Stick\n 109\n 02:00 PM\n BUN\n 12 mg/dL\n 02:13 PM\n Creatinine\n 0.6 mg/dL\n 02:13 PM\n Sodium\n 135 mEq/L\n 02:13 PM\n Potassium\n 4.3 mEq/L\n 02:13 PM\n Chloride\n 104 mEq/L\n 02:13 PM\n TCO2\n 25 mEq/L\n 02:13 PM\n PO2 (arterial)\n 86 mm Hg\n 02:36 PM\n PCO2 (arterial)\n 42 mm Hg\n 02:36 PM\n pH (arterial)\n 7.38 units\n 02:36 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 02:36 PM\n Albumin\n 2.7 g/dL\n 03:02 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:13 PM\n Phosphorus\n 2.0 mg/dL\n 02:13 PM\n Ionized Calcium\n 1.22 mmol/L\n 10:35 AM\n Magnesium\n 2.2 mg/dL\n 02:13 PM\n ALT\n 21 IU/L\n 03:02 AM\n Alkaline Phosphate\n 57 IU/L\n 03:02 AM\n AST\n 32 IU/L\n 03:02 AM\n Total Bilirubin\n 2.4 mg/dL\n 03:02 AM\n WBC\n 14.9 K/uL\n 02:13 PM\n Hgb\n 10.3 g/dL\n 02:13 PM\n Hematocrit\n 29.9 %\n 02:13 PM\n Current diet order / nutrition support: NPO\n GI: soft, distended, -BS\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs based on adjusted BW\n Calories: 1760-2200 (20-25 cal/kg)\n Protein: 106-132 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate\n Specifics: 47 year old male admitted with hernia. Pt taken to OR on\n for ex lap herniorrhaphy ventral hernia c/ mesh, he was taken back\n to the OR c/ perforation and has partial ileum & ascending colon\n resection c/ mesh removal and primary closure of wound/VAC placement.\n Noted plan is to start TF slowly. TF recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend Replete with Fiber @ 15 ml/hr advance q 6 hrs by 10 ml/hr to\n goal of 75 ml/hr (1800 kcals/ 112 g pro)\n Check residuals q 4 hrs hold if >150 cc\n Monitor lytes and BG with initiation of TF\n Multivitamin / Mineral supplement: via TF\n Will follow POC pls page with questions\n" }, { "category": "Respiratory ", "chartdate": "2118-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553001, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Possible air trapping\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt weaned to 40% W/10peep; but over the PM has slowly dropped his O2\n Sat. to ~90/91, Considering increasing the peep back to 12cms. ETT\n re-tied @ 23cms lip.\n, RRT 16:07\n" }, { "category": "Physician ", "chartdate": "2118-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 553129, "text": "TSICU\n HPI:\n 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Chief complaint:\n ventral hernia\n PMHx:\n pneumonia\n Current medications:\n Heparin 5000 UNIT SC TID,Insulin SC Sliding Scale,Ipratropium Bromide\n MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate IV Sliding Scale, LR at\n 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP, Midazolam 1-10 mg/hr IV\n DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Albuterol Inhaler \n PUFF IH Q4H:PRN, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Calcium\n Gluconate IV Sliding Scale, Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Fentanyl Citrate 100-200 mcg IV Q1HR PRN\n pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP, Vasopressin 1.2-3.6\n UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200 mg IV Q24H\n Vancomycin 1000 mg IV Q 12H\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 05:15 PM\n : milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n Post operative day:\n POD#4 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 11:00 AM\n Vancomycin - 07:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 250 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:30 PM\n Fentanyl - 12:04 AM\n Other medications:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.6\n HR: 107 (95 - 115) bpm\n BP: 90/49(62) {90/47(62) - 134/77(92)} mmHg\n RR: 26 (19 - 30) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 143.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (13 - 22) mmHg\n Total In:\n 6,462 mL\n 136 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,422 mL\n 136 mL\n Blood products:\n Total out:\n 3,965 mL\n 600 mL\n Urine:\n 2,915 mL\n 600 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 800 mL\n Balance:\n 2,497 mL\n -464 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 537 (537 - 667) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 26 cmH2O\n SPO2: 97%\n ABG: 7.37/47/86/24/0\n Ve: 12.5 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: right)\n Abdominal: Soft, Distended, VAC in place\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Noxious stimuli), Sedated, localizes to pain\n Labs / Radiology\n 191 K/uL\n 10.5 g/dL\n 78 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 136 mEq/L\n 30.3 %\n 11.2 K/uL\n [image002.jpg]\n 02:35 PM\n 09:29 PM\n 03:09 AM\n 10:35 AM\n 02:13 PM\n 02:36 PM\n 05:35 PM\n 07:20 PM\n 01:37 AM\n 01:45 AM\n WBC\n 15.2\n 14.6\n 14.9\n 11.2\n Hct\n 28.4\n 28.2\n 29.9\n 30.3\n Plt\n 91\n Creatinine\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 20\n 24\n 26\n 25\n 26\n 28\n Glucose\n 101\n 85\n 101\n 102\n 80\n 78\n Other labs: PT / PTT / INR:31.0/40.2/3.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.8 mg/dL, Mg:2.2\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n Neurologic:fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n Cardiovascular: Levophed and vasopressin (currently off) for MAP > 65 -\n continue to wean as tolerated; heplocked; milrinone now off\n Pulmonary: Vent dep resp failure, continue to optomize resp status,\n wean FiO2 and PEEP as tolerated\n Gastrointestinal / Abdomen: NPO/NGT, JP in place. VAC to suction.\n Nutrition: NPO. Would begin tube feeds. Impact\n Renal: f/u creat and UO.\n Hematology: f/u Hct\n stable vit K for elevated INR\n Endocrine: RISS\n Infectious Disease: vanc/zosyn/fluconazole post surgery\n Lines / Tubes / Drains: RIJ, R rad aline JP, VAC, Foley, NGT\n Wounds: abd wound w VAC\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Post-op hypotension, Post-op\n complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 min\n" }, { "category": "Nursing", "chartdate": "2118-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554315, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt s/p prolonged intubation w/sedation, now extubated, oriented to name\n only, visual hallucinations, nonsensical conversation\n Action:\n Pt reoriented frequently, Haldol 2mg ivp x1 for agitation with\n threatening language, swearing\n Response:\n Medicated with good effect, remains confused but cooperative, wrist\n restraints in place to prevent pulling of NGT\n Plan:\n Promote restful sleep at night, cont to reorient prn, medicate when\n needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated yesterday to nasal cannula, prolonged intubation postop\n with sepsis\n Action:\n OOB to chair for 2 hrs, deep breathe and cough with enc, wean to room\n air, freq mouth care\n Response:\n Pt tol well, C+R thick yellow sputum in small amts\n Plan:\n Continue pulmonary hygiene, ^ act as tolerated\n" }, { "category": "Nursing", "chartdate": "2118-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554316, "text": "ICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Altered mental status (not Delirium)\n Assessment:\n Pt s/p prolonged intubation w/sedation, now extubated, oriented to name\n only, visual hallucinations, nonsensical conversation\n Action:\n Pt reoriented frequently, Haldol 2mg ivp x1 for agitation with\n threatening language, swearing\n Response:\n Medicated with good effect, remains confused but cooperative, wrist\n restraints in place to prevent pulling of NGT\n Plan:\n Promote restful sleep at night, cont to reorient prn, medicate when\n needed\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated yesterday to nasal cannula, prolonged intubation postop\n with sepsis\n Action:\n OOB to chair for 2 hrs, deep breathe and cough with enc, wean to room\n air, freq mouth care\n Response:\n Pt tol well, C+R thick yellow sputum in small amts\n Plan:\n Continue pulmonary hygiene, ^ act as tolerated\n" }, { "category": "Respiratory ", "chartdate": "2118-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553191, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 75.3\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 500x24/+8 peep/.4\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: hiccough occ triggering vent\n Plan\n Next 24-48 hours: wean peep as tol, change to PSV if tol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures: RSBI attempted: pt\ns rr 44; attempted change to PSV\n failed d/t tachypnea; MDI for episodic wheeze.\n" }, { "category": "Physician ", "chartdate": "2118-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 554368, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n - ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : W->D dressing changes changed to TID; held on active diuresis and\n pt. ran even; continued TPN; Pt. pulled NGT several times overnight ->\n tolerating ice chips\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 08:00 PM\n NGT pulled out\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 11:00 PM\n pt pulled out NGT\n FEVER - 101.3\nF - 08:00 AM\n Post operative day:\n POD#12 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 11:06 AM\n Metronidazole - 11:49 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:46 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 11:30 PM\n Metoprolol - 12:00 AM\n Hydromorphone (Dilaudid) - 02:27 AM\n Other medications:\n Heparin 5000 UNIT SC TID, Insulin SC, Acetaminophen 650 mg PO/PR\n Q6H:PRN, Lorazepam 0.5-2 mg IV Q6H:PRN, Artificial Tear Ointment 1\n Appl BOTH EYES PRN, Bisacodyl 10 mg PO/PR DAILY, Magnesium Sulfate IV\n Sliding Scale, Calcium Gluconate IV Sliding Scale, Metoclopramide 10 mg\n IV Q6H, Metoprolol 10 mg IV Q4H, Ciprofloxacin 400 mg IV Q12H,\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Famotidine 20 mg PO Q12H,\n Potassium Chloride IV Sliding Scale, HYDROmorphone 2 mg IV Q2H:PRN,\n Potassium Phosphate IV Sliding Scale, Senna 1 TAB PO BID, Haloperidol\n 2 mg IV ONCE Duration: 1 Doses Order date: @ 0630 Haloperidol 2\n mg IV TID:PRN agitation\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.2\nC (100.8\n HR: 104 (96 - 125) bpm\n BP: 134/61(79) {134/61(79) - 179/90(121)} mmHg\n RR: 26 (22 - 41) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 7 (4 - 9) mmHg\n Total In:\n 2,851 mL\n 577 mL\n PO:\n 60 mL\n Tube feeding:\n 218 mL\n IV Fluid:\n 370 mL\n 27 mL\n Blood products:\n Total out:\n 2,825 mL\n 900 mL\n Urine:\n 2,290 mL\n 295 mL\n NG:\n 55 mL\n Stool:\n 450 mL\n 600 mL\n Drains:\n 30 mL\n 5 mL\n Balance:\n 26 mL\n -323 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases bilaterally), (Sternum: Stable )\n Abdominal: Soft, minimal bowel sounds, appropriately ttp\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 594 K/uL\n 8.0 g/dL\n 128 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 116 mEq/L\n 146 mEq/L\n 24.1 %\n 10.9 K/uL\n [image002.jpg]\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n 09:17 AM\n 02:43 AM\n 03:04 AM\n 03:17 AM\n WBC\n 13.5\n 15.0\n 12.7\n 10.9\n Hct\n 27.6\n 26.2\n 26.2\n 24.1\n Plt\n 375\n 410\n 532\n 594\n Creatinine\n 1.0\n 0.9\n 0.7\n 0.6\n 0.5\n TCO2\n 30\n 27\n 26\n 22\n Glucose\n 134\n 136\n 134\n 142\n 132\n 128\n Other labs: PT / PTT / INR:14.8/22.8/1.3, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:49/58, Alk-Phos / T bili:152/1.5,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:234 IU/L, Ca:8.6 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR same day for perforation, now s/p partial ileum\n and ascending colon resection w mesh removal and primary closure of\n wound/VAC placement.\n .\n NEUROLOGIC: haldol for agitation. Monitor confusion.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis and allowing to autodiurese, continue\n to monitor net fluid balance. Lopressor for BP and HR control.\n PULMONARY: Extubated - appears stable; speaking in full sentences;\n continue aggressive pulmonary toilet\n GI / ABD: NPO, JP drain in place. W-->D dressing changes. Follow LFTS\n and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr until NGT\n pulled and replaced several times; TPN; consider starting oral intake\n today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: Stable\n ENDOCRINE: RISS\n ID: Started on Cipro/flagyl for Enterobacter Cloacae\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W->D gauze dressings - change .\n IMAGING: none pending\n FLUIDS: KVO, replete K and phosphate as needed.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n TPN w/ Lipids - 05:48 PM 91. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553188, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhonchorous upper fields, coarse crackles lower fields.\n Thin white sputum in moderate amounts loosens particularly with\n turning. SPO2 97-100%. PaO2 140\ns-150\ns on 2 normal ABG\n Action:\n Weaned FiO2 to 40%. Pulmonary toileting practiced. VAP care per\n protocol.\n Response:\n Tolerating vent changes well. Did not tolerate CPAP+PSV trial (became\n tachypnic).\n Plan:\n Diurese today then wean vent as tolerated.\n Acute Pain\n Assessment:\n Obtunded / lethargic / and withdrawn. Appears comfortable at rest.\n Tolerates turns, becomes purple in the face but quickly settles with no\n hemodynamic or respiratory compromise, but does become mildly\n tachycardic and relatively hypertensive.\n Action:\n Fentanyl gtt weaned off.\n Response:\n Remains comfortable at rest and tolerates turns and care, remains\n withdrawn.\n Plan:\n Use ordered prn fentanyl as indicated for pain.\n" }, { "category": "Respiratory ", "chartdate": "2118-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553268, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was attempted on PSV x 3 today and almost immediately develops a\n very high RR to 40\ns and ends up back to CMV.\n Then relaxes and appears almost normal ??\n, RRT 19:13\n" }, { "category": "Nursing", "chartdate": "2118-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553269, "text": "47 yo male admitted s/p ventral hernia. Pt c/o abdominal pain\n since , ongoing anorexia, pain, intermittent\n diarrhea/N/V. pt had ventral hernia repair with mesh placement;\n pt experienced tachycardia, abdominal pain, vomiting, decreasing UO and\n stool via NGT/JP drain in PACU. Pt brought back to OR for\n re-exploration, washout, removal of mesh, ileocolectomy and placement\n of VAC dressing. Pt remains in TSICU for care.\n Hernia, ventral / incisional\n Assessment:\n Abdomen with VAC dressing in place, last change done on in room by\n surgical team. Dressing is intact, drainage via VAC is serous,\n moderate. Under dressing, some adipose/subcutaneous tissue can be\n seen, team aware. Pt appears to be comfortable, does not seem to be\n experiencing pain at rest/with activity, coughing/repositioning. Pt\n not requiring pain medication, fentanyl gtt remains off. Pt arouses to\n voice, does not follow commands, does not communicate effectively\n (questionably nodding to respond).\n Action:\n Pain continuously assessed, no medication required throughout shift.\n Response:\n Pt appears to be comfortable, tolerating activity/repositioning/ET\n tube/VAC dressing.\n Plan:\n Continue to assess pain, treat as needed, reorient pt as needed while\n pt becomes more alert. Continue to support pt and family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented on CMV, PEEP 8, 40% FiO2, TV 500, RR 24-pt breathing\n over the vent 25-31 breaths/min. Suctioned for thick, white sputum,\n has strong, productive cough. Lung sounds clear in upper lobes,\n diminished at bases, bilaterally. O2 sats 96-100%.\n Action:\n Pt diuresed with 10mg lasix IV x2, attempted to place pt on CPAP/PS\n with high support, pt became tachypnic RR >40, did not tolerate.\n Response:\n ABG showed metabolic alkalosis after first dose of lasix. Pt remains\n on CMV. Pt diuresed 500cc with each dose of lasix, negative 1.5 liters\n for the day.\n Plan:\n Continue to wean the vent as tolerated, pulmonary toilet, continue to\n diurese pt as tolerated. Continue to support pt and family.\n" }, { "category": "Physician ", "chartdate": "2118-01-31 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 553357, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n Post operative day:\n POD#6 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:00 PM\n Famotidine (Pepcid) - 07:46 PM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,Magnesium Sulfate IV Sliding\n Scale, Acetaminophen 650 mg PR Q6H, Midazolam 1-10 mg/hr IV DRIP\n TITRATE TO sedation, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium\n Gluconate IV Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Potassium Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H,\n Potassium Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV\n Q1HR PRN, Fentanyl Citrate 100-500 mcg/hr, Fluconazole 200 mg IV Q24H,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38\nC (100.4\n HR: 116 (105 - 117) bpm\n BP: 134/73(94) {109/55(71) - 143/82(102)} mmHg\n RR: 27 (24 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (9 - 21)mmHg\n Total In:\n 1,601 mL\n 204 mL\n PO:\n TF:\n IVF:\n 1,601 mL\n 204 mL\n Blood products:\n Total out:\n 4,160 mL\n 552 mL\n Urine:\n 2,565 mL\n 402 mL\n NG:\n 550 mL\n 150 mL\n Stool:\n Drains:\n 1,045 mL\n Balance:\n -2,559 mL\n -348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 502 (502 - 502) mL\n RR (Set): 24\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 96%\n ABG: 7.49/39/147/28/6\n Ve: 14.6 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: Well nourished, No acute distress, intubated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), mo m/r/g, slightly\n tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed), bilateral lower extrem warm\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), slightly coarse throughout /\n transmitted upper airway sounds\n Abdominal: Soft, wound vac in place, no bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 222 K/uL\n 10.0 g/dL\n 114 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 142 mEq/L\n 29.0 %\n 6.4 K/uL\n [image002.jpg]\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n WBC\n 11.2\n 8.9\n 9.1\n 6.4\n Hct\n 30.3\n 29.5\n 28.7\n 29.0\n Plt\n 191\n 191\n 193\n 222\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 80\n 78\n 100\n 97\n 105\n 114\n Other labs: PT / PTT / INR:13.6/30.4/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:30/62, Alk Phos / T Bili:79/6.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: Off pressor medication; continue diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated,\n continue CMV\n GI / ABD: NPO/NGT, JP in place. VAC to suction. RUQ ultrasound for\n elevated bilirubin\n NUTRITION: NPO. Start TPN today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery. Resite CVL\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition: NPO for now\n will consider TPN v. TF today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2118-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553338, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 7\n Ideal body weight: 75.\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C500x24/+8 peep/.4\n Visual assessment of breathing pattern: episodic tachypnea\n Assessment of breathing comfort: mildly tachypneic with rr high 20's\n -32\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Unable to measure RSBI as pt\ns rr immediately goes into 40\ns when\n support reduced.\n" }, { "category": "Nursing", "chartdate": "2118-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553448, "text": "Today\ns Events:\n ~New Central Line Placement (Left IJ)\n ~Removal of old Central Line (Right IJ) and Tip\n cultured\n ~Abdominal Ultrasound\n ~Wound Vac dressing changed\n ~Blood cultures drawn for increased temp\n Hernia, ventral / incisional\n Assessment:\n Pt has serous drainage in JP to bulb suction. Vac dsg on abdominal\n wound at 125mmHg of suction, draining serosanguinous fluid. BS absent.\n NG to suction.\n Action:\n Vac dsg changed today with some debridement. Abdominal Ultrasound\n done. Pt starting on TPN this evening.\n Response:\n Minimal drainage from JP drain. Per Surgery team, next vac dsg change,\n the team will change to a wet to dry dressing.\n Plan:\n Continue to monitor drainage and start TPN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhoncherous. Moderate amt of thin white secretions\n suctioned. Pt 30 liters positive. Pt on CMV 24/500 40%FiO2 and 0 of\n PEEP. O2 sats wnl. Pt in metabolic alkalosis.\n Action:\n Pt given 20mg of lasix. Vent setting remained the same. \n performed.\n Response:\n Increased urine output . Pt is neg 2.8 liters so far today. O2 sats\n remain adequate. During pt became tachypneic and had a score in\n the high 300s.\n Plan:\n Wean to PS as tolerated. ?Diamox tmr for met. Alkalosis. Continue\n diuresis.\n Acute Pain\n Assessment:\n Pt only arousable to pain with turns and procedures. Pt was grimacing\n during wound vac dsg change. Pt is tachycardic and diaphoretic.\n Action:\n Pt given PRN fentanyl and Ativan for pain and agitation.\n Response:\n Pt, per nonverbal cues, shows pain relieved with medication.\n Plan:\n Continue to monitor pain and give pain medication as needed.\n" }, { "category": "Physician ", "chartdate": "2118-01-31 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 553327, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n Post operative day:\n POD#6 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:00 PM\n Famotidine (Pepcid) - 07:46 PM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,Magnesium Sulfate IV Sliding\n Scale, Acetaminophen 650 mg PR Q6H, Midazolam 1-10 mg/hr IV DRIP\n TITRATE TO sedation, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium\n Gluconate IV Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Potassium Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H,\n Potassium Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV\n Q1HR PRN, Fentanyl Citrate 100-500 mcg/hr, Fluconazole 200 mg IV Q24H,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38\nC (100.4\n HR: 116 (105 - 117) bpm\n BP: 134/73(94) {109/55(71) - 143/82(102)} mmHg\n RR: 27 (24 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (9 - 21)mmHg\n Total In:\n 1,601 mL\n 204 mL\n PO:\n TF:\n IVF:\n 1,601 mL\n 204 mL\n Blood products:\n Total out:\n 4,160 mL\n 552 mL\n Urine:\n 2,565 mL\n 402 mL\n NG:\n 550 mL\n 150 mL\n Stool:\n Drains:\n 1,045 mL\n Balance:\n -2,559 mL\n -348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 502 (502 - 502) mL\n RR (Set): 24\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 96%\n ABG: 7.49/39/147/28/6\n Ve: 14.6 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: Well nourished, No acute distress, intubated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), mo m/r/g, slightly\n tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed), bilateral lower extrem warm\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), slightly coarse throughout /\n transmitted upper airway sounds\n Abdominal: Soft, wound vac in place, no bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 222 K/uL\n 10.0 g/dL\n 114 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 142 mEq/L\n 29.0 %\n 6.4 K/uL\n [image002.jpg]\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n WBC\n 11.2\n 8.9\n 9.1\n 6.4\n Hct\n 30.3\n 29.5\n 28.7\n 29.0\n Plt\n 191\n 191\n 193\n 222\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 80\n 78\n 100\n 97\n 105\n 114\n Other labs: PT / PTT / INR:13.6/30.4/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:30/62, Alk Phos / T Bili:79/6.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: Off pressor medication; continue diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO. Start TPN today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition: NPO for now\n will consider TPN v. TF today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-01-31 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 553433, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n Post operative day:\n POD#6 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:00 PM\n Famotidine (Pepcid) - 07:46 PM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,Magnesium Sulfate IV Sliding\n Scale, Acetaminophen 650 mg PR Q6H, Midazolam 1-10 mg/hr IV DRIP\n TITRATE TO sedation, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium\n Gluconate IV Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Potassium Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H,\n Potassium Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV\n Q1HR PRN, Fentanyl Citrate 100-500 mcg/hr, Fluconazole 200 mg IV Q24H,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12\n Flowsheet Data as of 05:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38\nC (100.4\n HR: 116 (105 - 117) bpm\n BP: 134/73(94) {109/55(71) - 143/82(102)} mmHg\n RR: 27 (24 - 35) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (9 - 21)mmHg\n Total In:\n 1,601 mL\n 204 mL\n PO:\n TF:\n IVF:\n 1,601 mL\n 204 mL\n Blood products:\n Total out:\n 4,160 mL\n 552 mL\n Urine:\n 2,565 mL\n 402 mL\n NG:\n 550 mL\n 150 mL\n Stool:\n Drains:\n 1,045 mL\n Balance:\n -2,559 mL\n -348 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 502 (502 - 502) mL\n RR (Set): 24\n RR (Spontaneous): 9\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 96%\n ABG: 7.49/39/147/28/6\n Ve: 14.6 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: Well nourished, No acute distress, intubated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), mo m/r/g, slightly\n tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed), bilateral lower extrem warm\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), slightly coarse throughout /\n transmitted upper airway sounds\n Abdominal: Soft, wound vac in place, no bowel sounds\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 222 K/uL\n 10.0 g/dL\n 114 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.3 mEq/L\n 12 mg/dL\n 107 mEq/L\n 142 mEq/L\n 29.0 %\n 6.4 K/uL\n [image002.jpg]\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n WBC\n 11.2\n 8.9\n 9.1\n 6.4\n Hct\n 30.3\n 29.5\n 28.7\n 29.0\n Plt\n 191\n 191\n 193\n 222\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 80\n 78\n 100\n 97\n 105\n 114\n Other labs: PT / PTT / INR:13.6/30.4/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:30/62, Alk Phos / T Bili:79/6.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: Off pressor medication; continue diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated,\n continue CMV\n GI / ABD: NPO/NGT, JP in place. VAC to suction. RUQ ultrasound for\n elevated bilirubin\n NUTRITION: NPO. Start TPN today\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery. Resite CVL\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition: NPO for now\n will consider TPN v. TF today\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553439, "text": "Today\ns Events:\n ~New Central Line Placement (Left IJ)\n ~Removal of old Central Line (Right IJ) and Tip\n cultured\n ~Abdominal Ultrasound\n ~Wound Vac dressing changed\n ~Blood cultures drawn for increased temp\n Hernia, ventral / incisional\n Assessment:\n Pt has serous drainage in JP to bulb suction. Vac dsg on abdominal\n wound at 125mmHg of suction, draining serosanguinous fluid. BS absent.\n NG to suction.\n Action:\n Vac dsg changed today with some debridement. Abdominal Ultrasound\n done. Pt starting on TPN this evening.\n Response:\n Minimal drainage from JP drain. Per Surgery team, next vac dsg change,\n the team will change to a wet to dry dressing.\n Plan:\n Continue to monitor drainage and start TPN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhoncherous. Moderate amt of thin white secretions\n suctioned. Pt 30 liters positive. Pt on CMV 24/500 40%FiO2 and 0 of\n PEEP. O2 sats wnl. Pt in metabolic alkalosis.\n Action:\n Pt given 20mg of lasix. Vent setting remained the same. \n performed.\n Response:\n Increased urine output . Pt is neg 2.8 liters so far today. O2 sats\n remain adequate. During pt became tachypneic and had a score in\n the high 300s.\n Plan:\n Wean to PS as tolerated. ?Diamox tmr for met. Alkalosis. Continue\n diuresis.\n Acute Pain\n Assessment:\n Pt only arousable to pain with turns and procedures. Pt was grimacing\n during wound vac dsg change. Pt is tachycardic and diaphoretic.\n Action:\n Pt given PRN fentanyl and Ativan for pain and agitation.\n Response:\n Pt, per nonverbal cues, shows pain relieved with medication.\n Plan:\n Continue to monitor pain and give pain medication as needed.\n" }, { "category": "Nursing", "chartdate": "2118-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553521, "text": "Acute Pain\n Assessment:\n Htn and tachy with turns.medicated with fentanyl 50 mics times 2 and\n ativan 1 mg iv once . pt also required labetalol 10 mg iv times 2 doses\n for htn.\n Action:\n Response:\n Bp improved after sedation and labetalol\n Plan:\n Assess for pain, agitation and medicate as necessary prn. If elevated\n bp/hr persist check with ho regarding increased labetalol .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioned frequently for sm to mod white . attempted risbi by resp\n this am failed resp rate increased to 50. temp to 101.5 tylenol 650 pr\n Action:\n Suctioned q 2-3 hours for sm to mod white. Lasix 20 mg iv given as\n ordered at 2400 to diurese\n Response:\n Good diuresis.\n Plan:\n Send sputum cx\n Hernia, ventral / incisional\n Assessment:\n Vac dressing to open abd incision, jp draining seous. Rash on\n back/abdomen/flanks.. dr . Rectal drainage tan liquid wih a very\n foul odor. Temp to 101.5 tylenol 650 mg pr given times\n Action:\n Tylenol for temp. dr viewed rash no change in tx.\n Response:\n Pt continues with temp.\n Plan:\n Monitor blood cx. Check with ho regarding orders to send urine cx,\n sputum cx.\n" }, { "category": "Respiratory ", "chartdate": "2118-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553491, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: Attempted RSBI resulted in rr reaching 50 in < 20\n seconds. Measurement terminated.\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553679, "text": "Hernia, ventral / incisional\n Assessment:\n Patient with abdominal incison to vac dressing. JP to right side of\n abdomen. High residual last evening after starting trophic TFs, now\n residuals <100. large amounts of liquid stool\n Action:\n VAC dressing maintained. Trophic TF restarted. Fecal incontinence bag\n placed to control stool output\n Response:\n No changes in VAC dressing. Feeding not to be advanced.\n Plan:\n ? reglan if high residuals continue. ? increase TF to a goal rate.\n Follow up with team regarding VAC dressing change.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains orally intubated and on vent settings as charted. Increasingly\n Tachypneic when more alert.\n Action:\n Weaned pressure support as tolerated. Medicated with ativan and\n fentanyl when patient appeared restless/agitated\n Response:\n Continues to require 18-20 of pressure support to maintain RR <40\n Plan:\n Wean vent if tolerated. Continue to medicated PRN>\n Electrolyte & fluid disorder, other\n Assessment:\n Total body overload. Negative about 7.5 liters at midnite, since\n midnite about 1.5 liters negative. Continues to be hypokalemic\n Action:\n Midnite dose of diamox held after very large diuresis with Ethacrynate\n Sodium Sodium dose (diuresed over 3 liters after 8pm dose of\n Ethacrynate Sodium. Potassium repleted as indicated.\n Response:\n Remains total body overloaded, weight down. K+ maintained WNL\n Plan:\n Continue diuresis as tolerated hemodynamically. Follow electrolytes\n closely and treat as indicated.\n" }, { "category": "Respiratory ", "chartdate": "2118-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553588, "text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min); Comments: pt weaned to PSV this shift and\n has transient periods of tachpynea. PSV increased to +20 and pt\n appears much more comfortable. Vt ~600s RR low 20s.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: wean PSV as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1400\n no complications.\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553655, "text": "Hernia, ventral / incisional\n Assessment:\n Patient with abdominal incison to vac dressing. JP to right side of\n abdomen. High residual last evening after starting trophic TFs, now\n residuals <100. large amounts of liquid stool\n Action:\n VAC dressing maintained. Trophic TF restarted. Fecal incontinence bag\n placed to control stool output\n Response:\n No changes in VAC dressing. Feeding not to be advanced.\n Plan:\n ? reglan if high residuals continue. ? increase TF to a goal rate.\n Follow up with team regarding VAC dressing change.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains orally intubated and on vent settings as charted. Increasingly\n Tachypneic when more alert.\n Action:\n Weaned pressure support as tolerated. Medicated with ativan and\n fentanyl when patient appeared restless/agitated\n Response:\n Continues to require 18-20 of pressure support to maintain RR <40\n Plan:\n Wean vent if tolerated. Continue to medicated PRN>\n Electrolyte & fluid disorder, other\n Assessment:\n Total body overload. Negative about 7.5 liters at midnite, since\n midnite about 1.5 liters negative. Continues to be hypokalemic\n Action:\n Midnite dose of diamox held after very large diuresis with Ethacrynate\n Sodium Sodium dose (diuresed over 3 liters after 8pm dose of\n Ethacrynate Sodium. Potassium repleted as indicated.\n Response:\n Remains total body overloaded, weight K+ maintained WNL\n Plan:\n Continue diuresis as tolerated hemodynamically. Follow electrolytes\n closely and treat as indicated.\n" }, { "category": "Physician ", "chartdate": "2118-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 553659, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Potassium\n Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV Q1HR PRN,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12H, Ethacrynic acid, Acetazolamide, Lopressor, Lorazepam.\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today. Aim to keep phos> 3. Monitoring LFTs and INR.\n Received 10mg SC vit K.\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; Ultrasound RUQ -> prelim read\n negative\n .\n 24 HOUR EVENTS:\n : Lasix dc'd due to rash. Started on ethacrynic acid- huge diuresis\n overnight. Lopressor started instead of labetolol. Continue day 2 of\n TPN. Trophic tube feeds started but residuals> 100cc so held briefly\n overnight. Switched to pressure support. Sputum, stool and UC sent. Ct\n head performed due to sluggish dilated right pupil-no acute pathology.\n Fluconazole dc'd due to rising bilirubin. Spiked a temp overnight- BC\n sent.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n 24 Hour Events:\n SPUTUM CULTURE - At 10:40 AM\n URINE CULTURE - At 10:50 AM\n BLOOD CULTURED - At 12:51 AM\n FEVER - 101.4\nF - 12:00 AM\n Post operative day:\n POD#8 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:16 PM\n Metoprolol - 12:01 AM\n Lorazepam (Ativan) - 12:16 AM\n Heparin Sodium (Prophylaxis) - 02:01 AM\n Fentanyl - 02:39 AM\n Other medications:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.7\nC (99.9\n HR: 107 (98 - 123) bpm\n BP: 120/73(88) {120/34(79) - 1,133/92(115)} mmHg\n RR: 34 (15 - 40) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 6 (3 - 16) mmHg\n Total In:\n 2,851 mL\n 582 mL\n PO:\n Tube feeding:\n 80 mL\n 26 mL\n IV Fluid:\n 1,701 mL\n 258 mL\n Blood products:\n Total out:\n 10,325 mL\n 2,260 mL\n Urine:\n 9,500 mL\n 1,950 mL\n NG:\n 550 mL\n Stool:\n Drains:\n 275 mL\n 10 mL\n Balance:\n -7,474 mL\n -1,678 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 650 (516 - 801) mL\n PS : 18 cmH2O\n RR (Set): 24\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: 7.48/37/178/29/4\n Ve: 14 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, puplils appear equal this a.m. and equally reactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Appears more responsive to verbal stimuli but not following commands\n Labs / Radiology\n 326 K/uL\n 11.2 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 106 mEq/L\n 141 mEq/L\n 32.9 %\n 12.4 K/uL\n [image002.jpg]\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n WBC\n 6.4\n 8.2\n 12.4\n Hct\n 29.0\n 28.3\n 32.9\n Plt\n 222\n 236\n 326\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.8\n TCO2\n 32\n 31\n 32\n 31\n 27\n 28\n Glucose\n 105\n 114\n 160\n 128\n 138\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:80/122, Alk-Phos / T bili:92/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.5 mg/dL, Mg:2.1\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Not following commands.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: diuresis with ethacrynic acid and acetazolamide.\n Lopressor for BP and HR control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS.\n GI / ABD: NPO/NGT, JP drain in place. VAC to suction. Follow LFTS and\n bilirubin.\n NUTRITION: Trophic tube feeds and TPN.\n TPN without Lipids - 06:48 PM 45. mL/hour\n Replete (Full) - 05:12 AM 20 mL/hour\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO. Replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis:\n ICU Care\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2118-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 553822, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : d/c diuretics as 7L neg yesterday; VAC changed to W->D;\n continuing to wean vent as tolerated; changed fentanyl to dilaudid prn\n and pt. doing well\n .\n MEDICAL: pneumonia\n 24 Hour Events:\n FEVER - 102.1\nF - 12:00 AM\n Post operative day:\n POD#9 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 05:03 PM\n Heparin Sodium (Prophylaxis) - 05:29 PM\n Fentanyl - 06:02 PM\n Famotidine (Pepcid) - 08:00 PM\n Metoprolol - 04:03 AM\n Hydromorphone (Dilaudid) - 04:03 AM\n Other medications:\n Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Lorazepam 0.5-2 mg IV\n Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN, Magnesium Sulfate IV\n Sliding Scale, Albuterol Inhaler PUFF IH Q4H:PRN, Metoprolol\n Tartrate 5 mg IV Q6H, Metoclopramide 10 mg IV Q6H, Bisacodyl 10 mg\n PO/PR DAILY, Metoprolol Tartrate 5 mg IV Q4H, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine\n Gluconate 0.12% Oral Rinse 15 ml ORAL , Potassium Chloride IV\n Sliding Scale, Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID,\n HYDROmorphone, Heparin 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg\n IV Q 12H\n Flowsheet Data as of 06:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 38.3\nC (101\n HR: 100 (91 - 121) bpm\n BP: 132/67(84) {97/52(65) - 143/80(95)} mmHg\n RR: 35 (18 - 35) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 10 (3 - 14) mmHg\n Total In:\n 3,218 mL\n 814 mL\n PO:\n Tube feeding:\n 175 mL\n 65 mL\n IV Fluid:\n 1,508 mL\n 142 mL\n Blood products:\n Total out:\n 9,505 mL\n 1,130 mL\n Urine:\n 7,995 mL\n 805 mL\n NG:\n Stool:\n 300 mL\n Drains:\n 10 mL\n 25 mL\n Balance:\n -6,287 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 660 (572 - 808) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 69\n PIP: 24 cmH2O\n SPO2: 96%\n ABG: 7.47/40/162/26/5\n Ve: 14 L/min\n PaO2 / FiO2: 405\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), slightly tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: slightly diminished at bases)\n Abdominal: Soft, midline abdominal wound with wet to dry dressing; no\n abdominal sounds; diffuse ttp\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: erythema on torso much decreased\n Neurologic: (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 375 K/uL\n 9.4 g/dL\n 136 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 24 mg/dL\n 111 mEq/L\n 142 mEq/L\n 27.6 %\n 13.5 K/uL\n [image002.jpg]\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n WBC\n 8.2\n 12.4\n 13.5\n Hct\n 28.3\n 32.9\n 27.6\n Plt\n \n Creatinine\n 0.6\n 0.8\n 1.0\n 0.9\n TCO2\n 31\n 32\n 31\n 27\n 28\n 30\n Glucose\n 160\n 128\n 138\n 134\n 136\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:71/81, Alk-Phos / T bili:98/2.6,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.3 mg/dL, Mg:2.3\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR same day for perforation, now s/p partial ileum\n and ascending colon resection w mesh removal and primary closure of\n wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: Held diuresis after am dose of ethacrinic acid -> as\n was 6L neg - will monitor today and consider lower dose for further\n diuresis. Lopressor for BP and HR control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS.\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W-> dressings - change \n IMAGING: am CXR\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Replete (Full) - 12:10 PM 10 mL/hour\n TPN without Lipids - 05:00 PM 91. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554511, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n - ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : W->D dressing changes changed to TID; held on active diuresis and\n pt. ran even; continued TPN; Pt. pulled NGT several times overnight ->\n tolerating ice chips\n Altered mental status (not Delirium)\n Assessment:\n Pt oriented x2-3 as of end of shift, appropriate, pleasant, cooperative\n Action:\n Reoriented as needed, up to chair x2, several hours each time,\n transfers well with assist\n Response:\n Tolerated activity well, lucid all day, no agitation, pt c/o being\n bored\n Plan:\n Call out to floor when sitter available\n Electrolyte & fluid disorder, other\n Assessment:\n Pt continues with TPN, NG pulled out x2 overnight\n Action:\n Clear liqs started, may advance as tolerated\n Response:\n Pt took> 2L water, applesauce, tol well, loose stool x2 in very small\n amts\n Plan:\n Advance diet as tolerated\n Hernia, ventral / incisional\n Assessment:\n Pt with open abd wound, dsg changes TID\n Action:\n W to D dsg changed, packed with 3 Kerlex rolls, 4 abd on top\n Response:\n Pt tolerated well- premedicated with Dialudid 2mg ivp, wound bed is\n red, granulating, with fibrous tan dge, serosang dge. Wound edges have\n small areas of necrosis\n Plan:\n Dsg changes TID, optimize nutrition\n" }, { "category": "Nursing", "chartdate": "2118-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554227, "text": "Altered mental status\n Assessment:\n Riker scale of 6, tachycardia, hypertension, tachypnea, hallucinations,\n vulgar language.\n Action:\n Verbal re-orientation strategies, established calm, quite environment,\n lorazepam administration, haldol administration, soft wrist restraint\n used\n Response:\n Appropriate response to haldol administration, Riker scale down to 3,\n VS stabilized.\n Plan:\n Continue to monitor and assess mental status q 1 hr and prn, treat with\n non-invasive re-orientation strategies first, then use lorazepam and\n haldol to treat acute agitation as ordered, Restraint use PRN to\n protect pt and pt\ns tubes/lines/drains.\n Hernia, ventral / incisional\n Assessment:\n Large abdominal wound s/p VAC therapy, moderate straw/pink colored\n serous drainage, foul odor, unable to approximate, tunneling and\n undermining ( R side greater than the L), will require ongoing\n measurements.\n Action:\n Abdominal dressing changed with sterile saline applied to 3 Kerlix and\n packed gently with Q-tip assistance.\n Response:\n Minimal black eschar and moderate amt of fibrin slough removed with\n dressing change, significant pain with wound packing despite pain\n medication, some red granulation tissue note along L lateral boarder of\n abdominal wound.\n Plan:\n Continue to dressing changes wet to dry as ordered, consider an\n abdominal binder or straps to add stability to healing wound\n environment.\n" }, { "category": "Physician ", "chartdate": "2118-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 554237, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Insulin SC Sliding Scale,Ipratropium Bromide MDI 2\n PUFF IH Q4H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN, Lorazepam 0.5-2 mg\n IV Q6H:PRN agitation, Albuterol Inhaler PUFF IH Q4H:PRN, Magnesium\n Sulfate IV Sliding Scale,Metoclopramide 10 mg IV Q6H, Bisacodyl 10 mg\n PO/PR DAILY, Metoprolol Tartrate 10 mg IV Q4H, Calcium Gluconate IV\n Sliding Scale, MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Potassium\n Chloride IV Sliding Scale, Ciprofloxacin 400 mg IV Q12H, Potassium\n Phosphate IV Sliding Scale, Famotidine 20 mg IV Q12H, HYDROmorphone\n (Dilaudid) 2 mg IV Q2H:PRN, Heparin 5000 UNIT SC TID.\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today. Aim to keep phos> 3. Monitoring LFTs and INR.\n Received 10mg SC vit K.\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; Ultrasound RUQ -> prelim read\n negative\n : Lasix dc'd due to rash. Started on ethacrynic acid- huge diuresis\n overnight. Lopressor started instead of labetolol. Continue day 2 of\n TPN. Trophic tube feeds started but residuals> 100cc so held briefly\n overnight. Switched to pressure support. Sputum, stool and UC sent. Ct\n head performed due to sluggish dilated right pupil-no acute pathology.\n Fluconazole dc'd due to rising bilirubin. Spiked a temp overnight- BC\n sent.\n : d/c diuretics as 7L neg yesterday; VAC changed to W->D;\n continuing to wean vent as tolerated; changed fentanyl to dilaudid prn\n and pt. doing well\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source.\n 24 HOUR EVENTS:\n :Extubated, appears confused. SC from positive for\n Enterobacter cloacae- switched to cipro and flagyl. Further diuresis\n witheld today. Had Upper and Lower ext US- no DVT, but small non\n occluding clot left cephalic vein.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: cipro/flagyl started \n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n : SC-25 PMNs and <10 epithelial cells/100X field. ENTEROBACTER\n CLOACAE.SPARSE GROWTH.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n : Upper and lower ext US: no DVT\n .\n 24 Hour Events:\n ULTRASOUND - At 11:06 AM\n upper and lower ext.\n INVASIVE VENTILATION - STOP 12:34 PM\n FEVER - 101.6\nF - 03:00 PM\n Post operative day:\n POD#11 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 11:06 AM\n Ciprofloxacin - 05:00 PM\n Metronidazole - 11:49 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:16 AM\n Famotidine (Pepcid) - 08:33 PM\n Metoprolol - 08:56 PM\n Hydromorphone (Dilaudid) - 03:45 AM\n Lorazepam (Ativan) - 05:05 AM\n Haloperidol (Haldol) - 05:08 AM\n Other medications:\n Flowsheet Data as of 06:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 38.3\nC (100.9\n HR: 118 (94 - 132) bpm\n BP: 161/79(106) {134/58(80) - 178/94(122)} mmHg\n RR: 32 (20 - 40) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 7 (2 - 15) mmHg\n Total In:\n 5,123 mL\n 687 mL\n PO:\n Tube feeding:\n 1,646 mL\n 62 mL\n IV Fluid:\n 1,270 mL\n 31 mL\n Blood products:\n Total out:\n 3,075 mL\n 1,070 mL\n Urine:\n 2,035 mL\n 545 mL\n NG:\n 120 mL\n 55 mL\n Stool:\n 900 mL\n 450 mL\n Drains:\n 20 mL\n 20 mL\n Balance:\n 2,048 mL\n -383 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 762 (475 - 762) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 96%\n ABG: 7.47/30/121/23/0\n Ve: 19.1 L/min\n PaO2 / FiO2: 303\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: Follows simple commands, Moves all extremities, Agitated\n Labs / Radiology\n 532 K/uL\n 8.9 g/dL\n 132 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 26.2 %\n 12.7 K/uL\n [image002.jpg]\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n 09:17 AM\n 02:43 AM\n 03:04 AM\n WBC\n 13.5\n 15.0\n 12.7\n Hct\n 27.6\n 26.2\n 26.2\n Plt\n 375\n 410\n 532\n Creatinine\n 1.0\n 0.9\n 0.7\n 0.6\n TCO2\n 28\n 30\n 27\n 26\n 22\n Glucose\n 134\n 136\n 134\n 142\n 132\n Other labs: PT / PTT / INR:14.8/22.8/1.3, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:54/53, Alk-Phos / T bili:129/1.5,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.0 mmol/L, Albumin:2.5 g/dL, LDH:234 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation. Monitor confusion and agitation\n Haldol as needed.\n Neuro checks Q:4H\n Pain: dilaudid for pain PRN with dressing changes and movement\n CARDIOVASCULAR: holding diuresis and allowing to autodiurese, continue\n to monitor net fluid balance. Lopressor for BP and HR control.\n PULMONARY: Extubated- remained extubated, pulmonary toilet and OOB\n today.\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n d/w advance TF with primary team.\n Replete with Fiber (Full) - 01:06 PM 10 mL/hour\n TPN w/ Lipids - 05:51 PM 91. mL/hour\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: Stable\n ENDOCRINE: RISS\n ID: Started on Cipro/flagyl for Enterobacter Cloacae and Flagyl\n empiric GI coverage for c/o C. Diff\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n WOUNDS: abd wound w/ W->D gauze dressings - change QID.\n IMAGING: none pending\n FLUIDS: KVO, replete K and phosphate as needed.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE - HOB elevation\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Respiratory Failure; Post-op Complication.\n ICU Care\n Total time spent: 14\n" }, { "category": "Physician ", "chartdate": "2118-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 554429, "text": "TSICU\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n - ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : W->D dressing changes changed to TID; held on active diuresis and\n pt. ran even; continued TPN; Pt. pulled NGT several times overnight ->\n tolerating ice chips\n 24 Hour Events:\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 08:00 PM\n NGT pulled out\n UNPLANNED LINE/CATHETER REMOVAL (PATIENT INITIATED) - At \n 11:00 PM\n pt pulled out NGT\n FEVER - 101.3\nF - 08:00 AM\n Post operative day:\n POD#12 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:20 AM\n Piperacillin/Tazobactam (Zosyn) - 11:06 AM\n Metronidazole - 11:49 PM\n Ciprofloxacin - 10:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:46 AM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Haloperidol (Haldol) - 11:30 PM\n Metoprolol - 12:00 AM\n Hydromorphone (Dilaudid) - 02:27 AM\n Other medications:\n Heparin 5000 UNIT SC TID, Insulin SC, Acetaminophen 650 mg PO/PR\n Q6H:PRN, Lorazepam 0.5-2 mg IV Q6H:PRN, Artificial Tear Ointment 1\n Appl BOTH EYES PRN, Bisacodyl 10 mg PO/PR DAILY, Magnesium Sulfate IV\n Sliding Scale, Calcium Gluconate IV Sliding Scale, Metoclopramide 10 mg\n IV Q6H, Metoprolol 10 mg IV Q4H, Ciprofloxacin 400 mg IV Q12H,\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Famotidine 20 mg PO Q12H,\n Potassium Chloride IV Sliding Scale, HYDROmorphone 2 mg IV Q2H:PRN,\n Potassium Phosphate IV Sliding Scale, Senna 1 TAB PO BID, Haloperidol\n 2 mg IV ONCE Duration: 1 Doses Order date: @ 0630 Haloperidol 2\n mg IV TID:PRN agitation\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.2\nC (100.8\n HR: 104 (96 - 125) bpm\n BP: 134/61(79) {134/61(79) - 179/90(121)} mmHg\n RR: 26 (22 - 41) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 7 (4 - 9) mmHg\n Total In:\n 2,851 mL\n 577 mL\n PO:\n 60 mL\n Tube feeding:\n 218 mL\n IV Fluid:\n 370 mL\n 27 mL\n Blood products:\n Total out:\n 2,825 mL\n 900 mL\n Urine:\n 2,290 mL\n 295 mL\n NG:\n 55 mL\n Stool:\n 450 mL\n 600 mL\n Drains:\n 30 mL\n 5 mL\n Balance:\n 26 mL\n -323 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: at bases bilaterally), (Sternum: Stable )\n Abdominal: Soft, minimal bowel sounds, appropriately ttp; dry dressing.\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 594 K/uL\n 8.0 g/dL\n 128 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 14 mg/dL\n 116 mEq/L\n 146 mEq/L\n 24.1 %\n 10.9 K/uL\n [image002.jpg]\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n 09:17 AM\n 02:43 AM\n 03:04 AM\n 03:17 AM\n WBC\n 13.5\n 15.0\n 12.7\n 10.9\n Hct\n 27.6\n 26.2\n 26.2\n 24.1\n Plt\n 375\n 410\n 532\n 594\n Creatinine\n 1.0\n 0.9\n 0.7\n 0.6\n 0.5\n TCO2\n 30\n 27\n 26\n 22\n Glucose\n 134\n 136\n 134\n 142\n 132\n 128\n Other labs: PT / PTT / INR:14.8/22.8/1.3, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:49/58, Alk-Phos / T bili:152/1.5,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.0 mmol/L, Albumin:2.3 g/dL, LDH:234 IU/L, Ca:8.6 mg/dL, Mg:2.2\n mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR same day for perforation, now s/p partial ileum\n and ascending colon resection w mesh removal and primary closure of\n wound/VAC placement.\n .\n NEUROLOGIC: haldol for agitation. Monitor confusion.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis and allowing to autodiurese, continue\n to monitor net fluid balance. Lopressor for BP and HR control and\n change to PO\n PULMONARY: Extubated - appears stable; speaking in full sentences;\n continue aggressive pulmonary toilet, OOB and IS\n GI / ABD: JP drain in place. W-->D dressing changes. Follow LFTS and\n bilirubin, Diarrhea\n C.Diff neg, hold antimotility agents for now.\n NUTRITION: NGT removed by patient; TPN; starting oral intake today and\n advance slowly as tolerated\n RENAL: monitor creat and UO and replete lytes.\n HEMATOLOGY: Stable\n ENDOCRINE: RISS\n ID: Started on Cipro/flagyl for Enterobacter Cloacae\n LINES/TUBES/DRAINS: Left IJ, R rad aline, JP, Foley,\n WOUNDS: abd wound w/ W->D gauze dressings - change TID.\n IMAGING: none pending\n FLUIDS: KVO, replete K and phosphate as needed.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER\n famotidine\n change to PO\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n TPN w/ Lipids - 05:48 PM 91. mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 14\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-02-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554522, "text": "Acute Pain\n Assessment:\n Tachycardia, hypertension, tachypnea, reports intermittent abdominal\n pain but unable to rate\n Action:\n IVP 2 mg hydromorphone q 2 hrs when needed\n Response:\n Sleeping with less tachycardia and hypertension and no nonverbal signs\n of pain.\n Plan:\n Continue to monitor and assess pain q 2 hrs and when appropriate.\n Hernia, ventral / incisional\n Assessment:\n Ventral hernia repair with post surgical wound s/p VAC therapy, large\n amount of fibrin slough, purulent and serosanguinous drainage, and\n necrotic tissue around periwound.\n Action:\n Abdominal dressing changes TID wet to dry.\n Response:\n Tolerates dressing changes well with pre-medication.\n Plan:\n Continue to abdominal assessments and wound care as ordered.\n" }, { "category": "Nursing", "chartdate": "2118-02-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 554523, "text": "Acute Pain\n Assessment:\n Tachycardia, hypertension, tachypnea, reports intermittent abdominal\n pain but unable to rate\n Action:\n IVP 2 mg hydromorphone q 2 hrs when needed\n Response:\n Sleeping with less tachycardia and hypertension and no nonverbal signs\n of pain.\n Plan:\n Continue to monitor and assess pain q 2 hrs and when appropriate.\n Hernia, ventral / incisional\n Assessment:\n Ventral hernia repair with post surgical wound s/p VAC therapy, large\n amount of fibrin slough, purulent and serosanguinous drainage, and\n necrotic tissue around periwound.\n Action:\n Abdominal dressing changes TID wet to dry.\n Response:\n Tolerates dressing changes well with pre-medication.\n Plan:\n Continue to abdominal assessments and wound care as ordered.\n Demographics\n Attending MD:\n G.\n Admit diagnosis:\n HERNIA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 126 kg\n Daily weight:\n 120.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: ETOH\n CV-PMH:\n Additional history: pneumonia, distant ORIF L wrist & L knee @ age 15,\n related to MVC\n Surgery / Procedure and date: ventral hernia repair with mesh\n placement\n In PACU, succus via NGT and surgical drain, tachycardic, abdominal\n pain, emesis, low urine output\n re-exploration, washout, removal of mesh, ileocolectomy and\n placement of VAC dressing.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:70\n Temperature:\n 99.2\n Arterial BP:\n S:156\n D:74\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 98 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 5,564 mL\n 24h total out:\n 2,620 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 03:17 AM\n Potassium:\n 3.8 mEq/L\n 03:17 AM\n Chloride:\n 116 mEq/L\n 03:17 AM\n CO2:\n 23 mEq/L\n 03:17 AM\n BUN:\n 14 mg/dL\n 03:17 AM\n Creatinine:\n 0.5 mg/dL\n 03:17 AM\n Glucose:\n 128 mg/dL\n 03:17 AM\n Hematocrit:\n 24.1 %\n 03:17 AM\n Finger Stick Glucose:\n 136\n 08:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 10\n Date & time of Transfer: 2230\n" }, { "category": "Nursing", "chartdate": "2118-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554346, "text": "Hernia, ventral / incisional\n Assessment:\n Large abdominal wound with purulent plus serosanguinous drainage,\n fibrin slough, necrotic tissue, new granulation tissue, tunneling, and\n undermining.\n Action:\n Abdominal dressing changed and packed, wet to dry as ordered.\n Response:\n Tolerated dressing change performed by Surgical team well.\n Plan:\n Continue with TID dressing changes to abdomen, use abdominal binder\n when up > 45 degrees and out of bed.\n Acute Pain\n Assessment:\n Intermittent tachycardia, hypertension, tachypnea, and agitation \n rest and with activity.\n Action:\n Intermittent dosing of hydromorphone IVP, acetaminophen PO, and\n repositioning.\n Response:\n Pt able to sleep undisturbed this early morning for 3 hrs after pain\n issues addressed with 2 mg of hydromorphone.\n Plan:\n Continue to assess pain q2 hrs and prn.\n Altered mental status (not Delirium)\n Assessment:\n Anxiety/Agitation requiring soft wrist restraints, pulled out NGT x 2.\n Action:\n Constant re-orientation, haldol administration x 1.\n Response:\n Significantly less agitation after haldol administration and\n re-orientation.\n Plan:\n Continue to assess for and treat delirium with haldol and\n re-orientation strategies.\n" }, { "category": "Nursing", "chartdate": "2118-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553075, "text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Tmax 100.7. WBC 11.2 from 14.9. General anasarca, ++scrotal edema.\n Noted autodiuresis.\n Action:\n Weaned off Levophed.\n Response:\n MAP remains >60.\n Plan:\n ?Diuresis today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhonchorous. Suctioned thick white sputum in moderate\n amounts. Discoordinate with ventilator.\n Action:\n Attempted wean to CPAP+PSV.\n Response:\n Became tachypneic with labored breathing pattern. Returned to assist\n control, thereafter more synchronous with ventilator with normal\n respiratory effort. ABG normal.\n Plan:\n Wean ventilator as tolerated.\n Acute Pain\n Assessment:\n Essentially unresponsive to examiner, but does localize to painful\n stimulus.\n Action:\n Weaned off versed gtt, weaned fentanyl gtt to 250mcg/hr.\n Response:\n Appears comfortable at rest. Becomes tachypneic with turns but settles\n quickly.\n Plan:\n Wean off infusions toward intermittent analgesics / sedatives. Restart\n versed if indicated, discuss need for ongoing benzo\ns on team rounds.\n" }, { "category": "Nursing", "chartdate": "2118-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553175, "text": "47 yo male admitted s/p ventral hernia. Pt c/o abdominal pain\n since , ongoing anorexia, pain, intermittent\n diarrhea/N/V. pt had ventral hernia repair with mesh placement;\n pt experienced tachycardia, abdominal pain, vomiting, decreasing UO and\n stool via NGT/JP drain in PACU. Pt brought back to OR for\n re-exploration, washout, removal of mesh, ileocolectomy and placement\n of VAC dressing. Pt remains in TSICU for care.\n Hernia, ventral / incisional\n Assessment:\n Pt has closed fascia, open tissue/skin with VAC dressing in place\n changed with 125mmHg suction. Drainage is serous, moderate. Pt\n on fentanyl gtt for pain management, appears comfortable as evidenced\n by nonverbal cues and vital signs.\n Action:\n Fentanyl gtt decreased to 100mcg/hr d/t pt appears comfortable and\n tolerating ET tube.\n Response:\n Pt tolerated decrease in fentanyl gtt, appears comfortable.\n Plan:\n Continue to wean fentanyl sedation as tolerated. Manage pain as needed,\n continue to assess sedation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhonchorous to clear. O2 sats increasing: 96-99% in\n evening. Suctioned for thick ,white, moderate amount of secretions.\n Action:\n Vent setting unchanged throughout day. ABG WNL.\n Response:\n Respiratory status unchanged, pt tolerated ET tube.\n Plan:\n Wean vent as tolerated overnight, diurese pt in AM as pressure\n tolerates. Continue to support pt and family.\n" }, { "category": "Nursing", "chartdate": "2118-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553417, "text": "Today\ns Events:\n ~New Central Line Placement (Left IJ)\n ~Removal of old Central Line (Right IJ) and Tip\n cultured\n ~Wound Vac dressing changed\n ~Blood cultures drawn for increased temp\n Hernia, ventral / incisional\n Assessment:\n Pt has serous drainage in JP to bulb suction. Vac dsg on abdominal\n wound at 125mmHg of suction, draining serosanguinous fluid. BS absent.\n NG to suction.\n Action:\n Vac dsg changed today with some debridement. Pt starting on TPN this\n evening.\n Response:\n Minimal drainage from JP drain. Per Surgery team, next vac dsg change,\n the team will change to a wet to dry dressing.\n Plan:\n Continue to monitor drainage and start TPN.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhoncherous. Moderate amt of thin white secretions\n suctioned. Pt 30 liters positive. Pt on CMV 24/500 40%FiO2 and 0 of\n PEEP. O2 sats wnl. Pt in metabolic alkalosis.\n Action:\n Pt given 20mg of lasix. Vent setting remained the same. \n performed.\n Response:\n Increased Urine Output . Pt is neg 2.8 liters so far today. O2 sats\n remain adequate. During pt became tachypneic and had a score in\n the high 300s.\n Plan:\n Wean to PS as tolerated. ?Diamox tmr for met. Alkalosis. Continue\n diuresis.\n Acute Pain\n Assessment:\n Pt only arousable to pain with turns and procedures. Pt was grimacing\n during wound vac dsg change. Pt is tachycardic and diaphoretic.\n Action:\n Pt given PRN fentanyl and Ativan for pain and agitation.\n Response:\n Pt, per nonverbal cues, shows pain relieved with medication.\n Plan:\n Continue to monitor pain and give pain medication as needed.\n" }, { "category": "Nursing", "chartdate": "2118-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552640, "text": "47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Today\ns Events:\n -TTE\n -Femoral a-line removed and Right radial a-line placed\n with vigileo\n Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen drain serous drainage and Vac dressing placed in\n incisional wound bed draining serosanguinous fluid. BS absent. Abdomen\n tender to palpation. NG tube to suction with thick tan drainage.\n Bladder pressures 20/21.\n Action:\n Monitoring drainage color and amt. Bladder pressure performed q4hrs.\n Response:\n Bladder pressures elevated to 24. Drains still accruing a moderate amt\n of fluid.\n Plan:\n Continue to monitor bladder pressures and drainage.\n Shock, cardiogenic\n Assessment:\n Pt had ejection fraction ~10% over night. Pt on three pressors to\n maintain adequate BP. Pt tachycardic. Cool extremities with pulses\n difficult to palpate. Pt\ns SVV in high 20s-low 30s. CVP wnl. Pt has\n adequate urine output.\n Action:\n TTE performed. Milrinone gtt on. Titrated off Neo and placed pt on\n Vasopressin. Titrated Levo down. Pt goal is MAP >60 Vigileo in place.\n Multiple albumin boluses given and 1liter LR bolus given. LR\n maintenance increased to 250cc/hr.\n Response:\n Pt\ns EF ~45% Pt\ns SVV decreased to <15. MAP with titration at goal. Pt\n still tachycardic. Upper extremities warm and lower extremities cool.\n Urine output still adequate.\n Plan:\n Continue to wean Levophed. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with tidal volume of 640, RR 18, Peep and FiO2 of 100%. ABG\n showing metabolic acidosis. O2 sats wnl. LS clear and diminished at\n bases. Minimal thick tan secretions.\n Action:\n Pt\ns FiO2 weaned, tidal volume decreased, and RR increased. Pt\ns tube\n placement changed per xray to 23 at the lip. VAP care performed.\n Response:\n Pt\ns PaO2 adequate. Pt\ns increased spontaneous breathing. ABG shows\n metabolic acidosis.\n Plan:\n Continue to monitor ABG\ns, wean vent settings as tolerated.\n Acute Pain\n Assessment:\n Pt denies pain at rest, but with turns and abdominal movement pt\n grimaces.\n Action:\n Pt on Fent and Midaz gtt. Prn Fentanyl boluses with turns. Fentanyl gtt\n concentrated.\n Response:\n Pt still grimaces a fair amt with incisional discomfort with any\n activity.\n Plan:\n Continue prn boluses with turns.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs. Tmax\n 100.9. Tachycardia and hypotension.\n Action:\n Pt on Vanco, Fluconazole and Zosyn.\n Response:\n Pt\ns temp continues to rise with elevated WBC\ns. Pt\ns clammy.\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n Acidosis, Metabolic\n Assessment:\n Pt has elevated lactate and negative base excess. Pt\ns ABG shows\n metabolic acidosis. Hypocalcemic.\n Action:\n Pt had multiple ABGs and lactates drawn. Electrolytes repleted.\n Response:\n Pt\ns respirations increased but pH remains acidic. Lactate still\n elevated.\n Plan:\n Continue to monitor Abg\n Pt\ns family visited today (mother, father, son and significant other).\n Dr spoke with the parents about plan of care and prognosis. Family\n decided that the son would be the spokesperson.\n" }, { "category": "Respiratory ", "chartdate": "2118-01-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 552641, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Expiratory wheezes\n LUL Lung Sounds: Expiratory wheezes\n LLL Lung Sounds: Diminished\n Comments: Pt suctioned and given MDI\ns as noted with improved aeration\n throughout and clear lung fields.\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: VT weaned to a 6mL/kg volume\n and RR increased to maintain MV. ABG's reveal a metabolic acidosis with\n partial compensation. PaO2 ranges from mid 70's to 90's. Pt is\n breathing above the set rate of 24 up to a total of 34.\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Plan to continue on current settings at this time and\n monitor ABG's closely.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2118-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552704, "text": "47 yo male admitted w/ incarcerated ventral hernia. s/p ex lap,\n VHR w/ mesh placement. Patient w/ dramatic hemodynamic decompensation,\n fecal drainage from drains in PACU post op, back to OR for repair of\n small bowel perforation. Patient to TSICU from OR w/ severe\n hemodynamic instability. After large volumes of fluid and high dose\n vasopressors ineffective to manage BP and CO, TTE revealed EF 10%,\n consistent w/ cardiogenic shock. See below for management since\n admission.\n Shock, cardiogenic\n Assessment:\n Initial TTE showed EF 10%, severe cardiomyopathy, both consistent w/\n shock.\n Action:\n Milrinone drip started, vasopressors adjusted to vasopressin and\n Levophed titrated to goal map>60. vigeleo monitor in place, fluid\n given initially to optimize SVV.\n Response:\n Much improved CO w/ milrinone infusion, high dose vasopressin\n continued. Levophed difficult to wean at this time. u/o adequate, SVV\n remains adequate, for shift.\n Plan:\n Cont to closely monitor CO, hemodynamics. Continue milrinone,\n pressors.\n Hernia, ventral / incisional\n Assessment:\n As above, s/p VHR, procedure c/b small bowel perforation.\n Action:\n VAC dsg in place to midline incision, JP x1 to periphery of wound.\n Response:\n Mod amts old bloody/brown drainage from VAC, JP w/ serous output to\n LWS. Sm amt old brown drainage per rectum, very foul in odor.\n Plan:\n Continue VAC, dsg change due . cont to monitor drainage from\n wounds, drains.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n In setting of small bowel perforation, fecal leakage in peritoneum,\n patient w/ hemodynamic instability, cardiogenic shock, metabolic\n acidosis, febrile, rising LFTs, INR, suspect SIRS\nsepsis response in\n this initial post op phase.\n Action:\n Milrinone, vasopressors & fluid resuscitation to support hemodynamics,\n optimizing electrolytes, close monitoring of u/o, labs. Pan cx\n obtained w/ tmax 102.1.\n Response:\n Shock greatly improved w/ milrinone and pressor regimen at present,\n fevers controlled w/ prn Tylenol, environmental cooling. INR rising\n quickly, LFTs stable at present, Tbili elevated.\n Plan:\n Continue current plan of care as above, serial coags, LFTs, lytes\n ongoing, optimize all.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In setting of large fluid resuscitation, patient remains intubated,\n mech ventilated. Oxygenation beginning to suffer last several hrs, w/\n pt desaturating w/ turns, unable to recover sats after time.\n Action:\n Peep titrated to 12 this hour w/ little to no improvement in o2 sats,\n most recent pao2 78 w/ o2 sat 88%. Fio2 adjusted to 70% as well.\n Response:\n Current o2 sats low 90s, as during most of shift, although note higher\n support necessary to maintain.\n Plan:\n Titrate fio2, peep as needed to maintain pao2 80-90 per team. ? attempt\n recruitment maneuver today if sats remain poor, CXR this am, ? triadyne\n rotating bed, closely follow abg ongoing.\n" }, { "category": "Physician ", "chartdate": "2118-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 552729, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#2 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:30 AM\n Vancomycin - 09:38 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Vasopressin - 3.6 units/hour\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 500 mcg/hour\n Norepinephrine - 0.27 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 04:30 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.7\nC (99.8\n HR: 128 (122 - 143) bpm\n BP: 107/44(65) {89/40(59) - 125/72(91)} mmHg\n RR: 22 (19 - 28) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 15 (8 - 15) mmHg\n Bladder pressure: 16 (16 - 24) mmHg\n Total In:\n 13,777 mL\n 2,397 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,977 mL\n 2,377 mL\n Blood products:\n 800 mL\n Total out:\n 2,529 mL\n 820 mL\n Urine:\n 1,804 mL\n 620 mL\n NG:\n 175 mL\n 150 mL\n Stool:\n Drains:\n 550 mL\n 50 mL\n Balance:\n 11,248 mL\n 1,577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 640) mL\n RR (Set): 24\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SPO2: 88%\n ABG: 7.29/41/78/21/-6\n Ve: 11.9 L/min\n PaO2 / FiO2: 130\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Bowel sounds present, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 275 K/uL\n 10.8 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.2 %\n 17.2 K/uL\n [image002.jpg]\n 01:46 PM\n 02:46 PM\n 03:00 PM\n 03:25 PM\n 05:20 PM\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n WBC\n 16.0\n 17.2\n Hct\n 34.5\n 31.2\n Plt\n 331\n 275\n Creatinine\n 1.1\n 0.9\n TCO2\n 21\n 20\n 21\n 20\n 22\n 21\n Glucose\n 128\n 121\n 140\n 120\n Other labs: PT / PTT / INR:29.1/43.1/2.9, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: HPI: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 60. Decrease\n milrinone to 0.375. LR @ 250cc/hr. Receiving large amounts of\n resuscitation.\n PULMONARY: Vent dep resp failure, attempting to optimize oxygenation\n by increasing PEEP and Fi02.\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO\n RENAL: f/u creat and UO.\n HEMATOLOGY: Hct - stable\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole for sepsis. Await pending culture results.\n LINES/TUBES/DRAINS: RIJ, right radial a-line, JP, VAC, Foley, NGT\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250, prn albumin\n CONSULTS: Gold Surgery\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: needs to be signed by son \n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Communication: Comments: Son is will get consent when he next\n visits\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 552734, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#2 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:30 AM\n Vancomycin - 09:38 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Vasopressin - 3.6 units/hour\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 500 mcg/hour\n Norepinephrine - 0.27 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 04:30 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.7\nC (99.8\n HR: 128 (122 - 143) bpm\n BP: 107/44(65) {89/40(59) - 125/72(91)} mmHg\n RR: 22 (19 - 28) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 15 (8 - 15) mmHg\n Bladder pressure: 16 (16 - 24) mmHg\n Total In:\n 13,777 mL\n 2,397 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,977 mL\n 2,377 mL\n Blood products:\n 800 mL\n Total out:\n 2,529 mL\n 820 mL\n Urine:\n 1,804 mL\n 620 mL\n NG:\n 175 mL\n 150 mL\n Stool:\n Drains:\n 550 mL\n 50 mL\n Balance:\n 11,248 mL\n 1,577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 640) mL\n RR (Set): 24\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SPO2: 88%\n ABG: 7.29/41/78/21/-6\n Ve: 11.9 L/min\n PaO2 / FiO2: 130\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Bowel sounds present, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 275 K/uL\n 10.8 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.2 %\n 17.2 K/uL\n [image002.jpg]\n 01:46 PM\n 02:46 PM\n 03:00 PM\n 03:25 PM\n 05:20 PM\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n WBC\n 16.0\n 17.2\n Hct\n 34.5\n 31.2\n Plt\n 331\n 275\n Creatinine\n 1.1\n 0.9\n TCO2\n 21\n 20\n 21\n 20\n 22\n 21\n Glucose\n 128\n 121\n 140\n 120\n Other labs: PT / PTT / INR:29.1/43.1/2.9, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: HPI: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 60. Decrease\n milrinone to 0.375. LR @ 250cc/hr. Receiving large amounts of\n resuscitation.\n PULMONARY: Vent dep resp failure, attempting to optimize oxygenation\n by increasing PEEP and Fi02.\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO\n RENAL: f/u creat and UO.\n HEMATOLOGY: Hct - stable\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole for sepsis. Await pending culture results.\n LINES/TUBES/DRAINS: RIJ, right radial a-line, JP, VAC, Foley, NGT\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250, prn albumin\n CONSULTS: Gold Surgery\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: needs to be signed by son \n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Communication: Comments: Son is will get consent when he next\n visits\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553248, "text": "Hernia, ventral / incisional\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2118-01-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 552531, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Respiratory ", "chartdate": "2118-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553166, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 22 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n No vent changes today, rotated ETT to R. @ ~ 1800hrs. No MDI\ns today.\n, RRT 06:22 PM\n" }, { "category": "Nursing", "chartdate": "2118-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553249, "text": "47 yo male admitted s/p ventral hernia. Pt c/o abdominal pain\n since , ongoing anorexia, pain, intermittent\n diarrhea/N/V. pt had ventral hernia repair with mesh placement;\n pt experienced tachycardia, abdominal pain, vomiting, decreasing UO and\n stool via NGT/JP drain in PACU. Pt brought back to OR for\n re-exploration, washout, removal of mesh, ileocolectomy and placement\n of VAC dressing. Pt remains in TSICU for care.\n Hernia, ventral / incisional\n Assessment:\n Abdomen with VAC dressing in place, last change done on in room by\n surgical team. Dressing is intact, drainage via VAC is serous,\n moderate. Under dressing, some adipose/subcutaneous tissue can be\n seen, team aware. Pt appears to be comfortable, does not seem to be\n experiencing pain at rest/with activity, coughing/repositioning. Pt\n not requiring pain medication, fentanyl gtt remains off. Pt arouses to\n voice, does not follow commands, does not communicate effectively\n (questionably nodding to respond)\n Action:\n Pain continuously assessed, no medication required throughout shift.\n Response:\n Pt appears to be comfortable, tolerating activity/repositioning/ET\n tube/VAC dressing.\n Plan:\n Continue\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2118-02-01 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 553579, "text": "24 Hour Events: ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; prelim read of RU negative\n MULTI LUMEN - START 09:59 AM\n BLOOD CULTURED - At 10:42 AM\n ULTRASOUND - At 11:15 AM\n MULTI LUMEN - STOP 01:44 PM\n FEVER - 101.5\nF - 08:00 PM\n Post operative day:\n POD#7 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:43 AM\n Piperacillin/Tazobactam (Zosyn) - 05:55 PM\n Vancomycin - 07:56 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:13 AM\n Labetalol - 04:00 AM\n Lorazepam (Ativan) - 07:28 AM\n Famotidine (Pepcid) - 07:56 AM\n Fentanyl - 08:32 AM\n Other medications:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.5\n HR: 108 (97 - 118) bpm\n BP: 146/83(104) {115/65(85) - 169/90(114)} mmHg\n RR: 27 (24 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (8 - 20)mmHg\n Total In:\n 1,475 mL\n 836 mL\n PO:\n TF:\n IVF:\n 1,219 mL\n 469 mL\n Blood products:\n Total out:\n 3,502 mL\n 2,490 mL\n Urine:\n 2,602 mL\n 2,000 mL\n NG:\n 600 mL\n 350 mL\n Stool:\n Drains:\n 300 mL\n 140 mL\n Balance:\n -2,027 mL\n -1,654 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///31/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), slightly tachycardic; no\n m/r/g)\n Respiratory / Chest: decreased at bases; slightly coarse BS but much\n improved\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+ edema\n Skin: Not assessed, Rash: diffusely erythematous; no vesicles\n Labs / Radiology\n 236 K/uL\n 10.1 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.3 %\n 8.2 K/uL\n [image002.jpg]\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n WBC\n 8.9\n 9.1\n 6.4\n 8.2\n Hct\n 29.5\n 28.7\n 29.0\n 28.3\n Plt\n 191\n 193\n 222\n 236\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 78\n 100\n 97\n 105\n 114\n 160\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:53/104, Alk Phos / T Bili:77/6.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn, received CT Head for unequal pupils, CT was\n negative for intracranial path\n CARDIOVASCULAR: Off pressor medication; holding lasix for rash\n will\n start ethocrinic acid for diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated,\n change to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction. RUQ u/s negative\n NUTRITION: NPO on TPN, start trophic TF\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n will restart hep sq today for INR of 1.2\n ENDOCRINE: RISS\n ID: vanc/ z osyn / fluconazole post surgery.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT\n boots, sq heparin\n STRESS ULCER - famotidine\n VAP BUNDLE\n hob elevation, oral care, daily wake up, RSBI\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:53 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots; hep sq\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 553232, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS:IV access: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Midazolam 1-10 mg/hr IV DRIP TITRATE TO sedation, Albuterol\n Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium Chloride IV Sliding\n Scale, Famotidine 20 mg IV Q12H, Potassium Phosphate IV Sliding Scale,\n Fentanyl Citrate 100-200 mcg IV Q1HR PRN, Fentanyl Citrate 100-500\n mcg/hr, Fluconazole 200 mg IV Q24H, Insulin SC (per Insulin\n Flowsheet)Sliding Scale, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF.\n 24 HOUR EVENTS:\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today, either NG feeds vs. TPN tomorrow. Aim to keep\n phos> 3. Monitoring LFTs and INR. Received 10mg SC vit K. .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn/fluc\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n 24 Hour Events:\n Post operative day:\n POD#5 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:17 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:30 PM\n Other medications:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.7\nC (99.8\n HR: 105 (98 - 108) bpm\n BP: 110/55(71) {90/51(64) - 116/62(77)} mmHg\n RR: 28 (22 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (11 - 19) mmHg\n Total In:\n 1,580 mL\n 364 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,580 mL\n 364 mL\n Blood products:\n Total out:\n 3,377 mL\n 935 mL\n Urine:\n 2,007 mL\n 435 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 1,170 mL\n 500 mL\n Balance:\n -1,797 mL\n -571 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 26 cmH2O\n SPO2: 98%\n ABG: 7.46/38/152/26/3\n Ve: 13.2 L/min\n PaO2 / FiO2: 380\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 193 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 9.1 K/uL\n [image002.jpg]\n 02:13 PM\n 02:36 PM\n 05:35 PM\n 07:20 PM\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n WBC\n 14.9\n 11.2\n 8.9\n 9.1\n Hct\n 29.9\n 30.3\n 29.5\n 28.7\n Plt\n 185\n 191\n 191\n 193\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 26\n 25\n 26\n 28\n 29\n 28\n Glucose\n 102\n 80\n 78\n 100\n 97\n Other labs: PT / PTT / INR:18.5/30.4/1.7, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:28/60, Alk-Phos / T bili:81/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L, Ca:8.5 mg/dL, Mg:2.2\n mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR on same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Off pressor medications. Start diuresis today.\n PULMONARY: Vent dep resp failure, weaning FiO2 , decrease PEEP, swich\n to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO. Start TPN today vs TFs.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0., lasix\n today for goal 2 liters negative\n HEMATOLOGY: f/u Hct and INR.\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553642, "text": "Hernia, ventral / incisional\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2118-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 552699, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#2 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:30 AM\n Vancomycin - 09:38 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Vasopressin - 3.6 units/hour\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 500 mcg/hour\n Norepinephrine - 0.27 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 04:30 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.7\nC (99.8\n HR: 128 (122 - 143) bpm\n BP: 107/44(65) {89/40(59) - 125/72(91)} mmHg\n RR: 22 (19 - 28) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 15 (8 - 15) mmHg\n Bladder pressure: 16 (16 - 24) mmHg\n Total In:\n 13,777 mL\n 2,397 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,977 mL\n 2,377 mL\n Blood products:\n 800 mL\n Total out:\n 2,529 mL\n 820 mL\n Urine:\n 1,804 mL\n 620 mL\n NG:\n 175 mL\n 150 mL\n Stool:\n Drains:\n 550 mL\n 50 mL\n Balance:\n 11,248 mL\n 1,577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 640) mL\n RR (Set): 24\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SPO2: 88%\n ABG: 7.29/41/77./21/-6\n Ve: 11.9 L/min\n PaO2 / FiO2: 130\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Bowel sounds present, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 275 K/uL\n 10.8 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.2 %\n 17.2 K/uL\n [image002.jpg]\n 01:46 PM\n 02:46 PM\n 03:00 PM\n 03:25 PM\n 05:20 PM\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n WBC\n 16.0\n 17.2\n Hct\n 34.5\n 31.2\n Plt\n 331\n 275\n Creatinine\n 1.1\n 0.9\n TCO2\n 21\n 20\n 21\n 20\n 22\n 21\n Glucose\n 128\n 121\n 140\n 120\n Other labs: PT / PTT / INR:29.1/43.1/2.9, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: HPI: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 65. Cont milrinone?\n LR @ 250cc/hr. Receiving large amounts of resuscitation.\n PULMONARY: Vent dep resp failure, attempting to optoimize oxygenation\n by increasing PEEP and Fi02.\n GI / ABD: NPO/NGT, JP in place. VAC to suction. Monitor bladder\n pressures Q4 if concern for ACS\n NUTRITION: NPO\n RENAL: f/u creat and UO.\n HEMATOLOGY: Hct - stable\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole for sepsis. Await pending culture results.\n LINES/TUBES/DRAINS: RIJ, L fem a-line, JP, VAC, Foley, NGT\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250, prn albumin\n CONSULTS: Gold Surgery\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, SQH\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: needs to be signed by son \n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Communication: Comments: Son is will get consent when he next\n visits\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 553218, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS:IV access: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Midazolam 1-10 mg/hr IV DRIP TITRATE TO sedation, Albuterol\n Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium Chloride IV Sliding\n Scale, Famotidine 20 mg IV Q12H, Potassium Phosphate IV Sliding Scale,\n Fentanyl Citrate 100-200 mcg IV Q1HR PRN, Fentanyl Citrate 100-500\n mcg/hr, Fluconazole 200 mg IV Q24H, Insulin SC (per Insulin\n Flowsheet)Sliding Scale, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF.\n 24 HOUR EVENTS:\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today, either NG feeds vs. TPN tomorrow. Aim to keep\n phos> 3. Monitoring LFTs and INR. Received 10mg SC vit K. .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn/fluc\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n 24 Hour Events:\n Post operative day:\n POD#5 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:00 AM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:17 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 11:30 PM\n Other medications:\n Flowsheet Data as of 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.7\nC (99.8\n HR: 105 (98 - 108) bpm\n BP: 110/55(71) {90/51(64) - 116/62(77)} mmHg\n RR: 28 (22 - 30) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 140.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (11 - 19) mmHg\n Total In:\n 1,580 mL\n 364 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,580 mL\n 364 mL\n Blood products:\n Total out:\n 3,377 mL\n 935 mL\n Urine:\n 2,007 mL\n 435 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 1,170 mL\n 500 mL\n Balance:\n -1,797 mL\n -571 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 28 cmH2O\n Plateau: 26 cmH2O\n SPO2: 98%\n ABG: 7.46/38/152/26/3\n Ve: 13.2 L/min\n PaO2 / FiO2: 380\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 193 K/uL\n 9.8 g/dL\n 97 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.7 %\n 9.1 K/uL\n [image002.jpg]\n 02:13 PM\n 02:36 PM\n 05:35 PM\n 07:20 PM\n 01:37 AM\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n WBC\n 14.9\n 11.2\n 8.9\n 9.1\n Hct\n 29.9\n 30.3\n 29.5\n 28.7\n Plt\n 185\n 191\n 191\n 193\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 26\n 25\n 26\n 28\n 29\n 28\n Glucose\n 102\n 80\n 78\n 100\n 97\n Other labs: PT / PTT / INR:18.5/30.4/1.7, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:28/60, Alk-Phos / T bili:81/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L, Ca:8.5 mg/dL, Mg:2.2\n mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR on same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Off pressor medications. Start diuresis today.\n PULMONARY: Vent dep resp failure, weaning FiO2 , decrease PEEP, swich\n to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: NPO. Start TPN today vs TFs.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0., lasix\n today for goal 2 liters negative\n HEMATOLOGY: f/u Hct and INR.\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2118-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 553582, "text": "24 Hour Events: ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; prelim read of RU negative\n MULTI LUMEN - START 09:59 AM\n BLOOD CULTURED - At 10:42 AM\n ULTRASOUND - At 11:15 AM\n MULTI LUMEN - STOP 01:44 PM\n FEVER - 101.5\nF - 08:00 PM\n Post operative day:\n POD#7 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:43 AM\n Piperacillin/Tazobactam (Zosyn) - 05:55 PM\n Vancomycin - 07:56 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:13 AM\n Labetalol - 04:00 AM\n Lorazepam (Ativan) - 07:28 AM\n Famotidine (Pepcid) - 07:56 AM\n Fentanyl - 08:32 AM\n Other medications:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.5\n HR: 108 (97 - 118) bpm\n BP: 146/83(104) {115/65(85) - 169/90(114)} mmHg\n RR: 27 (24 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (8 - 20)mmHg\n Total In:\n 1,475 mL\n 836 mL\n PO:\n TF:\n IVF:\n 1,219 mL\n 469 mL\n Blood products:\n Total out:\n 3,502 mL\n 2,490 mL\n Urine:\n 2,602 mL\n 2,000 mL\n NG:\n 600 mL\n 350 mL\n Stool:\n Drains:\n 300 mL\n 140 mL\n Balance:\n -2,027 mL\n -1,654 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///31/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), slightly tachycardic; no\n m/r/g)\n Respiratory / Chest: decreased at bases; slightly coarse BS but much\n improved\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+ edema\n Skin: Rash: diffusely erythematous; no vesicles\n Labs / Radiology\n 236 K/uL\n 10.1 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.3 %\n 8.2 K/uL\n [image002.jpg]\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n WBC\n 8.9\n 9.1\n 6.4\n 8.2\n Hct\n 29.5\n 28.7\n 29.0\n 28.3\n Plt\n 191\n 193\n 222\n 236\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 78\n 100\n 97\n 105\n 114\n 160\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:53/104, Alk Phos / T Bili:77/6.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn, received CT Head for unequal pupils, CT was\n negative for intracranial path\n CARDIOVASCULAR: Off pressor medication; holding lasix for rash\n will\n start ethocrinic acid for diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated,\n change to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction. RUQ u/s negative\n NUTRITION: NPO on TPN, start trophic TF\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n will restart hep sq today for INR of 1.2\n ENDOCRINE: RISS\n ID: vanc/ z osyn / and Fluc d/c today.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT\n boots, sq heparin\n STRESS ULCER - famotidine\n VAP BUNDLE\n hob elevation, oral care, daily wake up, RSBI\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:53 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots; hep sq\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553300, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds rhonchorous with bibasilar coarse crackles. SPO2 >96% on\n current vent settings; ABG reveals metabolic alkalosis with excellent\n oxygenation. Suctioned thin white sputum in moderate amounts.\n Action:\n No vent changes made. Diuresed on prior shift.\n Response:\n Negative 2500mL yesterday.\n Plan:\n Continue diuresis today?\n Acute Pain\n Assessment:\n Appears comfortable at rest. Tolerates turns with less facial grimacing\n noted today. Continues to be lethargic / withdrawn, does not follow\n commands or regard examiner.\n Action:\n Narcotic gtts remain off. Reoriented frequently.\n Response:\n Slightly more alert, arouses more easily to voice.\n Plan:\n Reorient frequently, minimize narcotics, emotional support for turns.\n" }, { "category": "Nutrition", "chartdate": "2118-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553394, "text": "Pertinent medications: NS, KPhos, lasix, IV abx, pepcid, others noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 02:02 AM\n Glucose Finger Stick\n 111\n 08:00 AM\n BUN\n 12 mg/dL\n 02:02 AM\n Creatinine\n 0.6 mg/dL\n 02:02 AM\n Sodium\n 142 mEq/L\n 02:02 AM\n Potassium\n 4.3 mEq/L\n 02:02 AM\n Chloride\n 107 mEq/L\n 02:02 AM\n TCO2\n 28 mEq/L\n 02:02 AM\n PO2 (arterial)\n 147 mm Hg\n 02:10 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:10 AM\n pH (arterial)\n 7.49 units\n 02:10 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 02:10 AM\n Albumin\n 2.3 g/dL\n 02:02 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:02 AM\n Phosphorus\n 2.0 mg/dL\n 02:02 AM\n Ionized Calcium\n 1.21 mmol/L\n 02:16 PM\n Magnesium\n 2.1 mg/dL\n 02:02 AM\n ALT\n 30 IU/L\n 02:02 AM\n Alkaline Phosphate\n 79 IU/L\n 02:02 AM\n AST\n 62 IU/L\n 02:02 AM\n Total Bilirubin\n 6.6 mg/dL\n 02:02 AM\n WBC\n 6.4 K/uL\n 02:02 AM\n Hgb\n 10.0 g/dL\n 02:02 AM\n Hematocrit\n 29.0 %\n 02:02 AM\n Current diet order / nutrition support: NPO\n TPN Order: Day 1 starter TPN c/ std lytes\n GI: soft, obese, -BS\n Assessment of Nutritional Status\n Specifics: 47 year old male admitted with hernia.\n Medical Nutrition Therapy Plan - Recommend the Following\n Pending glycemic control and TG advance to goal TPN 2.1 L (245 g Dex/\n 130 g AA/ 45 g Fat) to provide 1803 kcals/ 130 g pro\n Check FSBG q 4 hrs initiate RISS if >120\n Check TG hold lipids if >400\n Multivitamin / Mineral supplement: via TPN\n Check chemistry 10 panel daily and adjust lytes per am labs\n" }, { "category": "Nutrition", "chartdate": "2118-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553395, "text": "Pertinent medications: NS, KPhos, lasix, IV abx, pepcid, others noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 02:02 AM\n Glucose Finger Stick\n 111\n 08:00 AM\n BUN\n 12 mg/dL\n 02:02 AM\n Creatinine\n 0.6 mg/dL\n 02:02 AM\n Sodium\n 142 mEq/L\n 02:02 AM\n Potassium\n 4.3 mEq/L\n 02:02 AM\n Chloride\n 107 mEq/L\n 02:02 AM\n TCO2\n 28 mEq/L\n 02:02 AM\n PO2 (arterial)\n 147 mm Hg\n 02:10 AM\n PCO2 (arterial)\n 39 mm Hg\n 02:10 AM\n pH (arterial)\n 7.49 units\n 02:10 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 02:10 AM\n Albumin\n 2.3 g/dL\n 02:02 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:02 AM\n Phosphorus\n 2.0 mg/dL\n 02:02 AM\n Ionized Calcium\n 1.21 mmol/L\n 02:16 PM\n Magnesium\n 2.1 mg/dL\n 02:02 AM\n ALT\n 30 IU/L\n 02:02 AM\n Alkaline Phosphate\n 79 IU/L\n 02:02 AM\n AST\n 62 IU/L\n 02:02 AM\n Total Bilirubin\n 6.6 mg/dL\n 02:02 AM\n WBC\n 6.4 K/uL\n 02:02 AM\n Hgb\n 10.0 g/dL\n 02:02 AM\n Hematocrit\n 29.0 %\n 02:02 AM\n Current diet order / nutrition support: NPO\n TPN Order: Day 1 starter TPN c/ std lytes\n GI: soft, obese, -BS\n Assessment of Nutritional Status\n Specifics: 47 year old male admitted with hernia. Pt taken to OR on\n for ex lap herniorrhaphy ventral hernia c/ mesh, he was taken back\n to the OR c/ perforation and has partial ileum & ascending colon\n resection c/ mesh removal and primary closure of wound/VAC placement.\n Team does not want to feed gut at this time TPN ordered to start\n tonight. TPN goal recs below. Noted repletions.\n Medical Nutrition Therapy Plan - Recommend the Following\n Pending glycemic control and TG advance to goal TPN 2.1 L (245 g Dex/\n 130 g AA/ 45 g Fat) to provide 1803 kcals/ 130 g pro\n Check FSBG q 4 hrs initiate RISS if >120\n Check TG hold lipids if >400\n Multivitamin / Mineral supplement: via TPN\n Check chemistry 10 panel daily and adjust lytes per am labs\n Will follow POC pls page with questions\n" }, { "category": "Respiratory ", "chartdate": "2118-02-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553798, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: intermittent periods of tachypnea\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI this morning = 69. Pressure support weaned down slowly\n with good abgs.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Possible extubation later today or tomorrow.\n" }, { "category": "Physician ", "chartdate": "2118-02-01 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 553533, "text": "24 Hour Events: ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n 24 HOUR EVENTS:\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; prelim read of RU negative\n MULTI LUMEN - START 09:59 AM\n BLOOD CULTURED - At 10:42 AM\n ULTRASOUND - At 11:15 AM\n MULTI LUMEN - STOP 01:44 PM\n FEVER - 101.5\nF - 08:00 PM\n Post operative day:\n POD#7 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:43 AM\n Piperacillin/Tazobactam (Zosyn) - 05:55 PM\n Vancomycin - 07:56 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:13 AM\n Labetalol - 04:00 AM\n Lorazepam (Ativan) - 07:28 AM\n Famotidine (Pepcid) - 07:56 AM\n Fentanyl - 08:32 AM\n Other medications:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.5\n HR: 108 (97 - 118) bpm\n BP: 146/83(104) {115/65(85) - 169/90(114)} mmHg\n RR: 27 (24 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (8 - 20)mmHg\n Total In:\n 1,475 mL\n 836 mL\n PO:\n TF:\n IVF:\n 1,219 mL\n 469 mL\n Blood products:\n Total out:\n 3,502 mL\n 2,490 mL\n Urine:\n 2,602 mL\n 2,000 mL\n NG:\n 600 mL\n 350 mL\n Stool:\n Drains:\n 300 mL\n 140 mL\n Balance:\n -2,027 mL\n -1,654 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 96%\n ABG: ///31/\n Ve: 14.6 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal), slightly tachycardic; no\n m/r/g\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: decreased at bases; slightly coarse BS but much\n improved\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Rash: diffusely erythematous; no vesicles\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed\n Labs / Radiology\n 236 K/uL\n 10.1 g/dL\n 160 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 106 mEq/L\n 142 mEq/L\n 28.3 %\n 8.2 K/uL\n [image002.jpg]\n 01:45 AM\n 06:13 PM\n 06:33 PM\n 02:21 AM\n 02:28 AM\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n WBC\n 8.9\n 9.1\n 6.4\n 8.2\n Hct\n 29.5\n 28.7\n 29.0\n 28.3\n Plt\n 191\n 193\n 222\n 236\n Cr\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 29\n 28\n 32\n 31\n Glucose\n 78\n 100\n 97\n 105\n 114\n 160\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:53/104, Alk Phos / T Bili:77/6.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.3 g/dL, LDH:352 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: fentanyl and ativan prn for sedation.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: Off pressor medication; holding lasix for rash\n will\n start ethocrinic acid for diuresis\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated\n GI / ABD: NPO/NGT, JP in place. VAC to suction. RUQ u/s\n NUTRITION: NPO on TPN\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n will restart hep sq today for INR of 1.2\n ENDOCRINE: RISS\n ID: vanc/ z osyn / fluconazole post surgery.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound VAC\n IMAGING: none\n FLUIDS: KVO\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 05:53 PM 41. mL/hour\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n Prophylaxis:\n DVT: Boots; hep sq\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2118-02-03 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1059643, "text": " 12:29 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Any lung process?\n Admitting Diagnosis: HERNIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fevers, raised , unclear source of sepsis, vent dep\n resp failure\n REASON FOR THIS EXAMINATION:\n Any lung process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:31 PM\n 1. Status post ileocolectomy with ileocolonic anastomosis at the hepatic\n flexure. Abdominal drain courses through the region of the anastomosis. No\n intra-abdominal fluid collection or free air is noted. Large anterior\n abdominal soft tissue defect, without underlying fluid collection.\n\n 2. Fatty liver.\n\n 3. No pulmonary findings to account for patient's ventilator dependent\n respiratory failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male with fever, leucocytosis, unclear source of sepsis\n and ventilator dependent respiratory failure.\n\n COMPARISON: CT abdomen/pelvis of and chest radiographs, most recently\n performed on the same day at 6:10 a.m.\n\n TECHNIQUE: MDCT axial imaging was performed through the chest, abdomen, and\n pelvis after administration of oral contrast and 130 mL of Optiray 350.\n Multiplanar reformatted images were then obtained.\n\n CT CHEST WITH CONTRAST: An ETT terminates in the trachea, and the NG tube\n terminates in the stomach. A central venous catheter terminates in the mid\n SVC. The heart, great vessels, and pericardium appear unremarkable. Dependent\n atelectatic changes are noted in the lungs. No pleural effusion is noted. The\n central airways remain patent. No mediastinal, hilar, or axillary adenopathy\n is noted.\n\n CT ABDOMEN WITH IV CONTRAST: There is diffuse fatty infiltration of the liver\n with sparing along the gallbladder fossa. No definite gallstone is noted\n within the gallbladder. The spleen, pancreas, adrenal glands, kidneys, and\n ureters appear unremarkable. Atherosclerotic calcifications are noted along\n the abdominal aorta, without aneurysmal dilatation. No adenopathy is noted.\n\n The stomach and proximal small bowel appear unremarkable. The patient is\n status post ileocolectomy with ileocolostomy noted along the hepatic flexure.\n A right percutaneous abdominal drain courses through the region of the\n ileocolostomy. While there is diffuse mesenteric fat stranding, no focal\n (Over)\n\n 12:29 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Any lung process?\n Admitting Diagnosis: HERNIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid collection or free air is noted within the abdomen. There is a large\n overlying anterior abdominal wall defect, which is also without evidence of\n fluid collection.\n\n CT PELVIS WITH IV CONTRAST: The bladder is collapsed over Foley catheter.\n Calcifications are noted within the prostate. The rectosigmoid colon and\n pelvic loops of bowel appear unremarkable. No free fluid or adenopathy is\n noted within the pelvis.\n\n OSSEOUS STRUCTURES: Multilevel degenerative endplate changes are noted along\n the thoracolumbar spine. No region of bony destruction is seen concerning for\n malignancy.\n\n IMPRESSIONS:\n 1. Status post ileocolectomy with ileocolonic anastomosis at the hepatic\n flexure. Abdominal drain courses through the region of the anastomosis. No\n free air or fluid collection is noted within the abdomen.\n\n 2. Large soft tissue defect along the anterior abdominal wall, without\n evidence of underlying fluid collection.\n\n 3. Diffuse fatty infiltration of the liver.\n\n 4. No evidence of acute pulmonary process seen on CT to account for\n ventilator dependent pulmonary failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-02-03 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1059644, "text": ", G. TSICU 12:29 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Any lung process?\n Admitting Diagnosis: HERNIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fevers, raised , unclear source of sepsis, vent dep\n resp failure\n REASON FOR THIS EXAMINATION:\n Any lung process?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Status post ileocolectomy with ileocolonic anastomosis at the hepatic\n flexure. Abdominal drain courses through the region of the anastomosis. No\n intra-abdominal fluid collection or free air is noted. Large anterior\n abdominal soft tissue defect, without underlying fluid collection.\n\n 2. Fatty liver.\n\n 3. No pulmonary findings to account for patient's ventilator dependent\n respiratory failure.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058736, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lung fields\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with vent dep resp failure\n REASON FOR THIS EXAMINATION:\n assess lung fields\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:43 A.M., \n\n HISTORY: Vent dependent respiratory failure.\n\n IMPRESSION: AP chest compared to and 23:\n\n Mild pulmonary edema has worsened. Previous atelectasis in the right lower\n lobe has improved. ET tube, right internal jugular line, and nasogastric tube\n are in standard placements. Heart size is normal. No pneumothorax or\n appreciable pleural effusion.\n\n Dr. was paged to report these findings at the time of the\n dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058381, "text": ", G. TSICU 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man intubated in icu s/p vent hernia repair\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Worsening of parenchymal consolidation that might represent progression of\n pneumonia/aspiration pneumonia. Some degree of pulmonary edema cannot be\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-31 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1058959, "text": " 11:01 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval liver and ductal system in setting of rising bilirubin\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p incarcerated ventral hernia and R colectomy\n REASON FOR THIS EXAMINATION:\n eval liver and ductal system in setting of rising bilirubin\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LGS MON 5:16 PM\n No biliary dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with rising bilirubin.\n\n COMPARISON: Abdominal CT, .\n\n FINDINGS: Note is made that this is a limited study due to the patient's body\n habitus. No focal lesions are identified within the liver. There is no\n biliary dilatation and the common duct measures 0.4 cm. There is sludge noted\n within the lumen of the gallbladder, but there are no stones and no signs of\n cholecystitis. No ascites is seen in the right upper quadrant. The portal\n vein is patent with hepatopetal flow.\n\n IMPRESSION: Limited study due to the patient's body habitus. No focal\n hepatic lesions. Sludge in the gallbladder, but no stones and no signs of\n cholecystitis. No biliary dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-31 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 1058960, "text": ", G. TSICU 11:01 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: eval liver and ductal system in setting of rising bilirubin\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p incarcerated ventral hernia and R colectomy\n REASON FOR THIS EXAMINATION:\n eval liver and ductal system in setting of rising bilirubin\n ______________________________________________________________________________\n PFI REPORT\n No biliary dilatation.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059561, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for consolidation / interval change\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ex-lap persistantly spiking fevers; weaning from vent\n REASON FOR THIS EXAMINATION:\n please eval for consolidation / interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: persistently spiking fever.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube is seen in standard position. NG tube tip is out of view below the\n diaphragm. The left IJ catheter tip is in the SVC. There are lower lung\n volumes. Cardiac size is normal. Bibasilar atelectasis are minimal, greater\n on the left side.\n\n DR. \n" }, { "category": "Nursing", "chartdate": "2118-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553620, "text": "Hernia, ventral / incision\n Assessment:\n Wound VAC intact with serosanginous drainage in small amounts. Altered\n GI function.\n Recurring tachycardia and elevated blood pressure. Positive fluid\n balance with generalized edema: remains 10kg above admission weight;\n tolerating diuretic therapy.\n Action:\n Lopressor started for tachycardia and HTN;\n prn dosing of ativan and fentanyl for activities/procedures as needed\n and to deter withdrawal symptoms from high dose narcotic and benzo\n therapy;\n Diuresis continues with bumex, changed to ethecrinic acid due to?\n sulfonamide sensitivity with lasix therapy\n Trophic tube feedings started\n Fecal incontinence system applied\n Response:\n Decreased heart rate & blood pressure to beta-blocker therapy\n Transient and inconsistent effect to vital signs with narcotic and\n sedation dosing\n Daily fluid balance negative with ongoing diuresis: PVV within normal\n calculated range.\n High gastric residual; tube feedings put on hold\n Increased frequency of foul smelling liquid stool\n Plan:\n Continue with beta blocker therapy; monitor hemodynamic response\n Continue appropriate use of prn pain and sedation meds; monitor\n effectiveness; assess sedation level\n Continue diuretic therapy; daily weights\n Electrolyte replacement to wnl\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Failed RSBI again this am; increase in amount of retained secretions;\n increase in spontaneous coughing noted; temp of 101.5; WBC wnl but\n slightly increased today. Tolerating PSV of 20cm.\n Action:\n Changed to PSV with adjustments in level made for tachypnea\n Suctioned every 2-3 hours for small amounts thick white sputum\n Sputum culture sent\n Response:\n Ongoing need for suctioning ~ every 2-3 hours\n Respiratory rates now 18-25 with adequate tidal volumes\n Breath sounds rhonchorous and diminished at bases\n Temp range 101 to 100.3 orally\n Plan:\n Assess for increase work of breathing (^ RR and decreased tidal\n volumes, use of accessory muscles, nasal flaring, change in vital\n signs); clear retained secretions; monitor for elevation in temp and\n wbc; monitor culture results.\n Problem\n pupil changes: new\n Assessment:\n Routine neuro check @ noon revealed unequal pupil s: right greater than\n left by 2mm; reaction to light inconsistent: sluggish >/< brisk. No\n other changes in neuro exam noted.\n Action:\n ICU resident notified; ICU resident examined patient and confirmed\n papillary changes; surgical team notified; Urgent head CT obtained.\n Response:\n Head CT reported as WNL; no neurologic event noted.\n Plan:\n Continue with scheduled neuro checks; report further changes.\n" }, { "category": "Nursing", "chartdate": "2118-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553621, "text": "Hernia, ventral / incision\n Assessment:\n Wound VAC intact with serosanginous drainage in small amounts. JP drain\n with minimal serous output.\n Altered GI function; absent bowel sounds; bilious gastric output in\n moderate amounts. Onset of liquid stools.\n Recurring tachycardia and elevated blood pressure.\n Action:\n Lopressor started for tachycardia and HTN;\n prn dosing of ativan and fentanyl for activities/procedures as needed\n and to deter withdrawal symptoms from high dose narcotic and benzo\n therapy;\n Trophic tube feedings started\n Fecal incontinence system applied\n Response:\n Decreased heart rate & blood pressure to beta-blocker therapy\n Transient and inconsistent effect to vital signs with narcotic and\n sedation dosing\n High gastric residual (foul smelling); tube feedings put on hold\n Increased frequency of foul smelling liquid stool\n Plan:\n Continue with beta blocker therapy; monitor hemodynamic response\n Continue appropriate use of prn pain and sedation meds; monitor\n effectiveness; assess sedation level\n Resume tube feedings as tolerated; monitor residuals Q 4 hours\n Send stool for C. diff\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on CMV; failed RSBI; increase in amount of retained secretions;\n rhonchorous lung sounds; temp max-101.5; WBC wnl but slightly increased\n today. Positive fluid balance with generalized edema: 10 kg above\n admission weight. Adequate gas exchange per ABG with ongoing metabolic\n alkalosis.\n Action:\n Changed to PSV with adjustments in level made for tachypnea\n Suctioned every 2-3 hours for small amounts thick white sputum; sputum\n culture sent\n Diuretic therapy changed to bumex, then ethecrinc acid; diamox therapy\n initiated.\n Response:\n Continued need for frequent suctioning\n Breath sounds rhonchorous and diminished at bases\n Respiratory rates now 18-25 with adequate tidal volumes on PSV 20cm\n Temp range 101 to 100.3 orally\n Negative fluid balance; PVV within normal range\n Plan:\n Assess for increase work of breathing (^ RR and decreased tidal\n volumes, use of accessory muscles, nasal flaring, change in vital\n signs); clear retained secretions; monitor for elevation in temp and\n wbc; monitor culture results. Continue diuretic therapy as tolerated;\n daily weight.\n Replace electrolytes to wnl\n Problem\n pupil changes: new\n Assessment:\n Routine neuro check @ noon revealed unequal pupil s: right greater than\n left by 2mm; reaction to light inconsistent: sluggish >/< brisk. No\n other changes in neuro exam noted.\n Action:\n ICU resident notified; ICU resident examined patient and confirmed\n papillary changes; surgical team notified; Urgent head CT obtained.\n Response:\n Head CT reported as WNL; no neurologic event noted.\n Plan:\n Continue with scheduled neuro checks; report further changes.\n" }, { "category": "Nursing", "chartdate": "2118-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553622, "text": "47 yo male S/P repair ventral hernia with return to OR same day for\n perforation .; hospital course complicated by sepsis and\n cardiaogenic shock, respiratory failure, and metabolic acidosis.\n TODAY\nS EVENTS: Changed to PSV\n Urgent head CT for pupil changes\n Onset liquid stools\n Trophic tube feedings initiated\n Hernia, ventral / incision\n Assessment:\n Wound VAC intact with serosanginous drainage in small amounts. JP drain\n with minimal serous output.\n Altered GI function; absent bowel sounds; bilious gastric output in\n moderate amounts. Onset of liquid stools.\n Recurring tachycardia and elevated blood pressure.\n Action:\n Lopressor started for tachycardia and HTN;\n prn dosing of ativan and fentanyl for activities/procedures as needed\n and to deter withdrawal symptoms from high dose narcotic and benzo\n therapy;\n Trophic tube feedings started\n Fecal incontinence system applied\n Response:\n Decreased heart rate & blood pressure to beta-blocker therapy\n Transient and inconsistent effect to vital signs with narcotic and\n sedation dosing\n High gastric residual (foul smelling); tube feedings put on hold\n Increased frequency of foul smelling liquid stool\n Plan:\n Continue with beta blocker therapy; monitor hemodynamic response\n Continue appropriate use of prn pain and sedation meds; monitor\n effectiveness; assess sedation level\n Resume tube feedings as tolerated; monitor residuals Q 4 hours\n Send stool for C. diff\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on CMV; failed RSBI; increase in amount of retained secretions;\n rhonchorous lung sounds; temp max-101.5; WBC wnl but slightly increased\n today. Positive fluid balance with generalized edema: 10 kg above\n admission weight. Adequate gas exchange per ABG with ongoing metabolic\n alkalosis.\n Action:\n Changed to PSV with adjustments in level made for tachypnea\n Suctioned every 2-3 hours for small amounts thick white sputum; sputum\n culture sent\n Diuretic therapy changed to bumex, then ethecrinc acid; diamox therapy\n initiated.\n Response:\n Continued need for frequent suctioning\n Breath sounds rhonchorous and diminished at bases\n Respiratory rates now 18-25 with adequate tidal volumes on PSV 20cm\n Temp range 101 to 100.3 orally\n Negative fluid balance; PVV within normal range\n Plan:\n Assess for increase work of breathing (^ RR and decreased tidal\n volumes, use of accessory muscles, nasal flaring, change in vital\n signs); clear retained secretions; monitor for elevation in temp and\n wbc; monitor culture results. Continue diuretic therapy as tolerated;\n daily weight.\n Replace electrolytes to wnl\n Problem\n pupil changes: new\n Assessment:\n Routine neuro check @ noon revealed unequal pupil s: right greater than\n left by 2mm; reaction to light inconsistent: sluggish >/< brisk. No\n other changes in neuro exam noted.\n Action:\n ICU resident notified; ICU resident examined patient and confirmed\n papillary changes; surgical team notified; Urgent head CT obtained.\n Response:\n Head CT reported as WNL; no neurologic event noted.\n Plan:\n Continue with scheduled neuro checks; report further changes.\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553741, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Acute Pain\n Assessment:\n Pt resting. Will grimace when turned or abd palpated. Pt HR ST.\n Action:\n Wound Vac Dressing changed today. Dressing replaced with wet/dry\n dressing. Large opening noted once wound vac removed. Strong odor from\n wound. Dusky color to tissue. Pt given fentanyl 150mcg for pain control\n with dressing change.\n Response:\n Pt tolerated dressing change well. Surgical service informed they need\n to call and give the RN notification prior to dressing change.\n Plan:\n Surgical service to come back by to change dressing again tonight. ? CT\n scan of Abd tonight pending ok from attending.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains orally intubated and on vent settings as charted. Increasingly\n Tachypneic when more alert.\n Action:\n Weaned pressure support as tolerated. Medicated with ativan and\n fentanyl when patient appeared restless/agitated. Pt on 18 of PS at\n this time. Will try to wean down PS as tolerated. PCXR better this\n morning from last PCXR.\n Response:\n Plan:\n Continue to wean pt PS as tolerated. Plan for slow wean. Repeat ABG in\n am. PCXR in am.\n" }, { "category": "Respiratory ", "chartdate": "2118-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553743, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: Pt consistently breathing in the mid 30s at the beginning of\n the shift but appears more comfortable now with RR in the low 20s.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Slow wean with PS\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Comments: Pt weaned to PS 16 from 18 tol well thus far with RR in the\n mid to low 20s. Will cont with vent support and continue with wean as\n tol.\n" }, { "category": "Physician ", "chartdate": "2118-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 553723, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Potassium\n Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV Q1HR PRN,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12H, Ethacrynic acid, Acetazolamide, Lopressor, Lorazepam.\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today. Aim to keep phos> 3. Monitoring LFTs and INR.\n Received 10mg SC vit K.\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; Ultrasound RUQ -> prelim read\n negative\n .\n 24 HOUR EVENTS:\n : Lasix dc'd due to rash. Started on ethacrynic acid- huge diuresis\n overnight. Lopressor started instead of labetolol. Continue day 2 of\n TPN. Trophic tube feeds started but residuals> 100cc so held briefly\n overnight. Switched to pressure support. Sputum, stool and UC sent. Ct\n head performed due to sluggish dilated right pupil-no acute pathology.\n Fluconazole dc'd due to rising bilirubin. Spiked a temp overnight- BC\n sent.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n 24 Hour Events:\n SPUTUM CULTURE - At 10:40 AM\n URINE CULTURE - At 10:50 AM\n BLOOD CULTURED - At 12:51 AM\n FEVER - 101.4\nF - 12:00 AM\n Post operative day:\n POD#8 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:16 PM\n Metoprolol - 12:01 AM\n Lorazepam (Ativan) - 12:16 AM\n Heparin Sodium (Prophylaxis) - 02:01 AM\n Fentanyl - 02:39 AM\n Other medications:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.7\nC (99.9\n HR: 107 (98 - 123) bpm\n BP: 120/73(88) {120/34(79) - 1,133/92(115)} mmHg\n RR: 34 (15 - 40) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 6 (3 - 16) mmHg\n Total In:\n 2,851 mL\n 582 mL\n PO:\n Tube feeding:\n 80 mL\n 26 mL\n IV Fluid:\n 1,701 mL\n 258 mL\n Blood products:\n Total out:\n 10,325 mL\n 2,260 mL\n Urine:\n 9,500 mL\n 1,950 mL\n NG:\n 550 mL\n Stool:\n Drains:\n 275 mL\n 10 mL\n Balance:\n -7,474 mL\n -1,678 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 650 (516 - 801) mL\n PS : 18 cmH2O\n RR (Set): 24\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: 7.48/37/178/29/4\n Ve: 14 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, puplils appear equal this a.m. and equally reactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Appears more responsive to verbal stimuli but not following commands\n Labs / Radiology\n 326 K/uL\n 11.2 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 106 mEq/L\n 141 mEq/L\n 32.9 %\n 12.4 K/uL\n [image002.jpg]\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n WBC\n 6.4\n 8.2\n 12.4\n Hct\n 29.0\n 28.3\n 32.9\n Plt\n 222\n 236\n 326\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.8\n TCO2\n 32\n 31\n 32\n 31\n 27\n 28\n Glucose\n 105\n 114\n 160\n 128\n 138\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:80/122, Alk-Phos / T bili:92/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.5 mg/dL, Mg:2.1\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Not following commands.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: diuresis with ethacrynic acid. Lopressor for BP and HR\n control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS.\n GI / ABD: NPO/NGT, JP drain in place. VAC to suction. Follow LFTS and\n bilirubin (decreasing),,start reglan\n NUTRITION: Trophic tube feeds and TPN. Held currently for high\n residuals, restart at 10\n TPN without Lipids - 06:48 PM 45. mL/hour\n Replete (Full) - 05:12 AM 20 mL/hour\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0. D/C\n ethacrynic acid, large diuresis\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. CXray\n clear, may need possible ct abdomen if wbc continues to rise\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO. Replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE\n HOB elevation, Oral Care, RSBI, Daily Wake Up\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Resp Failure, Post Op Complication\n ICU Care\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553729, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554084, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.4 this am. Recheck of temp 101.3 this afternoon.\n Action:\n Pt given Tylenol for temp. MD aware no new cultures ordered at this\n time\n Response:\n Pt temp down\n Plan:\n f/u on cx\ns that were sent on around 1600, cont to treat fever\n with Tylenol as ordered\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554085, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.4 this am. Recheck of temp 101.3 this afternoon.\n Action:\n Pt given Tylenol for temp. MD aware no new cultures ordered at this\n time\n Response:\n Pt temp down\n Plan:\n f/u on cx\ns that were sent on around 1600, cont to treat fever\n with Tylenol as ordered\n Altered mental status (not Delirium)\n Assessment:\n Pt extubated at 1200. Pt voice very weak at first. Stronger as the day\n went on. Pt confused. Not able to state correct place, date, reason for\n visit. Pt is able to state correct year and month. Pt stated\nleave me\n alone\nm having a bad week\n Action:\n Pt reoriented to location and plan of care. Pt OOb to chair for 2 hr\n today. Ativan given per orders.\n Response:\n No change in pt mental status. Pt to bed at 1630. Tolerated well.\n Ativan given and pt more calm.\n Plan:\n Continue to monitor pt neuro status and provide ativan as needed.\n Acute Pain\n Assessment:\n Pt grimaces with repositioning and dressing changes\n Action:\n Prn dilaudid given per orders\n Response:\n Changed prn order to 2mg q2 hours\n Plan:\n Cont to assess pain level, premedicate before turns and dressing\n changes.\n" }, { "category": "Nursing", "chartdate": "2118-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553736, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains orally intubated and on vent settings as charted. Increasingly\n Tachypneic when more alert.\n Action:\n Weaned pressure support as tolerated. Medicated with ativan and\n fentanyl when patient appeared restless/agitated\n Response:\n Continues to require 18 of pressure support to maintain RR <40\n Plan:\n Wean vent if tolerated. Continue to medicated PRN>\n" }, { "category": "Physician ", "chartdate": "2118-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 553706, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH\n Q4H:PRN,Magnesium Sulfate IV Sliding Scale, Acetaminophen 650 mg PR\n Q6H, Albuterol Inhaler PUFF IH Q4H:PRN, Calcium Gluconate IV\n Sliding Scale, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Potassium\n Phosphate IV Sliding Scale, Fentanyl Citrate 100-200 mcg IV Q1HR PRN,\n Insulin SC (per Insulin Flowsheet)Sliding Scale, Vancomycin 1500 mg IV\n Q 12H, Ethacrynic acid, Acetazolamide, Lopressor, Lorazepam.\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR and IV albumin. On milrinone, vaso and levophed.\n Spiked temp and was pan cultured. Fem a line removed, radial a line\n placed.\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; FiO2 down to 50%\n 1/23: milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n : Off levophed. Vancomycin dose increased to 1500mg , team\n deferred feeding today. Aim to keep phos> 3. Monitoring LFTs and INR.\n Received 10mg SC vit K.\n : Lasix 10mg IV x 2 given for goal 2L negative; TPN held as trying\n to diuresis today - gold team strongly against feeding gut; phos\n repletion continuing; weaning sedation and vent as tolerated\n : CVL replaced; TPN started; able to keep negative; prn ativan;\n rash worse through the day; VAC changed; Ultrasound RUQ -> prelim read\n negative\n .\n 24 HOUR EVENTS:\n : Lasix dc'd due to rash. Started on ethacrynic acid- huge diuresis\n overnight. Lopressor started instead of labetolol. Continue day 2 of\n TPN. Trophic tube feeds started but residuals> 100cc so held briefly\n overnight. Switched to pressure support. Sputum, stool and UC sent. Ct\n head performed due to sluggish dilated right pupil-no acute pathology.\n Fluconazole dc'd due to rising bilirubin. Spiked a temp overnight- BC\n sent.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n 24 Hour Events:\n SPUTUM CULTURE - At 10:40 AM\n URINE CULTURE - At 10:50 AM\n BLOOD CULTURED - At 12:51 AM\n FEVER - 101.4\nF - 12:00 AM\n Post operative day:\n POD#8 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:16 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:16 PM\n Metoprolol - 12:01 AM\n Lorazepam (Ativan) - 12:16 AM\n Heparin Sodium (Prophylaxis) - 02:01 AM\n Fentanyl - 02:39 AM\n Other medications:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 37.7\nC (99.9\n HR: 107 (98 - 123) bpm\n BP: 120/73(88) {120/34(79) - 1,133/92(115)} mmHg\n RR: 34 (15 - 40) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 135 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 6 (3 - 16) mmHg\n Total In:\n 2,851 mL\n 582 mL\n PO:\n Tube feeding:\n 80 mL\n 26 mL\n IV Fluid:\n 1,701 mL\n 258 mL\n Blood products:\n Total out:\n 10,325 mL\n 2,260 mL\n Urine:\n 9,500 mL\n 1,950 mL\n NG:\n 550 mL\n Stool:\n Drains:\n 275 mL\n 10 mL\n Balance:\n -7,474 mL\n -1,678 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 650 (516 - 801) mL\n PS : 18 cmH2O\n RR (Set): 24\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 26 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: 7.48/37/178/29/4\n Ve: 14 L/min\n PaO2 / FiO2: 445\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, puplils appear equal this a.m. and equally reactive\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Appears more responsive to verbal stimuli but not following commands\n Labs / Radiology\n 326 K/uL\n 11.2 g/dL\n 138 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 17 mg/dL\n 106 mEq/L\n 141 mEq/L\n 32.9 %\n 12.4 K/uL\n [image002.jpg]\n 02:07 PM\n 02:16 PM\n 02:02 AM\n 02:10 AM\n 01:45 AM\n 10:15 AM\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n WBC\n 6.4\n 8.2\n 12.4\n Hct\n 29.0\n 28.3\n 32.9\n Plt\n 222\n 236\n 326\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.8\n TCO2\n 32\n 31\n 32\n 31\n 27\n 28\n Glucose\n 105\n 114\n 160\n 128\n 138\n Other labs: PT / PTT / INR:13.9/22.8/1.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:80/122, Alk-Phos / T bili:92/4.7,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.5 g/dL, LDH:298 IU/L, Ca:9.5 mg/dL, Mg:2.1\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION\n IN COMMENTS, HERNIA, VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), ACUTE PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Not following commands.\n Neuro checks Q:4H\n Pain: fentanyl prn\n CARDIOVASCULAR: diuresis with ethacrynic acid. Lopressor for BP and HR\n control.\n PULMONARY: Vent dep resp failure, weaning FiO2 and PEEP as tolerated-\n now on PS.\n GI / ABD: NPO/NGT, JP drain in place. VAC to suction. Follow LFTS and\n bilirubin (decreasing),,start reglan\n NUTRITION: Trophic tube feeds and TPN. Held currently for high\n residuals, restart at 10\n TPN without Lipids - 06:48 PM 45. mL/hour\n Replete (Full) - 05:12 AM 20 mL/hour\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0. D/C\n ethacrynic acid, large diuresis\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. CXray\n clear, may need possible ct abdomen if wbc continues to rise\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: KVO. Replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE\n HOB elevation, Oral Care, RSBI, Daily Wake Up\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Resp Failure, Post Op Complication\n ICU Care\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2118-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552865, "text": "47 yo male admitted w/ incarcerated ventral hernia. s/p ex lap,\n VHR w/ mesh placement. Patient w/ dramatic hemodynamic decompensation,\n fecal drainage from drains in PACU post op, back to OR for repair of\n small bowel perforation. Patient to TSICU from OR w/ severe\n hemodynamic instability. After large volumes of fluid and high dose\n vasopressors ineffective to manage BP and CO, TTE revealed EF 10%,\n consistent w/ cardiogenic shock. See below for management since\n admission.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rising peep & fio2 requirements in setting of massive fluid\n resuscitation, cardiogenic shock. Abg reveals metabolic acidosis.\n Mild desaturations noted last night w/ turns w/ inability to recover\n after time. CXR worse from am.\n Action:\n Peep holding at 12, most recent abg w/ pao2 190s. weaned fio2\n overnight. Frequent oral care, ett care.\n Response:\n O2 sats when positioned on R side 94-96%, when on L side 92-94%. Team\n aware, acceptable. Minimal secretions present, clear, thin.\n Plan:\n f/u CXR today, maintain current settings in light of worsening pulm\n status, likely d/t third spacing, fluid mobilization.\n Hernia, ventral / incisional\n Assessment:\n s/p VHR, small bowel perf repair .\n Action:\n VAC dsg in place to midline abdomen, freq belly exams continue.\n Response:\n Foul, watery brown drainage from VAC, canister changed prn. No further\n rectal drainage noted, JP w/ mod amts serous output to LWS. Wound\n edges exposed under transparent VAC tegederm, areas beefy red.\n Plan:\n Cont to monitor belly exam, VAC drainage. VAC dsg due to be changed\n today .\n" }, { "category": "Nutrition", "chartdate": "2118-02-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553893, "text": "Pertinent medications: KCl x 1, NS, RISS, IV abx, pepcid, heparin,\n others noted\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 01:47 AM\n Glucose Finger Stick\n 160\n 08:00 AM\n BUN\n 24 mg/dL\n 01:47 AM\n Creatinine\n 0.9 mg/dL\n 01:47 AM\n Sodium\n 142 mEq/L\n 01:47 AM\n Potassium\n 3.8 mEq/L\n 01:47 AM\n Chloride\n 111 mEq/L\n 01:47 AM\n TCO2\n 26 mEq/L\n 01:47 AM\n PO2 (arterial)\n 162 mm Hg\n 01:51 AM\n PCO2 (arterial)\n 40 mm Hg\n 01:51 AM\n pH (arterial)\n 7.47 units\n 01:51 AM\n pH (urine)\n 7.0 units\n 09:57 AM\n CO2 (Calc) arterial\n 30 mEq/L\n 01:51 AM\n Albumin\n 2.5 g/dL\n 02:02 AM\n Calcium non-ionized\n 9.3 mg/dL\n 01:47 AM\n Phosphorus\n 3.1 mg/dL\n 01:47 AM\n Ionized Calcium\n 1.24 mmol/L\n 03:15 AM\n Magnesium\n 2.3 mg/dL\n 01:47 AM\n ALT\n 71 IU/L\n 01:47 AM\n Alkaline Phosphate\n 98 IU/L\n 01:47 AM\n AST\n 81 IU/L\n 01:47 AM\n Total Bilirubin\n 2.6 mg/dL\n 01:47 AM\n WBC\n 13.5 K/uL\n 01:47 AM\n Hgb\n 9.4 g/dL\n 01:47 AM\n Hematocrit\n 27.6 %\n 01:47 AM\n Current diet order / nutrition support: Replete with Fiber @ 10 ml/hr\n TPN Order: 2.2 L Dex: 245 g AA: 130 g (1353 kcals/ 130 g pro)\n GI: soft, distended, obese, hypoactive BS\n Assessment of Nutritional Status\n Specifics: Pt was tolerating trophic TF with minimal residuals, TF were\n put on hold for CT of abd this morning. Current TPN provides 1353\n kcals/ 130 g pro. Recommend checking TG so that lipids can be added to\n TPN. Recommend 45 g Lipids/day therefore TPN will provide 1803 kcals/\n 130 g pro (20 kcals/ kg and 1.5 g pro/kg of adjusted BW). Recommend\n advancing TF to goal of Replete with Fiber @ 80 ml/hr (1800 kcals/ 112\n g pro)\n Medical Nutrition Therapy Plan - Recommend the Following\n Pending TG level advance to goal TPN 2.2 L Dex: 245 g AA: 130g Fat: 45\n g (1803 kcals/ 130 g pro)\n Check triglycerides hold lipids if >400\n Lyte and BG management as you already are\n Advance TF to goal Replete with Fiber @ 80 ml/hr and monitor TF\n tolerance\n Will follow POC pls page with questions\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554075, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.4 this am. Recheck of temp 101.3 this afternoon.\n Action:\n Pt given Tylenol for temp. MD aware no new cultures ordered at this\n time\n Response:\n Pt temp down to\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554083, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.4 this am. Recheck of temp 101.3 this afternoon.\n Action:\n Pt given Tylenol for temp. MD aware no new cultures ordered at this\n time\n Response:\n Pt temp down to\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553969, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp to 101.8\n Action:\n Tylenol given,fan on\n Response:\n Pt diaphoretic after Tylenol, temp down to 100.8\n Plan:\n f/u on cx\ns that were sent on around 1600, cont to treat fever\n with Tylenol as ordered\n Acute Pain\n Assessment:\n Pt grimaces with repositioning and dressing changes\n Action:\n Prn dilaudid given 1mg at a time\n Response:\n Changed prn order to 1-2mg q2 hours instead of 1mg q 3 hour, pt seems\n to grimace less after dilaudid\n Plan:\n Cont to assess pain level, premedicate before turns and dressing\n changes\n Hernia, ventral / incisional\n Assessment:\n Weaping serous/yellow drainage, foul smelling, pink ,eccymotic,some\n necrotic areas noted around border of wound\n Action:\n Reinforced dressing throughout the night prn\n Response:\n Lrg amt of drainage, dressing needs to be reinforced frequently\n Plan:\n ? surgery teams plan-wound vac?, keep with wet to dry dressing\n Respiratory failure, acute (not ARDS/)\n Assessment:\n CPAP 10/5/40%, LS coarse bilat and clear bilat after sxning\n Action:\n Sxn\nd prn, ABG drawn this am\n Response:\n Moderate amt of white/thin sputum, abg wnl\n Plan:\n ? extubate in am, sxn as needed\n" }, { "category": "Nursing", "chartdate": "2118-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552862, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hernia, ventral / incisional\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2118-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 553085, "text": "TSICU\n HPI:\n 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Chief complaint:\n ventral hernia\n PMHx:\n pneumonia\n Current medications:\n Heparin 5000 UNIT SC TID,Insulin SC Sliding Scale,Ipratropium Bromide\n MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate IV Sliding Scale, LR at\n 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP, Midazolam 1-10 mg/hr IV\n DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Albuterol Inhaler \n PUFF IH Q4H:PRN, Piperacillin-Tazobactam Na 4.5 g IV Q8H, Calcium\n Gluconate IV Sliding Scale, Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Fentanyl Citrate 100-200 mcg IV Q1HR PRN\n pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP, Vasopressin 1.2-3.6\n UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200 mg IV Q24H\n Vancomycin 1000 mg IV Q 12H\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 05:15 PM\n : milrinone discontinued, vasopressin weaned off, some troubles\n oxygenating when moving patient to left side, heplocked IVF\n Post operative day:\n POD#4 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 11:00 AM\n Vancomycin - 07:54 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Fentanyl (Concentrate) - 250 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:30 PM\n Fentanyl - 12:04 AM\n Other medications:\n Flowsheet Data as of 05:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.6\n HR: 107 (95 - 115) bpm\n BP: 90/49(62) {90/47(62) - 134/77(92)} mmHg\n RR: 26 (19 - 30) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 143.8 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 13 (13 - 22) mmHg\n Total In:\n 6,462 mL\n 136 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,422 mL\n 136 mL\n Blood products:\n Total out:\n 3,965 mL\n 600 mL\n Urine:\n 2,915 mL\n 600 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 800 mL\n Balance:\n 2,497 mL\n -464 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 537 (537 - 667) mL\n PS : 12 cmH2O\n RR (Set): 24\n RR (Spontaneous): 1\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 26 cmH2O\n SPO2: 97%\n ABG: 7.37/47/86/24/0\n Ve: 12.5 L/min\n PaO2 / FiO2: 172\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: right)\n Abdominal: Soft, Distended, VAC in place\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Noxious stimuli), Sedated, localizes to pain\n Labs / Radiology\n 191 K/uL\n 10.5 g/dL\n 78 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 10 mg/dL\n 105 mEq/L\n 136 mEq/L\n 30.3 %\n 11.2 K/uL\n [image002.jpg]\n 02:35 PM\n 09:29 PM\n 03:09 AM\n 10:35 AM\n 02:13 PM\n 02:36 PM\n 05:35 PM\n 07:20 PM\n 01:37 AM\n 01:45 AM\n WBC\n 15.2\n 14.6\n 14.9\n 11.2\n Hct\n 28.4\n 28.2\n 29.9\n 30.3\n Plt\n 91\n Creatinine\n 0.8\n 0.7\n 0.6\n 0.6\n TCO2\n 20\n 24\n 26\n 25\n 26\n 28\n Glucose\n 101\n 85\n 101\n 102\n 80\n 78\n Other labs: PT / PTT / INR:31.0/40.2/3.2, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.8 mg/dL, Mg:2.2\n mg/dL, PO4:1.6 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n Neurologic: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n Cardiovascular: Levophed and vasopressin (currently off) for MAP > 65 -\n continue to wean as tolerated; heplocked; milrinone no off\n Pulmonary: Vent dep resp failure, continue to optomize resp status,\n wean FiO2 and PEEP as tolerated\n Gastrointestinal / Abdomen: NPO/NGT, JP in place. VAC to suction.\n Nutrition: NPO\n Renal: f/u creat and UO.\n Hematology: f/u Hct - stable\n Endocrine: RISS\n Infectious Disease: vanc/zosyn/fluconazole post surgery\n Lines / Tubes / Drains: RIJ, R rad aline JP, VAC, Foley, NGT\n Wounds: abd wound w VAC\n Imaging: none\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress), Post-op hypotension, Post-op\n complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2118-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552653, "text": "47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Today\ns Events:\n -TTE\n -Femoral a-line removed and Right radial a-line placed\n with vigileo\n Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen with serous drainage and Vac dressing placed in\n incisional wound bed draining serosanguinous fluid. BS absent. Abdomen\n tender to palpation. NG tube to suction with thick tan drainage.\n Bladder pressures 20/21.\n Action:\n Monitoring drainage color and amt. Bladder pressure performed q4hrs.\n Response:\n Bladder pressures elevated to 24. Drains still accruing a moderate amt\n of fluid.\n Plan:\n Continue to monitor bladder pressures for compartment syndrome and\n drainage.\n Shock, cardiogenic\n Assessment:\n Pt had ejection fraction ~10% over night. Pt on three pressors to\n maintain adequate BP. Pt tachycardic. Cool extremities with pulses\n difficult to palpate. Pt\ns SVV in high 20s-low 30s. CVP 8. Pt has\n adequate urine output.\n Action:\n TTE performed. Milrinone gtt on. Titrated off Neo and placed pt on\n Vasopressin. Titrated Levo down. Pt goal is MAP >60 Vigileo in place.\n Multiple albumin boluses given and 1liter LR bolus given. LR\n maintenance increased to 250cc/hr.\n Response:\n Pt\ns EF ~45% Pt\ns SVV decreased to <15. MAP with titration at goal. Pt\n still tachycardic. Upper extremities warm and lower extremities cool.\n Urine output still adequate. CVP mid-teens.\n Plan:\n Continue to wean Levophed. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with tidal volume of 640, RR 18, Peep 8 and FiO2 of 100%. ABG\n showing metabolic acidosis. O2 sats wnl. LS clear and diminished at\n bases. Minimal thick tan secretions.\n Action:\n Pt\ns FiO2 weaned, tidal volume decreased, and RR increased. Pt\ns tube\n placement changed per xray to 23 at the lip. VAP care performed.\n Response:\n Pt\ns PaO2 adequate (per team 80-90 range). Pt\ns increased spontaneous\n breathing. ABG shows metabolic acidosis.\n Plan:\n Continue to monitor ABG\ns, continue vent support.\n Acute Pain\n Assessment:\n Pt denies pain at rest, but with turns and abdominal movement pt\n grimaces.\n Action:\n Pt on Fent and Midaz gtt. Prn Fentanyl boluses with turns. Fentanyl gtt\n concentrated.\n Response:\n Pt still grimaces a fair amt with incisional discomfort with any\n activity.\n Plan:\n Continue prn boluses with turns.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs. Tmax\n 101.2. Tachycardia and hypotension.\n Action:\n Pt on Vanco, Fluconazole and Zosyn.\n Response:\n Pt\ns temp continues to rise with elevated WBC\ns. Pt\ns clammy.\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n Acidosis, Metabolic\n Assessment:\n Pt has elevated lactate and negative base excess. Pt\ns ABG shows\n metabolic acidosis. Hypocalcemic.\n Action:\n Pt had multiple ABGs and lactates drawn. Electrolytes repleted.\n Response:\n Pt\ns respirations increased but pH remains acidic. Lactate still\n elevated.\n Plan:\n Continue to monitor Abg\n Pt\ns family visited today (mother, father, son and significant other).\n Dr spoke with the parents about plan of care and prognosis. Family\n decided that the son would be the spokesperson.\n" }, { "category": "Nursing", "chartdate": "2118-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552552, "text": "47 male presents to with acute exacerbation of abdominal pain\n since . PMHx significant only for ETOH, remote ORIF left wrist.\n NKDA, allergic to peanuts. On arrival, found to have large ventral\n hernia. He was taken to the OR on for repair with mesh\n placement. In the PACU, he became tachycardic, had low urine output,\n emesis, and was draining succus from his NGT and surgical drain. He was\n taken back to the OR for exploration; a hole was found in his bowel, a\n washout was performed, and an ileocolectomy done. He was then\n transferred to the T/SICU for further care.\n Hernia, ventral / incisional\n Assessment:\n Abdomen obese, tender to palpation. Bowel sounds absent. NGT sumps foul\n smelling thick tan matter. Surgical incision with VAC dressing to\n 125mmHg suction drains serosanguenous fluid.\n Action:\n Q4 bladder pressure. Fluid resuscitation and hemodynamic support.\n Response:\n Bladder pressure 16->16->21. Urine output marginal. Lactate rose to\n 4.0, now trending downward.\n Plan:\n Bladder pressure q4hrs and monitor abdominal exam.\n Shock, cardiogenic\n Assessment:\n Hypotensive refractory to IVF boluses and pressors.\n Action:\n Transthoracic echo done by Dr revealed EF ~10%. Multiple IVF\n boluses and 25% albumin given. Cardiology consult obtained.\n Response:\n Milrinone added with Levophed for inotropic effect. Neo titrated to\n 1mcg/kg/min.\n Plan:\n Maintain MAP>65.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung sounds clear, diminished at the bases R>L. Poor oxygenation on\n arrival.\n Action:\n Increased PEEP to 8, adjusted to Vt640, RR18.\n Response:\n PaO2 improved to >200, weaned FiO2 to 50%, but later hemodynamic\n compromise lead to desat to 89% and PaO2 ~90, so returned to 100% FiO2.\n Plan:\n Wean ventilator as tolerated.\n Acute Pain\n Assessment:\n Very tender abdomen. Patient generally denies pain through non-verbal\n communication at rest, but has severe facial grimace with palpation or\n turns.\n Action:\n Fentanyl gtt titrated up to 400mcg/hr with breakthrough given for turns\n and care.\n Response:\n Comfortable at rest, however continues to have pain with turning.\n Plan:\n Provide adequate analgesia and anxiolytics for comfort and compliance\n with care.\n" }, { "category": "Physician ", "chartdate": "2118-01-26 00:00:00.000", "description": "Intensivist Note", "row_id": 552566, "text": "TSICU\n HPI:\n 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Chief complaint:\n ventral hernia\n PMHx:\n pneumonia\n Current medications:\n Insulin SC, Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Magnesium\n Sulfate IV Sliding Scale, Milrinone 0.5 mcg/kg/min IV DRIP INFUSION,\n Midazolam 1-10 mg/hr IV DRIP, Morphine Sulfate 1-5 mg IV PRN, Albuterol\n Inhaler PUFF IH Q4H:PRN, Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Phenylephrine 0.5-5 mcg/kg/min IV DRIP, Famotidine 20 mg IV Q12H,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Fentanyl Citrate 100-500\n mcg/hr IV DRIP, Potassium Chloride IV Sliding Scale, Fentanyl Citrate\n 100-200 mcg IV Q1HR, Fluconazole 200 mg IV Q24H, Vancomycin 1000 mg IV\n Q 12H, Heparin 5000 UNIT SC TID\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:50 PM\n OR RECEIVED - At 09:00 PM\n ARTERIAL LINE - START 09:00 PM\n MULTI LUMEN - START 09:00 PM\n EKG - At 10:00 PM\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n TRANSTHORACIC ECHO - At 03:12 AM\n TRANSTHORACIC ECHO - At 05:15 AM\n Post operative day:\n POD#1 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:30 PM\n Heparin Sodium (Prophylaxis) - 10:59 PM\n Midazolam (Versed) - 11:21 PM\n Fentanyl - 03:39 AM\n Other medications:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 38.2\nC (100.8\n HR: 126 (116 - 150) bpm\n BP: 99/55(71) {72/45(57) - 125/74(91)} mmHg\n RR: 22 (16 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 13 (8 - 18) mmHg\n Bladder pressure: 21 (16 - 21) mmHg\n Total In:\n 16,319 mL\n 5,166 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,394 mL\n 4,966 mL\n Blood products:\n 1,000 mL\n 200 mL\n Total out:\n 2,608 mL\n 529 mL\n Urine:\n 315 mL\n 304 mL\n NG:\n 75 mL\n 75 mL\n Stool:\n Drains:\n 130 mL\n 150 mL\n Balance:\n 13,711 mL\n 4,637 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 640 (600 - 650) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 100%\n RSBI Deferred: Hemodynamic Instability\n PIP: 14 cmH2O\n Plateau: 21 cmH2O\n SPO2: 96%\n ABG: 7.27/37/89./15/-8\n Ve: 14 L/min\n PaO2 / FiO2: 89\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, Tender: , VAC in place\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 466 K/uL\n 14.0 g/dL\n 113 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 41.9 %\n 8.2 K/uL\n [image002.jpg]\n 10:03 PM\n 10:12 PM\n 01:07 AM\n 01:13 AM\n 03:33 AM\n 03:51 AM\n 05:39 AM\n WBC\n 4.4\n 8.2\n Hct\n 40.3\n 41.9\n Plt\n 400\n 466\n Creatinine\n 1.3\n 1.2\n 1.4\n Troponin T\n <0.01\n <0.01\n TCO2\n 21\n 20\n 19\n 18\n Glucose\n 148\n 126\n 115\n 113\n Other labs: PT / PTT / INR:17.8/30.8/1.6, CK / CK-MB / Troponin\n T:328/12/<0.01, Lactic Acid:3.8 mmol/L, Albumin:2.5 g/dL, Ca:7.6 mg/dL,\n Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n Neurologic: midaz and fentanyl drips\n Neuro checks Q:4\n Pain: fentanyl gtt\n Cardiovascular: Echo shows global LV dysfunction, cardiac enzymes\n negative thus far. Levophed and neo for MAP > 65. Cont milrinone. LR @\n 125cc/hr. Receiving large amounts of resuscitation. Continue to give\n fluid/albumin as needed and continue to monitor bladder pressure.\n Pulmonary: Vent management - wean as tolerated\n Gastrointestinal / Abdomen: NPO/NGT, JP in place. VAC to suction.\n Monitor bladder pressures Q4 if concern for ACS\n Nutrition: NPO\n Renal: f/u creat - initially increasing after OR. Urine output has\n continued since the OR and responds to resuscitation.\n Hematology: f/u Hct - stable\n Endocrine: RISS\n Infectious Disease: vanc/zosyn/fluconazole\n Lines / Tubes / Drains: RIJ, L fem a-line, JP, VAC, Foley, NGT\n Wounds: abd wound w VAC\n Imaging:\n Fluids: LR @ 125\n Consults: Cardiology, Gold Surgery\n Billing Diagnosis: Post-op complication, Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2118-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 554117, "text": "TSICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN,\n Lorazepam 0.5-2 mg IV Q6H:PRN, Acetaminophen 650 mg PO/PR Q6H:PRN,\n Magnesium Sulfate IV Sliding Scale, Albuterol Inhaler PUFF IH\n Q4H:PRN, Metoprolol Tartrate 10 mg IV Q4H, Metoclopramide 10 mg IV Q6H,\n Bisacodyl 10 mg PO/PR DAILY, Calcium Gluconate IV Sliding Scale,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Chlorhexidine Gluconate 0.12%\n Oral Rinse 15 ml ORAL , Potassium Chloride IV Sliding Scale,\n Famotidine 20 mg IV Q12H, Senna 1 TAB PO BID, HYDROmorphone, Heparin\n 5000 UNIT SC TID, Insulin SC, Vancomycin 1500 mg IV Q 12H\n .\n EVENTS:\n .\n 24 HOUR EVENTS:\n : spiked 101.8 - pan cx. CT torso showed no obvious collection or\n fever source, tolerating minimal vent settings\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n : BC pending\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs wound culture : MESH.GRAM\n NEGATIVE ROD(S). ISOLATED FROM BROTH MEDIA ONLY.\n : RARE GROWTH OROPHARYNGEAL FLORA.\n : UC no growth\n : SC pending\n : CVL tip culture pending\n : SC, stool, urine pending\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n CXR: Interval worsening of bilateral opacities is\n demonstrated, essentially in the right lung that might represent\n developing pneumonia/aspiration pneumonia. Some element of pulmonary\n edema cannot be excluded.\n : RUQ US: Note is made that this is a limited study due to the\n patient's body habitus. No focal lesions are identified within the\n liver. There is no biliary dilatation and the common duct measures 0.4\n cm. There is sludge noted within the lumen of the gallbladder, but\n there are no stones and no signs of cholecystitis. No ascites is seen\n in the right upper quadrant. The portal vein is patent with hepatopetal\n flow.\n : CT head: No acute intracranial process identified.\n : CT torso: no fluid collection or pulmonay process\n BLOOD CULTURED - At 04:30 PM\n blood culture #1 from central line\n blood culture #2 from new PIV\n SPUTUM CULTURE - At 04:30 PM\n endotracheal\n URINE CULTURE - At 04:30 PM\n catheter\n STOOL CULTURE - At 04:30 PM\n c diff\n FEVER - 101.8\nF - 04:00 PM\n Post operative day:\n POD#10 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:59 AM\n Vancomycin - 08:11 PM\n Piperacillin/Tazobactam (Zosyn) - 01:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 01:54 AM\n Lorazepam (Ativan) - 03:38 AM\n Metoprolol - 04:16 AM\n Hydromorphone (Dilaudid) - 06:59 AM\n Other medications:\n Flowsheet Data as of 07:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.8\nC (101.8\n T current: 38.2\nC (100.8\n HR: 114 (94 - 121) bpm\n BP: 161/76(101) {120/55(74) - 179/76(101)} mmHg\n RR: 26 (20 - 34) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 119.2 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 12 (4 - 16) mmHg\n Total In:\n 4,633 mL\n 1,029 mL\n PO:\n Tube feeding:\n 180 mL\n 72 mL\n IV Fluid:\n 1,070 mL\n 234 mL\n Blood products:\n Total out:\n 3,300 mL\n 1,410 mL\n Urine:\n 2,765 mL\n 710 mL\n NG:\n 150 mL\n 90 mL\n Stool:\n 300 mL\n 600 mL\n Drains:\n 35 mL\n 10 mL\n Balance:\n 1,333 mL\n -381 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 426 (426 - 899) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 15 cmH2O\n SPO2: 100%\n ABG: 7.44/38/158/24/2\n Ve: 11 L/min\n PaO2 / FiO2: 395\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Distended, Tender:\n Left Extremities: (Edema: 3+), (Temperature: Warm)\n Right Extremities: (Edema: 3+), (Temperature: Warm)\n Labs / Radiology\n 410 K/uL\n 9.2 g/dL\n 142 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 111 mEq/L\n 141 mEq/L\n 26.2 %\n 15.0 K/uL\n [image002.jpg]\n 01:26 PM\n 08:07 PM\n 02:02 AM\n 03:15 AM\n 01:25 PM\n 01:47 AM\n 01:51 AM\n 08:00 PM\n 01:42 AM\n 01:52 AM\n WBC\n 12.4\n 13.5\n 15.0\n Hct\n 32.9\n 27.6\n 26.2\n Plt\n 326\n 375\n 410\n Creatinine\n 0.8\n 1.0\n 0.9\n 0.7\n TCO2\n 31\n 27\n 28\n 30\n 27\n Glucose\n 128\n 138\n 134\n 136\n 134\n 142\n Other labs: PT / PTT / INR:15.7/22.8/1.4, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:59/59, Alk-Phos / T bili:105/1.9,\n Differential-Neuts:87.5 %, Lymph:8.8 %, Mono:2.4 %, Eos:1.2 %, Lactic\n Acid:1.6 mmol/L, Albumin:2.4 g/dL, LDH:286 IU/L, Ca:9.0 mg/dL, Mg:2.3\n mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), ELECTROLYTE & FLUID\n DISORDER, OTHER, PROBLEM - ENTER DESCRIPTION IN COMMENTS, HERNIA,\n VENTRAL / INCISIONAL, RESPIRATORY FAILURE, ACUTE (NOT ARDS/), ACUTE\n PAIN, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: ASSESSMENT AND PLAN: 47M with incarcerated ventral\n hernia with intermittent obstructive symptoms s/p LOA and ventral\n herniorraphy w mesh. Taken back to OR same day for perforation, now\n s/p partial ileum and ascending colon resection w mesh removal and\n primary closure of wound/VAC placement.\n .\n NEUROLOGIC: ativan prn for agitation, off IV infusions for sedation.\n Neuro checks Q:4H\n Pain: dilaudid for pain\n CARDIOVASCULAR: holding diuresis--monitor net fluid balance. Lopressor\n for BP and HR control. Venous dopplers to r/o DVT\n PULMONARY: consider extubation today\n GI / ABD: NPO/NGT, JP drain in place. W-->D dressing changes. Follow\n LFTS and bilirubin.\n NUTRITION: Trophic tube feeds - tolerating rate of 10cc/hr and TPN.\n RENAL: monitor creat and UO and replete lytes. Keep phos > 3.0.\n HEMATOLOGY: f/u Hct and INR\n ENDOCRINE: RISS\n ID: vanc/zosyn post surgery. Await recent culture results. Pt.\n persistantly spiking temp and WBC continue to trend up -> will need CT\n abdomen today. -\n changing antibx this afternoon to Cipro / Flagyl.\n LINES/TUBES/DRAINS: Left IJ, R rad aline JP, VAC, Foley, NGT\n WOUNDS: abd wound w/ W->D gauze dressings - change , possible\n further bedside debridement by primary team.\n IMAGING:\n FLUIDS: KVO, replete K and phosphate.\n CONSULTS: Gold Surgery\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, heparin SC\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: with family\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n TPN without Lipids - 04:57 PM 91. mL/hour\n Replete with Fiber (Full) - 03:40 AM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:45 PM\n Multi Lumen - 09:59 AM\n 20 Gauge - 09:00 AM\n Communication: Comments:\n Disposition:\n Total time spent: 36\n" }, { "category": "Nursing", "chartdate": "2118-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554074, "text": "HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n -ventral hernia repair complicated by perforation requiring resection\n of ileum and ascending colon\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Pain\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2118-01-26 00:00:00.000", "description": "Generic Note", "row_id": 552557, "text": "TITLE: Intensivist note\n Patient is severe septic shock s/p exploratory laparotomy and small\n bowel resection with primary anasthemosis. I examined the patient\n several times throughout the night. I discussed with house officer\n several times throughout the night the management plan. I also spoke\n with interventional cardiology fellow, as well as in house cardiology\n fellow the patient severe septic shock and the indication for IABP.\n Focused TTE done twice during the night (please see separate report)\n for assessment of cardiac function and fluid therapy. Patient appears\n to be stabilizing with inotropy and fluid therapy, and will continue\n current regimen. Will sign out to T/SICU attending.\n Time spent: 2.5 hours\n" }, { "category": "Nursing", "chartdate": "2118-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552767, "text": "Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen with no drainage on this shift. Vac dressing\n placed in incisional wound bed draining minimal serosanguinous fluid.\n BS absent. NG tube to suction with thick tan drainage. Bladder\n pressures 22 at beginning of shift. Adequate pain management.\n Action:\n Monitoring drainage color and amt. Bladder pressures discontinued.\n Fentanyl gtt in place for pain and midaz gtt for sedation.\n Response:\n Vac draining minimal fluid and skin surrounding wound bed shows\n ecchymosis\n Plan:\n Vac drsg to be changed tomorrow. ?JP removal\n Shock, cardiogenic\n Assessment:\n Pt tachycardic. Pt\ns requiring pressors for adequate BP. Cool, dusky\n lower extremities with pulses difficult to palpate. Pt\ns SVV and CO\n remain adequate, pt\ns successfully fluid resuscitated.\n Action:\n TTE performed by ICU fellow. Milrinone gtt decreased to .25 Levophed\n titrated down. Pt goal is MAP >60 Vigileo in place.\n Response:\n Pt\ns tachycardia decreased. With titration MAP still within goal range.\n SVV stable and wnl.\n Plan:\n Continue to wean Levophed. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with Peep increased over night to 12 and FiO2 to 70% ABG with\n adequate PaO2 but still in metabolic acidosis. O2 sats low 90s. LS\n clear and diminished at bases. Minimal thin tan secretions.\n Action:\n Pt\ns FiO2 decreased to 60. VAP care performed. XRay taken showing\n increased fluid in right lungs.\n Response:\n O2 sats in mid 90s when pt place on right side and low 90s on left\n side. Team aware and satisfied with abg and O2 saturations.\n Plan:\n Continue to monitor ABG\ns, continue vent support. ?Bronch tomorrow\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs and\n afebrile. Tachycardia and hypotension. Pan culture performed on night\n shift. Electrolytes and lactate wnl. Bilirubin minimally increased.\n Action:\n Pt on Vanco, Fluconazole and Zosyn. Electrolytes and lactates\n monitored. Fan in place.\n Response:\n Low grade fever remains.\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n ICU consent done today. Son and Mother visited.\n" }, { "category": "Respiratory ", "chartdate": "2118-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 552858, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2118-01-28 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 552939, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; levophed weaned; FiO2 down to 50%; output from Wound Vac foul\n smelling\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#3 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:27 AM\n Vancomycin - 09:17 PM\n Piperacillin/Tazobactam (Zosyn) - 02:30 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Milrinone - 0.25 mcg/Kg/min\n Norepinephrine - 0.14 mcg/Kg/min\n Midazolam (Versed) - 8 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:59 AM\n Midazolam (Versed) - 09:30 PM\n Famotidine (Pepcid) - 09:59 PM\n Fentanyl - 05:08 AM\n Other medications:\n Heparin 5000 UNIT SC TID,Insulin SC Sliding Scale,Ipratropium Bromide\n MDI 2 PUFF IH Q4H:PRN, Milrinone 0.5 mcg/kg/min IV DRIP, Midazolam \n mg/hr IV DRIP, Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Albuterol\n Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Famotidine 20 mg IV Q12H, Fentanyl Citrate 100-200 mcg IV Q1HR PRN\n pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP, Vasopressin 1.2-3.6\n UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200 mg IV Q24H\n Vancomycin 1000 mg IV Q 12H, milrinone gtt\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.4\nC (99.4\n HR: 108 (105 - 123) bpm\n BP: 104/51(66) {96/42(61) - 110/67(79)} mmHg\n RR: 22 (21 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 143 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (12 - 18)mmHg\n Bladder pressure: 21 (21 - 21) mmHg\n Total In:\n 9,374 mL\n 1,964 mL\n PO:\n TF:\n IVF:\n 9,354 mL\n 1,924 mL\n Blood products:\n Total out:\n 2,090 mL\n 520 mL\n Urine:\n 1,720 mL\n 370 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 120 mL\n 150 mL\n Balance:\n 7,284 mL\n 1,444 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n ABG: 7.34/36/194/23/-5\n Ve: 12 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, intubated and sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g; RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), coarse breath sounds bilaterally\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+, no c/c\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed, intubated and sedated\n Labs / Radiology\n 206 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.2 %\n 14.6 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n 08:49 AM\n 09:31 AM\n 02:35 PM\n 09:29 PM\n 03:09 AM\n WBC\n 17.2\n 17.0\n 15.2\n 14.6\n Hct\n 31.2\n 30.7\n 28.4\n 28.2\n Plt\n 275\n 256\n 224\n 206\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 20\n 22\n 21\n 21\n 20\n Glucose\n 140\n 120\n 128\n 101\n 85\n 101\n Other labs: PT / PTT / INR:28.6/42.5/2.9, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:21/32, Alk Phos / T Bili:57/2.4,\n Lactic Acid:2.3 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation. Wean sedation today\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 65 - continue to\n wean as tolerated; change LR @ 150cc/hr; milrinone off today\n PULMONARY: Vent dep resp failure, continue to optimize resp status,\n decrease PEEP to 10, switch to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: would start tube feeds slowly\n RENAL: f/u creat and UO.\n HEMATOLOGY: f/u Hct\n stable, elevated INR, monitor\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R radial a-line, JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots,\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Nutrition:\n General:\n ICU Care\n Nutrition: NPO presently\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots,\n Stress ulcer: H2B\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2118-01-28 00:00:00.000", "description": "Physician Surgical Progress Note", "row_id": 552943, "text": "24 Hour Events: CHIEF COMPLAINT: ventral hernia\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n 24 HOUR EVENTS:\n : milrinone weaned; fluid continued at 250cc/hr; vasopressin\n weaned; levophed weaned; FiO2 down to 50%; output from Wound Vac foul\n smelling\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#3 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:27 AM\n Vancomycin - 09:17 PM\n Piperacillin/Tazobactam (Zosyn) - 02:30 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Milrinone - 0.25 mcg/Kg/min\n Norepinephrine - 0.14 mcg/Kg/min\n Midazolam (Versed) - 8 mg/hour\n Fentanyl (Concentrate) - 500 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:59 AM\n Midazolam (Versed) - 09:30 PM\n Famotidine (Pepcid) - 09:59 PM\n Fentanyl - 05:08 AM\n Other medications:\n Heparin 5000 UNIT SC TID,Insulin SC Sliding Scale,Ipratropium Bromide\n MDI 2 PUFF IH Q4H:PRN, Milrinone 0.5 mcg/kg/min IV DRIP, Midazolam \n mg/hr IV DRIP, Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Albuterol\n Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam Na 4.5 g IV Q8H,\n Famotidine 20 mg IV Q12H, Fentanyl Citrate 100-200 mcg IV Q1HR PRN\n pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP, Vasopressin 1.2-3.6\n UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200 mg IV Q24H\n Vancomycin 1000 mg IV Q 12H, milrinone gtt\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.4\nC (99.4\n HR: 108 (105 - 123) bpm\n BP: 104/51(66) {96/42(61) - 110/67(79)} mmHg\n RR: 22 (21 - 27) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 143 kg (admission): 126 kg\n Height: 70 Inch\n CVP: 15 (12 - 18)mmHg\n Bladder pressure: 21 (21 - 21) mmHg\n Total In:\n 9,374 mL\n 1,964 mL\n PO:\n TF:\n IVF:\n 9,354 mL\n 1,924 mL\n Blood products:\n Total out:\n 2,090 mL\n 520 mL\n Urine:\n 1,720 mL\n 370 mL\n NG:\n 250 mL\n Stool:\n Drains:\n 120 mL\n 150 mL\n Balance:\n 7,284 mL\n 1,444 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 32 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n ABG: 7.34/36/194/23/-5\n Ve: 12 L/min\n PaO2 / FiO2: 388\n Physical Examination\n General Appearance: Well nourished, intubated and sedated\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g; RRR\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: at bases bilaterally), coarse breath sounds bilaterally\n Abdominal: Soft, wound vac in place\n Extremities: Right: 1+, Left: 1+, no c/c\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed, intubated and sedated\n Labs / Radiology\n 206 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.4 mEq/L\n 13 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.2 %\n 14.6 K/uL\n [image002.jpg]\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n 08:49 AM\n 09:31 AM\n 02:35 PM\n 09:29 PM\n 03:09 AM\n WBC\n 17.2\n 17.0\n 15.2\n 14.6\n Hct\n 31.2\n 30.7\n 28.4\n 28.2\n Plt\n 275\n 256\n 224\n 206\n Cr\n 0.9\n 0.9\n 0.8\n 0.7\n TCO2\n 20\n 22\n 21\n 21\n 20\n Glucose\n 140\n 120\n 128\n 101\n 85\n 101\n Other labs: PT / PTT / INR:28.6/42.5/2.9, CK / CKMB /\n Troponin-T:346/9/<0.01, ALT / AST:21/32, Alk Phos / T Bili:57/2.4,\n Lactic Acid:2.3 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n .\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n NEUROLOGIC: midaz and fentanyl drips for sedation. Wean sedation today\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 65 - continue to\n wean as tolerated; change LR @ 150cc/hr; milrinone off today\n PULMONARY: Vent dep resp failure, continue to optimize resp status,\n decrease PEEP to 10, switch to PSV\n GI / ABD: NPO/NGT, JP in place. VAC to suction.\n NUTRITION: would start tube feeds slowly\n RENAL: f/u creat and UO.\n HEMATOLOGY: f/u Hct\n stable, elevated INR, monitor\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole post surgery.\n LINES/TUBES/DRAINS: RIJ, R radial a-line, JP, VAC, Foley, NGT\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250\n CONSULTS: Gold Surgery\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots,\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: yes\n CODE STATUS: full\n DISPOSITION: ICU\n Nutrition:\n General:\n ICU Care\n Nutrition: NPO presently\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n Prophylaxis:\n DVT: Boots,\n Stress ulcer: H2B\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2118-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553078, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2118-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553174, "text": "Hernia, ventral / incisional\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2118-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553253, "text": "47 yo male admitted s/p ventral hernia. Pt c/o abdominal pain\n since , ongoing anorexia, pain, intermittent\n diarrhea/N/V. pt had ventral hernia repair with mesh placement;\n pt experienced tachycardia, abdominal pain, vomiting, decreasing UO and\n stool via NGT/JP drain in PACU. Pt brought back to OR for\n re-exploration, washout, removal of mesh, ileocolectomy and placement\n of VAC dressing. Pt remains in TSICU for care.\n Hernia, ventral / incisional\n Assessment:\n Abdomen with VAC dressing in place, last change done on in room by\n surgical team. Dressing is intact, drainage via VAC is serous,\n moderate. Under dressing, some adipose/subcutaneous tissue can be\n seen, team aware. Pt appears to be comfortable, does not seem to be\n experiencing pain at rest/with activity, coughing/repositioning. Pt\n not requiring pain medication, fentanyl gtt remains off. Pt arouses to\n voice, does not follow commands, does not communicate effectively\n (questionably nodding to respond).\n Action:\n Pain continuously assessed, no medication required throughout shift.\n Response:\n Pt appears to be comfortable, tolerating activity/repositioning/ET\n tube/VAC dressing.\n Plan:\n Continue to assess pain, treat as needed, reorient pt as needed while\n pt becomes more alert. Continue to support pt and family.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains vented\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2118-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 552696, "text": "SICU\n HPI:\n HPI: 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:52 AM\n ARTERIAL LINE - START 12:45 PM\n ARTERIAL LINE - STOP 12:52 PM\n PAN CULTURE - At 12:08 AM\n urine, sputum, peripheral stick blood cx x4 bottles\n FEVER - 102.1\nF - 08:00 PM\n Post operative day:\n POD#2 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:30 AM\n Vancomycin - 09:38 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Vasopressin - 3.6 units/hour\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl (Concentrate) - 500 mcg/hour\n Norepinephrine - 0.27 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Fentanyl - 04:30 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.7\nC (99.8\n HR: 128 (122 - 143) bpm\n BP: 107/44(65) {89/40(59) - 125/72(91)} mmHg\n RR: 22 (19 - 28) insp/min\n SPO2: 88%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 15 (8 - 15) mmHg\n Bladder pressure: 16 (16 - 24) mmHg\n Total In:\n 13,777 mL\n 2,397 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,977 mL\n 2,377 mL\n Blood products:\n 800 mL\n Total out:\n 2,529 mL\n 820 mL\n Urine:\n 1,804 mL\n 620 mL\n NG:\n 175 mL\n 150 mL\n Stool:\n Drains:\n 550 mL\n 50 mL\n Balance:\n 11,248 mL\n 1,577 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 640) mL\n RR (Set): 24\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 23 cmH2O\n Plateau: 24 cmH2O\n Compliance: 31.3 cmH2O/mL\n SPO2: 88%\n ABG: 7.29/41/77./21/-6\n Ve: 11.9 L/min\n PaO2 / FiO2: 130\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Bowel sounds present, Tender:\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 275 K/uL\n 10.8 g/dL\n 120 mg/dL\n 0.9 mg/dL\n 21 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 105 mEq/L\n 134 mEq/L\n 31.2 %\n 17.2 K/uL\n [image002.jpg]\n 01:46 PM\n 02:46 PM\n 03:00 PM\n 03:25 PM\n 05:20 PM\n 09:39 PM\n 10:00 PM\n 01:26 AM\n 03:02 AM\n 05:30 AM\n WBC\n 16.0\n 17.2\n Hct\n 34.5\n 31.2\n Plt\n 331\n 275\n Creatinine\n 1.1\n 0.9\n TCO2\n 21\n 20\n 21\n 20\n 22\n 21\n Glucose\n 128\n 121\n 140\n 120\n Other labs: PT / PTT / INR:29.1/43.1/2.9, CK / CK-MB / Troponin\n T:346/9/<0.01, ALT / AST:21/32, Alk-Phos / T bili:57/2.4, Lactic\n Acid:2.0 mmol/L, Albumin:2.7 g/dL, LDH:148 IU/L, Ca:8.4 mg/dL, Mg:2.2\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: HPI: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n .\n ISSUES:\n ventral hernia repair complicated by perforation requiring resection of\n ileum and ascending colon\n .\n CHIEF COMPLAINT: ventral hernia\n .\n CURRENT MEDICATIONS: Heparin 5000 UNIT SC TID,Insulin SC Sliding\n Scale,Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN SOB, Magnesium Sulfate\n IV Sliding Scale, LR at 250 ml/hr, Milrinone 0.5 mcg/kg/min IV DRIP,\n Midazolam 1-10 mg/hr IV DRIP,Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Albuterol Inhaler PUFF IH Q4H:PRN, Piperacillin-Tazobactam\n Na 4.5 g IV Q8H, Calcium Gluconate IV Sliding Scale, Potassium\n Chloride IV Sliding Scale, Famotidine 20 mg IV Q12H, Fentanyl Citrate\n 100-200 mcg IV Q1HR PRN pain, Fentanyl Citrate 100-500 mcg/hr IV DRIP,\n Vasopressin 1.2-3.6 UNIT/HR IV DRIP TITRATE TO MAP>65, Fluconazole 200\n mg IV Q24H Vancomycin 1000 mg IV Q 12H\n .\n EVENTS:\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n .\n 24 HOUR EVENTS:\n : Phenylephrine switched to vasopressin. Had FU Echo with EF\n 45%. Received LR fluid resuscitaion and IV albumin. On milrinone, vaso\n and levophed. Spiked temp and was pan cultured. Fem a line removed,\n radial a line placed.\n .\n MEDICAL: pneumonia\n .\n : none\n .\n SURGICAL Hx: ORIF L wrist and L knee after MVC at age 15\n .\n ALLERGIES: NKDA\n .\n ABX: vanc/zosyn\n .\n MICRO:\n swab : 1+ PMNs, 2+ GNRs, 1+ GPCs\n wound culture : MESH.GRAM NEGATIVE ROD(S). ISOLATED FROM BROTH\n MEDIA ONLY.\n .\n IMAGING:\n Echo: Suboptimal image quality, but there is severe global left\n ventricular dysfunction (EF=10%). Right ventricular systolic function\n appears to be normal.\n Echo: EF 45%.There is mild regional left ventricular systolic\n dysfunction with inferior hypokinesis.\n CXR: Cardiomediastinal silhouette is unchanged. The lung volumes\n are low. New left retrocardiac opacity may be consistent with\n atelectasis due to suboptimal position of the ET tube.\n ASSESSMENT AND PLAN: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n NEUROLOGIC: midaz and fentanyl drips for sedation.\n Neuro checks Q:4H\n Pain: on fentanyl gtt\n CARDIOVASCULAR: Levophed and vasopressin for MAP > 65. Cont milrinone?\n LR @ 250cc/hr. Receiving large amounts of resuscitation.\n PULMONARY: Vent dep resp failure, attempting to optoimize oxygenation\n by increasing PEEP and Fi02.\n GI / ABD: NPO/NGT, JP in place. VAC to suction. Monitor bladder\n pressures Q4 if concern for ACS\n NUTRITION: NPO\n RENAL: f/u creat and UO.\n HEMATOLOGY: Hct - stable\n ENDOCRINE: RISS\n ID: vanc/zosyn/fluconazole for sepsis. Await pending culture results.\n LINES/TUBES/DRAINS: RIJ, L fem a-line, JP, VAC, Foley, NGT\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Arterial Line - 12:45 PM\n WOUNDS: abd wound w VAC\n IMAGING: none\n FLUIDS: LR @ 250, prn albumin\n CONSULTS: Gold Surgery\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - boots, SQH\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: needs to be signed by son \n CODE STATUS: full\n DISPOSITION: ICU\n Billing Diagnosis: Post-op hypotension, Sepsis\n ICU Care\n Communication: Comments: Son is will get consent when he next\n visits\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2118-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552629, "text": "47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen drain serous drainage and Vac dressing placed in\n incisional wound bed draining serosanguinous fluid. BS absent. Abdomen\n tender to palpation. NG tube to suction with thick tan drainage.\n Bladder pressures 20/21.\n Action:\n Monitoring drainage color and amt. Bladder pressure performed q4hrs.\n Response:\n Bladder pressures remain stable. Drains still accruing a moderate amt\n of fluid.\n Plan:\n Continue to monitor bladder pressures and drainage.\n Shock, cardiogenic\n Assessment:\n Pt had ejection fraction ~10% over night. Pt on three pressors to\n maintain adequate BP. Pt tachycardic. Cool extremities with pulses\n difficult to palpate. Pt\ns SVV in high 20s-low 30s. CVP wnl. Pt has\n adequate urine output.\n Action:\n TTE performed. Milrinone gtt on. Titrated off Neo and placed pt on\n Vasopressin. Titrated Levo down. Pt goal is MAP >60 Vigileo in place.\n Multiple albumin boluses given and 1liter LR bolus given. LR\n maintenance increased to 250cc/hr.\n Response:\n Pt\ns EF ~45% Pt\ns SVV decreased to <15. MAP with titration at goal. Pt\n still tachycardic. Upper extremities warm and lower extremities cool.\n Urine output still adequate.\n Plan:\n Continue to wean Levophed. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with tidal volume of 640, RR 18, Peep and FiO2 of 100%. ABG\n showing metabolic acidosis. O2 sats wnl. LS clear and diminished at\n bases. Minimal thick tan secretions.\n Action:\n Pt\ns FiO2 weaned, tidal volume decreased, and RR increased. Pt\ns tube\n placement changed per xray to 23 at the lip. VAP care performed.\n Response:\n Pt\ns PaO2 adequate. Pt breathing more over the vent. ABG shows\n uncompensated metabolic acidosis.\n Plan:\n Continue to monitor ABG\ns, wean vent settings as tolerated.\n Acute Pain\n Assessment:\n Pt denies pain at rest, but with turns and abdominal movement pt\n grimaces.\n Action:\n Pt on Fent and Midaz gtt. Prn Fentanyl boluses with turns. Fentanyl gtt\n concentrated.\n Response:\n Pt still grimaces a fair amt with incisional discomfort with any\n activity.\n Plan:\n Continue prn boluses with turns.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs. Tmax\n 100.9. Tachycardia and hypotension.\n Action:\n Pt on Vanco, Fluconazole and Zosyn.\n Response:\n Pt still is afebrile with elevated WBC\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n Pt\ns family visited today (mother, father, son and significant other).\n Dr spoke with the parents about plan of care and prognosis. Family\n decided that the son would be the spokesperson.\n" }, { "category": "Nursing", "chartdate": "2118-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 552630, "text": "47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Today\ns Events:\n -TTE\n -Femoral a-line removed and Right radial a-line placed\n with vigileo\n Hernia, ventral / incisional\n Assessment:\n Pt has JP in abdomen drain serous drainage and Vac dressing placed in\n incisional wound bed draining serosanguinous fluid. BS absent. Abdomen\n tender to palpation. NG tube to suction with thick tan drainage.\n Bladder pressures 20/21.\n Action:\n Monitoring drainage color and amt. Bladder pressure performed q4hrs.\n Response:\n Bladder pressures remain stable. Drains still accruing a moderate amt\n of fluid.\n Plan:\n Continue to monitor bladder pressures and drainage.\n Shock, cardiogenic\n Assessment:\n Pt had ejection fraction ~10% over night. Pt on three pressors to\n maintain adequate BP. Pt tachycardic. Cool extremities with pulses\n difficult to palpate. Pt\ns SVV in high 20s-low 30s. CVP wnl. Pt has\n adequate urine output.\n Action:\n TTE performed. Milrinone gtt on. Titrated off Neo and placed pt on\n Vasopressin. Titrated Levo down. Pt goal is MAP >60 Vigileo in place.\n Multiple albumin boluses given and 1liter LR bolus given. LR\n maintenance increased to 250cc/hr.\n Response:\n Pt\ns EF ~45% Pt\ns SVV decreased to <15. MAP with titration at goal. Pt\n still tachycardic. Upper extremities warm and lower extremities cool.\n Urine output still adequate.\n Plan:\n Continue to wean Levophed. Monitor SVV and MAP.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CMV with tidal volume of 640, RR 18, Peep and FiO2 of 100%. ABG\n showing metabolic acidosis. O2 sats wnl. LS clear and diminished at\n bases. Minimal thick tan secretions.\n Action:\n Pt\ns FiO2 weaned, tidal volume decreased, and RR increased. Pt\ns tube\n placement changed per xray to 23 at the lip. VAP care performed.\n Response:\n Pt\ns PaO2 adequate. Pt breathing more over the vent. ABG shows\n uncompensated metabolic acidosis.\n Plan:\n Continue to monitor ABG\ns, wean vent settings as tolerated.\n Acute Pain\n Assessment:\n Pt denies pain at rest, but with turns and abdominal movement pt\n grimaces.\n Action:\n Pt on Fent and Midaz gtt. Prn Fentanyl boluses with turns. Fentanyl gtt\n concentrated.\n Response:\n Pt still grimaces a fair amt with incisional discomfort with any\n activity.\n Plan:\n Continue prn boluses with turns.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt had perforated bowel repaired in OR . Pt has elevated WBCs. Tmax\n 100.9. Tachycardia and hypotension.\n Action:\n Pt on Vanco, Fluconazole and Zosyn.\n Response:\n Pt still is afebrile with elevated WBC\n Plan:\n Continue with antibiotic treatment and monitor vital signs.\n Pt\ns family visited today (mother, father, son and significant other).\n Dr spoke with the parents about plan of care and prognosis. Family\n decided that the son would be the spokesperson.\n" }, { "category": "Physician ", "chartdate": "2118-01-26 00:00:00.000", "description": "Intensivist Note", "row_id": 552591, "text": "TSICU\n HPI:\n 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Chief complaint:\n ventral hernia\n PMHx:\n pneumonia\n Current medications:\n Insulin SC, Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Magnesium\n Sulfate IV Sliding Scale, Milrinone 0.5 mcg/kg/min IV DRIP INFUSION,\n Midazolam 1-10 mg/hr IV DRIP, Morphine Sulfate 1-5 mg IV PRN, Albuterol\n Inhaler PUFF IH Q4H:PRN, Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Phenylephrine 0.5-5 mcg/kg/min IV DRIP, Famotidine 20 mg IV Q12H,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Fentanyl Citrate 100-500\n mcg/hr IV DRIP, Potassium Chloride IV Sliding Scale, Fentanyl Citrate\n 100-200 mcg IV Q1HR, Fluconazole 200 mg IV Q24H, Vancomycin 1000 mg IV\n Q 12H, Heparin 5000 UNIT SC TID\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:50 PM\n OR RECEIVED - At 09:00 PM\n ARTERIAL LINE - START 09:00 PM\n MULTI LUMEN - START 09:00 PM\n EKG - At 10:00 PM\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n TRANSTHORACIC ECHO - At 03:12 AM\n TRANSTHORACIC ECHO - At 05:15 AM\n Post operative day:\n POD#1 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:30 PM\n Heparin Sodium (Prophylaxis) - 10:59 PM\n Midazolam (Versed) - 11:21 PM\n Fentanyl - 03:39 AM\n Other medications:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 38.2\nC (100.8\n HR: 126 (116 - 150) bpm\n BP: 99/55(71) {72/45(57) - 125/74(91)} mmHg\n RR: 22 (16 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 13 (8 - 18) mmHg\n Bladder pressure: 21 (16 - 21) mmHg\n Total In:\n 16,319 mL\n 5,166 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,394 mL\n 4,966 mL\n Blood products:\n 1,000 mL\n 200 mL\n Total out:\n 2,608 mL\n 529 mL\n Urine:\n 315 mL\n 304 mL\n NG:\n 75 mL\n 75 mL\n Stool:\n Drains:\n 130 mL\n 150 mL\n Balance:\n 13,711 mL\n 4,637 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 640 (600 - 650) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 100%\n RSBI Deferred: Hemodynamic Instability\n PIP: 14 cmH2O\n Plateau: 21 cmH2O\n SPO2: 96%\n ABG: 7.27/37/89/15/-8\n Ve: 14 L/min\n PaO2 / FiO2: 89\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, Tender: , VAC in place\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 466 K/uL\n 14.0 g/dL\n 113 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 41.9 %\n 8.2 K/uL\n [image002.jpg]\n 10:03 PM\n 10:12 PM\n 01:07 AM\n 01:13 AM\n 03:33 AM\n 03:51 AM\n 05:39 AM\n WBC\n 4.4\n 8.2\n Hct\n 40.3\n 41.9\n Plt\n 400\n 466\n Creatinine\n 1.3\n 1.2\n 1.4\n Troponin T\n <0.01\n <0.01\n TCO2\n 21\n 20\n 19\n 18\n Glucose\n 148\n 126\n 115\n 113\n Other labs: PT / PTT / INR:17.8/30.8/1.6, CK / CK-MB / Troponin\n T:328/12/<0.01, Lactic Acid:3.8 mmol/L, Albumin:2.5 g/dL, Ca:7.6 mg/dL,\n Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n Neurologic: midaz and fentanyl drips\n Neuro checks Q:4\n Pain: fentanyl gtt\n Cardiovascular: Echo shows global LV dysfunction, cardiac enzymes\n negative thus far. Levophed and neo for MAP > 65. Cont milrinone. LR @\n 125cc/hr. Receiving large amounts of resuscitation. Continue to give\n fluid/albumin as needed and continue to monitor bladder pressure. Add\n vasopressin to d/c neo\n Pulmonary: Vent management - wean as tolerated\n Gastrointestinal / Abdomen: NPO/NGT, JP in place. VAC to suction.\n Monitor bladder pressures Q4 if concern for ACS\n Nutrition: NPO\n Renal: f/u creat - initially increasing after OR. Urine output has\n continued since the OR and responds to resuscitation.\n Hematology: f/u Hct - stable\n Endocrine: RISS\n Infectious Disease: vanc/zosyn/fluconazole\n Lines / Tubes / Drains: RIJ, L fem a-line, JP, VAC, Foley, NGT\n Wounds: abd wound w VAC\n Imaging:\n Fluids: LR @ 250\n Consults: Cardiology, Gold Surgery\n Billing Diagnosis: Post-op complication, Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: full\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2118-01-26 00:00:00.000", "description": "Intensivist Note", "row_id": 552597, "text": "TSICU\n HPI:\n 47M with incarcerated ventral hernia with intermittent obstructive\n symptoms s/p LOA and ventral herniorraphy w mesh. Taken back to OR on\n same day for perforation, now s/p partial ileum and ascending colon\n resection w mesh removal and primary closure of wound/VAC placement.\n Chief complaint:\n ventral hernia\n PMHx:\n pneumonia\n Current medications:\n Insulin SC, Ipratropium Bromide MDI 2 PUFF IH Q4H:PRN, Magnesium\n Sulfate IV Sliding Scale, Milrinone 0.5 mcg/kg/min IV DRIP INFUSION,\n Midazolam 1-10 mg/hr IV DRIP, Morphine Sulfate 1-5 mg IV PRN, Albuterol\n Inhaler PUFF IH Q4H:PRN, Norepinephrine 0.03-0.5 mcg/kg/min IV\n DRIP, Phenylephrine 0.5-5 mcg/kg/min IV DRIP, Famotidine 20 mg IV Q12H,\n Piperacillin-Tazobactam Na 4.5 g IV Q8H, Fentanyl Citrate 100-500\n mcg/hr IV DRIP, Potassium Chloride IV Sliding Scale, Fentanyl Citrate\n 100-200 mcg IV Q1HR, Fluconazole 200 mg IV Q24H, Vancomycin 1000 mg IV\n Q 12H, Heparin 5000 UNIT SC TID\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:50 PM\n OR RECEIVED - At 09:00 PM\n ARTERIAL LINE - START 09:00 PM\n MULTI LUMEN - START 09:00 PM\n EKG - At 10:00 PM\n to OR for ventral hernia repair w mesh, taken back for\n perforation. Now s/p partial ileum and ascending colon resection w\n primary closure and VAD placement. Intubated, requiring large fluid\n resuscitation and pressors. Echo w < 10% EF, milrinone drip started,\n albumin given w some effect\n TRANSTHORACIC ECHO - At 03:12 AM\n TRANSTHORACIC ECHO - At 05:15 AM\n Post operative day:\n POD#1 - ventral hernia re-exploration; ex-lap; washout; ileocecal,\n hepatic flexure, distal ileum, mesh removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Midazolam (Versed) - 8 mg/hour\n Milrinone - 0.5 mcg/Kg/min\n Fentanyl - 500 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:30 PM\n Heparin Sodium (Prophylaxis) - 10:59 PM\n Midazolam (Versed) - 11:21 PM\n Fentanyl - 03:39 AM\n Other medications:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 38.2\nC (100.8\n HR: 126 (116 - 150) bpm\n BP: 99/55(71) {72/45(57) - 125/74(91)} mmHg\n RR: 22 (16 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 70 Inch\n CVP: 13 (8 - 18) mmHg\n Bladder pressure: 21 (16 - 21) mmHg\n Total In:\n 16,319 mL\n 5,166 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,394 mL\n 4,966 mL\n Blood products:\n 1,000 mL\n 200 mL\n Total out:\n 2,608 mL\n 529 mL\n Urine:\n 315 mL\n 304 mL\n NG:\n 75 mL\n 75 mL\n Stool:\n Drains:\n 130 mL\n 150 mL\n Balance:\n 13,711 mL\n 4,637 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 640 (600 - 650) mL\n RR (Set): 18\n RR (Spontaneous): 2\n PEEP: 8 cmH2O\n FiO2: 100%\n RSBI Deferred: Hemodynamic Instability\n PIP: 14 cmH2O\n Plateau: 21 cmH2O\n SPO2: 96%\n ABG: 7.27/37/89/15/-8\n Ve: 14 L/min\n PaO2 / FiO2: 89\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic), tachycardic\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, Tender: , VAC in place\n Left Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 3+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 466 K/uL\n 14.0 g/dL\n 113 mg/dL\n 1.4 mg/dL\n 15 mEq/L\n 4.2 mEq/L\n 22 mg/dL\n 109 mEq/L\n 137 mEq/L\n 41.9 %\n 8.2 K/uL\n [image002.jpg]\n 10:03 PM\n 10:12 PM\n 01:07 AM\n 01:13 AM\n 03:33 AM\n 03:51 AM\n 05:39 AM\n WBC\n 4.4\n 8.2\n Hct\n 40.3\n 41.9\n Plt\n 400\n 466\n Creatinine\n 1.3\n 1.2\n 1.4\n Troponin T\n <0.01\n <0.01\n TCO2\n 21\n 20\n 19\n 18\n Glucose\n 148\n 126\n 115\n 113\n Other labs: PT / PTT / INR:17.8/30.8/1.6, CK / CK-MB / Troponin\n T:328/12/<0.01, Lactic Acid:3.8 mmol/L, Albumin:2.5 g/dL, Ca:7.6 mg/dL,\n Mg:2.0 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n HERNIA, VENTRAL / INCISIONAL, SHOCK, CARDIOGENIC, RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), ACIDOSIS, METABOLIC, ACUTE PAIN, SEPSIS, SEVERE\n (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 47M with incarcerated ventral hernia with\n intermittent obstructive symptoms s/p LOA and ventral herniorraphy w\n mesh. Taken back to OR on same day for perforation, now s/p partial\n ileum and ascending colon resection w mesh removal and primary closure\n of wound/VAC placement.\n Neurologic: midaz and fentanyl drips\n Neuro checks Q:4\n Pain: fentanyl gtt\n Cardiovascular: Echo shows global LV dysfunction, cardiac enzymes\n negative thus far. Levophed and neo for MAP > 65. Cont milrinone. LR @\n 125cc/hr. Receiving large amounts of resuscitation. Continue to give\n fluid/albumin as needed and continue to monitor bladder pressure. Add\n vasopressin to d/c neo\n Pulmonary: Vent management - wean as tolerated\n Gastrointestinal / Abdomen: NPO/NGT, JP in place. VAC to suction.\n Monitor bladder pressures Q4 if concern for ACS\n Nutrition: NPO\n Renal: f/u creat - initially increasing after OR. Urine output has\n continued since the OR and responds to resuscitation.\n Hematology: f/u Hct - stable\n Endocrine: RISS\n Infectious Disease: vanc/zosyn/fluconazole\n Lines / Tubes / Drains: RIJ, L fem a-line, JP, VAC, Foley, NGT\n Wounds: abd wound w VAC\n Imaging:\n Fluids: LR @ 250\n Consults: Cardiology, Gold Surgery\n Billing Diagnosis: Post-op complication, Sepsis, (Shock: Septic)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 09:00 PM\n 16 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: full\n Disposition: ICU\n Total time spent: 32 minutes\n" }, { "category": "Respiratory ", "chartdate": "2118-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 552783, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n, RRT 17:02\n" }, { "category": "Respiratory ", "chartdate": "2118-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 552675, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Radiology", "chartdate": "2118-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058380, "text": " 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man intubated in icu s/p vent hernia repair\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc 11:21 AM\n Worsening of parenchymal consolidation that might represent progression of\n pneumonia/aspiration pneumonia. Some degree of pulmonary edema cannot be\n excluded.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient intubated in ICU for hernia\n repair.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 5.6 cm above the carina. The NG tube tip is in the\n stomach. The right internal jugular line tip is at the mid SVC.\n\n Interval worsening of bilateral opacities is demonstrated, essentially in the\n right lung that might represent developing pneumonia/aspiration pneumonia.\n Some element of pulmonary edema cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059389, "text": " 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumonia?\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fevers, increased WCC\n REASON FOR THIS EXAMINATION:\n Pneumonia?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb WED 11:14 AM\n Improved pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old male with fevers and elevated white blood cell count.\n\n COMPARISON: CXR and priors.\n\n PORTABLE CHEST: A nasogastric tube courses below the diaphragm, tip out of\n view. Because the chin is elevated, the endotracheal tube terminating\n approximately 1 cm above the level of the clavicles is only 2 cm above optimal\n positioning. A left internal jugular central venous catheter terminates in the\n lower superior vena cava. The pulmonary vascularity is normal and mild\n pulmonary edema has improved. Mild retrocardiac atelectasis is likely. No\n obvious pleural effusion or pneumothorax is seen. The cardiomediastinal\n silhouette remains normal.\n\n IMPRESSION: 1. Improved mild pulmonary edema.\n 2. ETT 2cm too high.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059390, "text": ", G. TSICU 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumonia?\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fevers, increased \n REASON FOR THIS EXAMINATION:\n Pneumonia?\n ______________________________________________________________________________\n PFI REPORT\n Improved pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057843, "text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval. for interval change\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ventral hernia repair\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with ventral hernia repair. Evaluate for\n interval change.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: The nasogastric tube tip terminates within\n the proximal stomach with side port well below the GE junction. This lordotic\n view reveals mild rightward displacement of the upper trachea, which may\n represent thyroid nodule/asymmetry. Ultrasound can be performed if there is\n further clinical concern.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058926, "text": " 10:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute pulmonary process\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p incarcerated ventral hernia and R colectomy\n REASON FOR THIS EXAMINATION:\n eval for acute pulmonary process and eval for ptx s/p new L IJ line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb MON 1:14 PM\n Persistent mild pulmonary edema. New left central venous catheter terminates\n in high right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old male with incarcerated ventral hernia, status post\n right colectomy.\n\n COMPARISON: CXR, .\n\n PORTABLE UPRIGHT CHEST: Mild bilateral pulmonary edema is stable.\n Retrocardiac atelectasis appears unchanged. The endotracheal, right internal\n jugular catheter, and nasogastric tube appear unchanged. A new left central\n enous catheter terminates in the upper right atrium. No pneumothorax or\n significant pleural effusion is observed.\n\n IMPRESSION: 1. Persistent mild pulmonary edema.\n 2. New left CVL terminates in upper right atrium No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1060121, "text": " 8:44 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Confirm NGT placement\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with recent NGT placement\n REASON FOR THIS EXAMINATION:\n Confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n A single portable radiograph of the chest demonstrates interval removal of the\n endotracheal tube seen on . The bilateral apices are excluded which\n does limit assessment somewhat. The remaining support lines are unchanged.\n Cardiomediastinal contours and the visualized lung remain similar in\n appearance as well. No effusion is evident.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-02-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1060292, "text": " 10:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 45cm\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with\n REASON FOR THIS EXAMINATION:\n r dl picc 45cm\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:30 A.M. ON \n\n HISTORY: New right PICC line.\n\n IMPRESSION: AP chest compared to and 31:\n\n Tip of the new right PIC line projects over the mid SVC, just central to the\n tip of a left internal jugular line. No pneumothorax, pleural effusion or\n mediastinal widening. Lungs clear. Heart size normal.\n\n\n" }, { "category": "ECG", "chartdate": "2118-02-09 00:00:00.000", "description": "Report", "row_id": 241639, "text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2118-01-25 00:00:00.000", "description": "Report", "row_id": 241640, "text": "Sinus tachycardia. Modest non-specific inferolateral T wave changes.\nSince the previous tracing T wave changes appear slightly more prominent.\n\n" }, { "category": "ECG", "chartdate": "2118-01-25 00:00:00.000", "description": "Report", "row_id": 241641, "text": "Sinus tachycardia. Non-specific inferolateral ST-T wave changes similar\nto those recorded on .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2118-01-24 00:00:00.000", "description": "Report", "row_id": 241642, "text": "Sinus tachycardia. Non-specific inferior ST-T wave change. No previous\ntracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2118-01-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1057903, "text": " 9:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Eval new CVL, ETT\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with new CVL, ETT\n REASON FOR THIS EXAMINATION:\n Eval new CVL, ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, there is now an\n endotracheal tube in place with its tip approximately 4.8 cm above the carina.\n Right IJ catheter extends to the mid to lower portion of the SVC and there is\n no evidence of pneumothorax. Nasogastric tube extends well into the stomach.\n\n\n No change in the appearance of the heart and lungs. The suspected impression\n on the trachea on the previous study is not appreciated at this time.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-02-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1059212, "text": " 1:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Any signs of an acute cerebral event?\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with new finding of dilated poorly reactive left pupil.\n Currently intubated after surgery for bowel perforation and ventral hernia\n repair.\n REASON FOR THIS EXAMINATION:\n Any signs of an acute cerebral event?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RXCg 3:12 PM\n No acute intracranial process identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male patient with a new dilated poorly reactive left\n pupil. Patient is currently intubated after surgery for perforation and\n ventral hernia repair.\n\n COMPARISON: None.\n\n TECHNIQUE: CT scan without IV contrast.\n\n FINDINGS:\n\n There is preservation of the -white matter differentiation. There is no\n evidence of midline shift or mass effect. There is no evidence for intra-\n axial or extra-axial hemorrhage.\n\n The ventricles are normal in size with no evidence of hydrocephalus.\n\n The orbital structures are incompletely imaged, however, the visualized upper\n portions of the orbits appear unremarkable. There is mild mucosal thickening\n of the bilateral, right greater than left, ethmoid air cells. Otherwise, the\n remainder of the paranasal sinuses and mastoid air cells are clear.\n\n The calvarial and extracalvarial soft tissues are unremarkable. No fracture\n identified.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. No evidence of hemorrhage, mass lesion, or infarct. If ischemia or acute\n infarction is of clinical concern, MRI with diffusion is recommended to\n further assess.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1059213, "text": ", G. TSICU 1:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Any signs of an acute cerebral event?\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with new finding of dilated poorly reactive left pupil.\n Currently intubated after surgery for bowel perforation and ventral hernia\n repair.\n REASON FOR THIS EXAMINATION:\n Any signs of an acute cerebral event?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial process identified.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-24 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1057684, "text": " 11:53 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HERNIA\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with incarcerated ventral hernia\n REASON FOR THIS EXAMINATION:\n Acute cardiopulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl 3:51 AM\n No acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male with incarcerated ventral hernia.\n\n COMPARISON: None.\n\n CHEST, TWO VIEWS: The lungs are clear. There is no airspace consolidation or\n effusion. Cardiac size, mediastinal contours and pulmonary vasculature are\n within normal limits. Nasogastric tube terminates in the expected location of\n the stomach, with the side hole inferior to the diaphragm.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-24 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1057685, "text": ", G. FA9A 11:53 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HERNIA\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with incarcerated ventral hernia\n REASON FOR THIS EXAMINATION:\n Acute cardiopulmonary process\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058927, "text": ", G. TSICU 10:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute pulmonary process\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p incarcerated ventral hernia and R colectomy\n REASON FOR THIS EXAMINATION:\n eval for acute pulmonary process and eval for ptx s/p new L IJ line placement\n ______________________________________________________________________________\n PFI REPORT\n Persistent mild pulmonary edema. New left central venous catheter terminates\n in high right atrium.\n\n" }, { "category": "Radiology", "chartdate": "2118-02-04 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1059864, "text": " 9:45 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER, ELEVATED WBC, ?DVT\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fever and elev. WBC\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with fever and elevated WBC. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color, and Doppler son of bilateral common\n femoral, superficial femoral, popliteal, and tibial veins were performed.\n There is normal flow, compression, and augmentation seen in all of the\n vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-02-04 00:00:00.000", "description": "P BILAT UP EXT VEINS US PORT", "row_id": 1059865, "text": " 9:46 AM\n BILAT UP EXT VEINS US PORT Clip # \n Reason: FEVER, INCREASED WBC, ?DVT\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with fever and elev. WBC\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with fever and elevated WBC. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: scale, color and Doppler son of bilateral IJ,\n subclavian, axillary, brachial, basilic, and cephalic veins were performed.\n There is non-occlusive thrombus identified within the left cephalic vein.\n This vein does not entirely compress but there is vascular flow documented\n within the vein. There is normal flow, compression and augmentation seen in\n all of the deep veins of both arms and in the remainder of the superficial\n veins.\n\n IMPRESSION: Non-occlusive thrombus in the left cephalic vein which is a\n superficial vein. There is no deep vein thrombosis identified in either arm.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-24 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1057617, "text": " 12:46 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? obstruction or incarceration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with ventral hernia\n REASON FOR THIS EXAMINATION:\n ? obstruction or incarceration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old male with ventral hernia. Evaluate for obstruction\n or incarceration.\n\n FINDINGS/IMPRESSION:\n\n Single supine abdominal radiograph show distended loops of small bowel\n measuring up to 6 cm for which is worrisome for obstruction. Cross-sectional\n imaging may be warranted if clinically indicated.\n\n" }, { "category": "Radiology", "chartdate": "2118-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058033, "text": ", G. TSICU 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: to check ETT position\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with resp failure, sepsis\n REASON FOR THIS EXAMINATION:\n to check ETT position\n ______________________________________________________________________________\n PFI REPORT\n ET tube tip at the orifice of the right main bronchus.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1057623, "text": " 1:55 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? obstruction, hernia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with hernia and decreased bm\n REASON FOR THIS EXAMINATION:\n ? obstruction, hernia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen and pelvis.\n\n HISTORY: 47-year-old male with known hernia and decreased bowel movements.\n Assess for obstruction.\n\n COMPARISON: None.\n\n TECHNIQUE: Following the administration of oral and intravenous contrast,\n MDCT axial images were acquired from the lung bases to the pubic symphysis.\n Coronal and sagittal reformatted images were then obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The lungs bases are clear. The liver,\n spleen, pancreas, adrenal glands, and kidneys are unremarkable. The\n gallbladder is not distended and no gallstones are evident. Within the lower\n mid abdominal wall, a large ventral hernia is evident containing the distal\n small bowel and the proximal colon to the level of the mid- distal transverse\n colon with a neck diameter of approximately 6 cm. Within the large hernia\n sac, proximal small bowel loops are slightly dilated. There is a second area\n of herniation ont he left lateral aspect which raises concern for a\n superimposed hernia on the hernia sac, where the more distal small bowel and\n colon within the large hernia sac is non- dialted, possibliity representing\n the transition point. The distal colon is collapsed.\n\n No free fluid is evident within the abdomen or within the ventral hernia.\n There is no pneumatosis or portal venous gas. However, note is made of\n traction of the mesenteric vessels into the ventral hernia and possible\n differential enhancement of the wall of several loops of bowel which raises\n the possibility of early ischemia. The proximal small bowel is significantly\n dilated measuring up to 5 cm in the right mid abdomen. Oral contrast material\n is present within the stomach but has not progressed through the GI tract. The\n stomach is not significantly distended. There is no free intra-abdominal air.\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley balloon is present within a\n collapsed bladder.\n\n OSSEOUS STRUCTURES: There are no other suspicious lytic or blastic lesions.\n\n IMPRESSION: Large ventral hernia(s) containing loops of both small and large\n bowel, likely site of transition point for high-grade bowel obstruction. While\n there are no definite signs of ischemia by CT, early ischemia cannot be\n excluded. The exact transition point is difficult to assess secondary to lack\n of progression of oral contrast material but appears within the hernia sac\n (Over)\n\n 1:55 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? obstruction, hernia\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n itself possibly at the site of a second smaller satellite hernia off the\n major hernia sac.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058195, "text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening hypoxia\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Findings were discussed with Dr. over the phone by Dr. at\n the time of dictation. This physician was covering Dr. .\n\n\n\n 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening hypoxia\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n worsening hypoxia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:49 AM\n Newly developed right lower lung opacity very concerning for aspiration. ET\n tube tip just above the level of clavicular heads. Advancement of .5 cm\n might be considered.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Worsening hypoxia.\n\n Portable AP chest radiograph was compared to prior study obtained on , at 1407.\n\n The ET tube has been re-positioned and it is now approximately 6 cm above the\n carina with its tip at the upper margin of the clavicular heads and might be\n advanced further 1/1.5 cm. Newly developed right lower lobe opacity is\n concerning for aspiration given the rapid development. The left retrocardiac\n opacity is unchanged and might represent a combination of atelectasis and\n aspiration. The NG tube tip is in the stomach. The right internal jugular\n line tip is in mid SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058032, "text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: to check ETT position\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with resp failure, sepsis\n REASON FOR THIS EXAMINATION:\n to check ETT position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 4:34 PM\n ET tube tip at the orifice of the right main bronchus.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: ET tube position.\n\n Portable AP chest radiograph was compared to .\n\n The current study demonstrates too low position of the ET tube being at the\n origin of the right main bronchus. The NG tube tip is in the stomach. The\n right internal jugular line tip is in low SVC.\n\n Cardiomediastinal silhouette is unchanged. The lung volumes are low. New\n left retrocardiac opacity may be consistent with atelectasis due to suboptimal\n position of the ET tube.\n\n Findings discussed with Dr. over the phone by Dr. at the\n time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058196, "text": ", G. TSICU 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening hypoxia\n Admitting Diagnosis: HERNIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n worsening hypoxia\n ______________________________________________________________________________\n PFI REPORT\n Newly developed right lower lung opacity very concerning for aspiration. ET\n tube tip just above the level of clavicular heads. Advancement of .5 cm\n might be considered.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2159-06-17 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 796855, "text": " 4:05 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: tube placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n FINAL ADDENDUM\n\n ADDENDUM:\n\n Additional information has been obtained from CareWeb Clinical Lookup since\n the approval of the original report. Reason for exam should also state 32 \n weeker weighing 1605 grams.\n\n\n 4:05 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: tube placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with newly placed ETT\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST: 4:10 pm.\n\n The cardiomediastinal silhouette is normal. The lungs are clear. There is no\n evidence of edema or pleural effusions. Endotracheal tube is 1 cm above the\n carina.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997062, "text": "npn\nBlood pressure mean trending downward. Bolused with 16 cc ns over 20 minutes with subsequent mild rise in b/p means. Dad in to visit. Mom is being transfered to the MICU. Unsure of issues with mom at this time. Infant is starting to be more alert at times. Responded better to cares at 9pm. Tone is improving as well. Will continue to monitor.\nD/S 85 at 9pm.Ventilator settings being weaned as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997063, "text": "1 Infant with Potential Sepsis\n2 FEN\n3 ALT.in parenting\n4 Growth and Development\n5 Respiratory-32+ weeks\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 FEN; added\n Start date: \n 3 ALT.in parenting; added\n Start date: \n 4 Growth and Development; added\n Start date: \n 5 Respiratory-32+ weeks; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997064, "text": "NICU nursing note\n\n\n1. Sepsis=O/Cont on Ampi and Gent. A/pot sepsis. P/cont\nwith current Rx. Cont to check blood cx results.\n\n2. FEN=O/BW=1605g. TF cont at 80cc/k/d of D10W infusing\nvia patent/intact PIV Rhand. Abd benign. (Please refer to\nflowsheet for assessment and dstick.) Voiding. No stool.\nA/Stable on current regime. P/Cont to monitor FEN status.\n\n3. Parents=O/Dad and sibling in to visit. Updated by this\nRN and RT. A/appropriate and actively involved. P/Cont to\nsupport and educate parents.\n\n4. G&D=O/Temp stable nested on open warmer. Alert and\nactive with cares. Good tone noted in all extr. Sleeping\nwell between cares. A/Alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n5. Resp=O/Received on SIMV settings of 15/5 R16. Weaned x1\nthen extub at 0200 after CBG results. Presently in RA.\nSats >94%. LSC. (Please refer to flowsheet for resp\nassessment, sxning, vent wean, and CBG reults.) No spells\nor sat drifts. A/Stable in room air. P/Cont to monitor for\nresp distress.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997065, "text": "Respiratory Care\nBaby rec'd orally intubated on SIMV 20, 18/5, 21%. Weaned as per flowsheet. BS clear with good air entry. Sxn for mod white secretions. CBG on 15/5, R 14: 7.36/46/41/27/0. Extubated to RA. No spells or increased noted. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997066, "text": "Neonatology Attending\n\nDay 1\n\nRemains in RA after extubation at 0200. Sats 94-98%. Clear breath sounds. No murmur. Received one normal saline bolus for bp mean in mid-30s. Current bp 42. Pink, well-perfused. HR 130-150s. Hct 45. Plts 115k. WBC 5.5 with 16p 0b. On ampicillin and gentamicin. Weight 1605 gms. NPO. On IV dextrose. Blood glucose 97. Benign abdomen. Stable temperature in incubator.\n\nResolving TTN. Will continue to monitor closely. Transitioning well at present. Will start feeds. Following blood glucose. Leukopenic and minimally thrombocytopenic, presumably related to maternal disease. Ruling out on antibiotics. Will follow cbc.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-02 00:00:00.000", "description": "Report", "row_id": 1997121, "text": "NICU nursing note\n\n\n2. FEN=O/Current wt 1630g (^35g). TF cont at 150cc/k/d of\nBM30PM/PE30PM po/pg. No po attempts so far this shift. Ngt\nfeeds gavaged over 40 min. Abd benign. (Please refer to\nflowsheet for assessment.) No spits. Voiding. No stool.\nCont on iron. A/Tolerating current regime. P/Cont to\nmonitor for feeding intolerance. Cont to offer po/BF when\nawake and .\n\n3. =O/Mom and in to visit at start of shift.\nUpdated by this RN. A/appropriate and actively involved.\nP/cont to support and educate .\n\n4. G&D=O/Temp stable in open crib. and\nactive with cares. Sleeping well between feeds. Sucks on\nbinky. A/Alt in G&D. P/Cont to monitor and support G&D.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-02 00:00:00.000", "description": "Report", "row_id": 1997122, "text": "Neonatology note\n14 d.o\nin RA\nwt= 1620 gm (+35)\n150 cc/kg/d with PE 30\n\nAFOF\nRR with no murmur\nclear lungs\nAbdomen soft\n\nA: ex 32 wks GA, growing preemie, anemia\nP: continue current management\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-02 00:00:00.000", "description": "Report", "row_id": 1997123, "text": "Nrsg Progress NOte-0700-1900\n\n\n#2O/A-Tf remain 150 cc's/kg with bm 30/pe 30 with promod\nwith no spits, asps, or distention. Abd soft with reduceable\nhernia (unbilical). NO Stool. all pg fdgs. A-Fen needs\nwnl this shift. P-Cont to assess fen needs.\n#3O/A-No parental contact as of this writing. visit\ndaily. A-Parenting status unable to assess due to no visits.\nP-Cont to assess parenting needs.\n#4O/A-Rem and active with cares well. Asleep in\nbetween cares. A-G&d needs wnl this shift.P-COnt to assess\ng&d needs.\nPlans for report at 1900.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-03 00:00:00.000", "description": "Report", "row_id": 1997124, "text": "NPN 1900-0700\n\n\nFEN: wt=1655g (up 25g). TF=150cc/kg/d of PE/BM30 with\npromod. Equals 41cc q4hrs, gavaged over 40min. Tolerating\nwell. Belly soft, +BS, no loops, no spits, voiding and\n. Offered PO X1, took 5cc, gavaged remainder.\n\n: Both in briefly, updated at bedside.\n\nG&D: Temps stable, with hat in open crib. and\nactive with cares. Sleeps well between. Likes paci. Hands to\nface.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-10 00:00:00.000", "description": "Report", "row_id": 1997149, "text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 23.\nWt: g (+60)(~10th to 25th %ile); birth wt: 1605 g. Average wt gain over past wk ~22 g/kg/d.\nHC: 31.25 cm (~25th to 50th %ile); last: 29.5 cm\nLN: 42.5 cm (~10th %ile); last: 43 cm\nMeds include Fe\n due this wk\nNutrition: 150 cc/kg/d PE/BM26 w/ promod, alt po/pg. Also breastfeeding well. Infant taking ~ to full feeds po. Feeds just decreased due to good wt gain; projected intake for next 24 hrs ~130 kcal/kg/d, ~4.1 to 4.4 g pro/kg/d, plus additional unquantified intake from breastfeeding.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. due this wk. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is exceeding recommended ~15 to 20 g/kg/d for wt gain and ~0.5 to 1 cm/wk for HC gain; kcals decreased in response. LN shows loss of 0.5 cm over past wk, but question accuracy of measurements. Will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-10 00:00:00.000", "description": "Report", "row_id": 1997150, "text": "NICU nursing note\n\n\n2. FEN=O/TF cont at 150cc/k/d of BM26PM/PE26PM po/pg.\nBottled x2. Abd benign. (Please refer to flowsheet for\nassessment and po amts.) No spits. Voiding. Lg stool x1.\nCont on Vit E and iron. A/Tolerating current regime.\nP/Cont to monitor for feeding intolerance. Cont to\nalternate po/pg.\n\n3. =O/Mom in to visit. Updated by this nurse. Held\nbaby after feed. A/Appropriate and actively involved.\nP/Cont to support and educate .\n\n4. G&D=O/Temp stable in open crib. and\nactive with cares. Sleeping well between feeds. A/Alt in\nG&D. P/cont to monitor and support G&D.\n\n5. A's/B's=O/Spell x1 this shift with bottlefeeding.\n(Please refer to flowsheet for details of brady.) P/Cont to\nmonitor for A's/B's.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997151, "text": "coworker 1900-0700\n\n\n#2FEN: wt up 10. tf remains at 150cc's/kg/d of BM/PE26\nwith promod. 49cc's Q4H. infant taking 35-45cc's thus far\nthis shift. abd benign, belly is soft and round, no spits\nthus far this shift, no asp thus far this shift, +bowel\nsounds, no loops, voiding, no stool yet this shift. A:\nfeeds well P:Cont to monitor infant and encourage bottling\nas tolerated.\n\n#3PARENTING: mom was here to visit infant. very loving\ntoward infant and plans to be in for cares during the day.\nA:loving P:cont to support\n\n#4DEVE: temp stable. infant is in the oac. \nand active with cares. infant is waking for feedings. sleeps\nwell in between. settles well with binki. font are soft and\nflat. brings hands to face. mae. A:AGA P:cont to support g/d\nof infant\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997152, "text": "NPN 1900-700\nI have examined the infant and agree with above note by PCA.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997153, "text": "Neonatology note\n24 d.o\n36 wks PCA\nin RA, no spells\nwt= gm +10\n150 cc/kg/d with EBM/PE 26 po/pg\n\n\nRr with no murmur\nclear lungs\nabdomen soft\n\nA: ex 32 wks GA, growing preemie\nP: continue current management.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997154, "text": "Neonatology note\nlate entry note\n" }, { "category": "Nursing/other", "chartdate": "2159-06-30 00:00:00.000", "description": "Report", "row_id": 1997115, "text": "Newborn Med Attending\n\nDOL#13. Cont in RA, no spells. AF flat, clear BS, soft murmur, abd soft, MAE. WT=1570 up 30, on 150 cc/kg/d BM30 with PM PO/PG.\nA/P: Growing infant on full PG feeds. Cont to encourage PO feeds. Monitor or spells.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-30 00:00:00.000", "description": "Report", "row_id": 1997116, "text": "NICU Nursing PRogress Note\n\nNUTRITION/PARENTING\nO: Infant attempted to po feed using volufeed and yellow\nnipple and took 7cc before tiring. When Mom in to visit at\n1730, put infant to breast and infant latched on and did\nwell for about 10 mins. Mom handles infant very well and\nbreastfed her two previous children. Infant's abd exam\nbenign. Voiding and passing stool.\nA: Improved po behavior.\nP: Attempt BF when Mom visits and introduce po feeds as .\n\nDEVELOPMENT\nO: Temp in open crib. Active and laert with cares.\nSleeps between.\nA: Appropraite behavior.\nP: Support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-01 00:00:00.000", "description": "Report", "row_id": 1997117, "text": "NICU nursing note\n\n\n2. FEN=O/Current wt=1595g (^ 25g). TF cont at 150cc/k/d of\nBM30PM/PE30PM po/pg. Bottled x1. Abd benign. Ngt feeds\ngavaged over 40 min. (Please refer to flowsheet for\nassessment and po amt.) No spits. Voiding/. Cont\non iron. A/Tolerating current regime. P/cont to monitor\nfor feeding intolerance. Offer po's when awake and .\n\n3. =O/Mom in to visit for short time at start of\nshift. Updated by this RN. A/Appropriate and actively\ninvolved. P/Cont to support and educate .\n\n4. G&D=O/Temp stable in open crib. and\nactive with cares. Sleeping well in between feeds. 14day\nPKU sent. A/Alt in G&D. P/cont to monitor and support G&D.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-01 00:00:00.000", "description": "Report", "row_id": 1997118, "text": "Neonatology Attending\n\nDay 14\n\nRemains in RA. RR 30-50s. Clear breath sound. No apnea. No murmur. HR 150-160s. BP mean 46. Weight 1595 gms (+25). TF at 150 cc/kg/d. Minimal po feeds. Breast feeding well. Stable temperature in open crib.\n\nAdequate breathing control evident most recently. Will continue to monitor closely. Gaining weight well. Encouraging po feeding.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-01 00:00:00.000", "description": "Report", "row_id": 1997119, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-03 00:00:00.000", "description": "Report", "row_id": 1997125, "text": "Neonatology note\n16 d.o\nin RA, no spells\nwt= 1655 gm (+25)\n150 cc/kg/d with PE 30 po/pg\n\nAFOF\nclear lungs\nRR with no murmur\nabdomen soft\n\nA: ex 32 wks GA, growing preemie\nP: encourage po nippling\n" }, { "category": "Nursing/other", "chartdate": "2159-07-03 00:00:00.000", "description": "Report", "row_id": 1997126, "text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 16\nWt: 1655 g (+25)(~10th to 25th %ile); birth wt: 1605 g. Average wt gain over past wk ~18 g/kg/d.\nHC: 29.5 cm (~10th %ile); last: 28 cm\nLN: 43 cm (~10th to 25th %ile); last: 41 cm\nMeds include Fe\n not due yet\nNutrition: 150 cc/kg/d PE/BM 30 w/ promod, po/pg. Infant just starting po feeds, taking minimal amounts po. Average of past 3 d intake ~150 cc/kg/d, providing ~150 kcal/kg/d, and 4.1 to 4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is meeting recommendations for wt gain. HC and LN gains are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-03 00:00:00.000", "description": "Report", "row_id": 1997127, "text": "NPN 0700-1900\n\n\n# 2 FEN S/O: TF 150cc/k/d. Infant to get pe or bm 30w pm.\nInfant to get 41cc, q4h po/pg. Attempting to bottle infant\n1x shift. Infants abdomen benign, voiding, no stools on this\nshift. No spits, minimal aspirates. A: Tolerating po feeds.\nP: Continue to encourage po feeds.\n\n#3 Parenting S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#4 DEV S/O: Infant in OAC, maintaining temps. Active with\ncares. Sucking on pacifier. A:AGA P: Continue to support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997067, "text": "NPN 0700-1500\n\n#1 Possible Sepsis\nO: Infant on IV Ampicillin and Gentamycin. Alert and active with care. Appropriate tone and activity. Temp and VS stable and WNL. (see flow sheet)\nA: Acting well, on Antibiotic Rx\nP: Repeat CBC with 24 hr lab work. Continue close observation and monitoring for possible sepsis. Continue antibiotics as ordered.\n\n#2 Alt. in Nutrition\nO: TF=80cc/kg. Feeds started at 1300 at 30cc/kg=8cc PE20 Q 4 hrs and PIV D10W at 50cc/kg=3.3cc/hr. Abd. is flat, soft, with + BS. Girth 22cm. Voiding large amts, 6.3cc/kg/hr over last 8 hrs. No stools.\nA: Feeds started\nP: Check 24 lytes, bili and CBC. Close observation and monitoring for feeding tolerance. Follow D/S and daily wts.\n\n#3 Alt. in Parenting\nO: No contact with to time of note. OB in to see infant and reporting that Mom is in ICU for possible PE. Update on infant given to OB who stated she would give info. to Mom.\nA: Mom unable to call/visit. OB to give Mom update on infant\nP: Keep informed and support as able.\n\n#4 Alt. in Development\nO: Infant transfered from warmer to servo controlled isolette. Maintaining temp. Infant is nested in sheepskin with boundaries in place and position changed Q 4 hrs. Alert with cares, infant settles easily with containment. Able to get hands to mouth and also sucks well on pacifier.\nA: Appropriate behaviors for GA\nP: Continue to support developmental needs.\n\n#5 Alt. in Resp. Function\nO: Infant remains in RA with sat 94-98. Occasional brief sat drift to 88 after crying, QSR. RR 40's-80 with mild SC/IC retractions. Breath sounds are clear and =. No apnea or bradycardia spells noted.\nA: Doing well in RA\nP: Continue close observation and monitoring. Document any spells.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997068, "text": "Neonatology - Progress NOte\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No spells. She is currently NPO. Abd soft, active bowel sounds, no loops. Voiding, no stool yet. IV fluids infusing via PIV @ 80cc/kg/day. DS stable in 90 range. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997069, "text": "Addendum:\n\n#3 Alt. in Parenting\nO: Dad in with 4 other children at 1515. Updated and viewed infant. Mom still in ICU. Hopes to be transfered to post partum floor later today. Dad given NICU phone # so he can call us with infant's name. He will also give # to mom so she can call for update.\nA: Involved, loving family\nP: Keep informed and support.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997155, "text": "Neonatology note\nlate entry note\n 23 d.o\nin RA with no spells\nwt= +60\n150 cc/kg/d with EBM/PE 26\n\n\nRR with soft systolic murmur (PPS)\nclear lungs\nabdomen soft\n\nA: ex 32 wks GA, groeing preemie, heart murmur\nP: continue current management, no w/u for heart murmur now.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-28 00:00:00.000", "description": "Report", "row_id": 1997109, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. No spells over last 24 hours. She is tolerating full volume pg feeds. Abd soft, active bowel sounds, no loops. Voiding and . Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-28 00:00:00.000", "description": "Report", "row_id": 1997110, "text": "nursing note\n\n\nfen: continues on 150cc/kg/day total fluid. breastmilk/pe\nincreased to 30calorie with promod. weight 1535, up forty\ngrams. tolerating feeds well per ng tube with no spits.\nlarge stool noted with 1330 feed. abd. remains soft and\nround with abd. girth stable.\nalt in par: no parent contact noted. will encourage parent\ninvolvement with care when available.\ng & d: baby and changed to open crib. maintaining\nbody temperature appropriately in crib. sucks pacifier when\nstimulated. will continue to provide dev. appropriate care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-29 00:00:00.000", "description": "Report", "row_id": 1997111, "text": "NPN\n\n\n#2-O: On tf 150cc/k/d full enteral feeds of BM/PE30/promod =\n40cc PG q 4 hrs, wel min-no aspirates, abd soft, benign,\nactive bowel sounds. voiding, no stool this shift.\n\n#3-O: mom in to visit, could not stay for care, (had been in\nearlier also), attempts baby at breast qd.\n\n#4-O: temps stable in open crib. active and \nwith cares, afof, acts app. for age, cont to assess.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-01 00:00:00.000", "description": "Report", "row_id": 1997120, "text": "NICU NURSING PROGRESS NOTE\n\nNUTRITION\nO: Infant receiving 150cc/kg/day of 30BM/PE withPM every 4\nhrs. Attempted po X1 and infant took 7cc with volufeed and\nyellow nipple before tiring. Gavage supplemented for\nremainder. Attempted BF X1 and infant was sleepy. Abd exam\nbenign. Voiding. No stool this shift.\nA: Slowly learning to feed.\nP: Advance po feeds as .\n\nDEVELOPMENT\nO: Active and with cares. Sleeps between. Temp stable\nin open crib. Sucking on pacifier.\nA: Appopriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom in for 1700 cares. Updated regarding infant's status\nand plan of care. Mom states she is tired and needs more\nrest. Handles infant well.\nA: Invovled parent visiting daily.\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-04 00:00:00.000", "description": "Report", "row_id": 1997128, "text": "NPN 7p-7a\n\n\nFen: Infant's wt tonoc 1.680kg (+25gms). Conts on tf\n150cc/kg of pe/bm30 with pm. Po'ed x1 15cc. Gavaged\nremainder. No spits. Minimal aspirates. Abd soft. Active bs.\nVoiding with each diaper change. Conts on fe. Cont to\nencourage po feeds.\n\nParenting: Mom in this evening with siblings. Independant\nwith temp and diaper. Po'ed infant without difficulty.\nUpdated at bedside. Cont to support and update.\n\nG&D; Temp stable in open crib. and active\nwith cares. Well co-ordinated with po feeds. Tires easily.\nVery when mom and siblings were visiting. Cont to\nsupport developmental milestones.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-04 00:00:00.000", "description": "Report", "row_id": 1997129, "text": "Neonatology note\n17 d.o\nin RA, no spells\n\nwt= 1680 gm (+25)\n150 cc/kg/d with EBM 30\n\nAFOF\nclear lungs\nRR with no murmur\nabdomen soft\n\nA: ex 32 wks GA, growing preemie\nP: continue current management\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-04 00:00:00.000", "description": "Report", "row_id": 1997130, "text": "Nursing Progress Note\n\n\n2. FEN O/A TF=150cc/kg/day of PE or BM 30 w/PM. Inf PO\nfed 43cc at 0930 with encouragement. Inf PG fed at 1330.\n well. No spits, no asp thus far. Belly soft, no loops.\n Inf voiding, no stool thus far. P cont to assess FEN\nneeds.\n3. O/A No contact thus far. P support, educate.\n4. DEV O/A Baby remains in an OAC with stable temp. A/A\nw/cares. Not waking for cares this shift. Sleeping well\nbetween cares. Passed hearing test. P cont to asses dev\nneeds.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-06 00:00:00.000", "description": "Report", "row_id": 1997131, "text": "NPN 1900-0700\n\n\n#2 FEN\nTF=150cc/kg/day of BM/PE30 with PM, 44cc q4hr. Infant took\n43cc at 9:30pm. Weight=1.755kg, up 30grams. No spits.\nAspirates=0.2-0.4cc. Voiding. No stool thus far. AG=22cm.\nAbdomen benign. Active bowel sounds. Cont to monitor and\nencourage PO feeds.\n#3 \nNo contact with thus far.\n#4 G&D\nInfant remains in OAC. . Temp stable. A/A with\ncares. Sucks on pacifier. Brings hands to mouth. Sleeps well\nin between cares. Applying desitin to bottom. Cont to\nmonitor and support G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-06 00:00:00.000", "description": "Report", "row_id": 1997132, "text": "NPN 1900-0700\nAddendum:\nI have examined this infant and agree with above note by .\n" }, { "category": "Nursing/other", "chartdate": "2159-07-06 00:00:00.000", "description": "Report", "row_id": 1997133, "text": "Neonatology NP Note\nPE\n in open crib, AFOF, sutures opposed, respirations unlabored in room air, lungs clear/=, RRR, no murmur, pink and well perfused, abdomen soft, good tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-11 00:00:00.000", "description": "Report", "row_id": 1997156, "text": "NPN 0700-1900\n\n\n2. FEN\nO: TF 150cc/kg/d of BM26/PE26 + PM. Offering po's x2/shift\nor as interested. BF well x20 mins @ 1330 and suppl w/25cc\npo; remainder of volume gavaged. Abd soft, +BS, no loops.\nA/G stable. No spits. Min asps. Voiding and \n(heme-). A: Tolerating feeds. P: Cont to monitor nutritional\nstatus, encourage po's.\n\n3. \nO: Mom in for 1330 feed. Met w/Lactation. Independent\nw/cares. Asking appropriate questions. Scheduled for CPR\nclass tomorrow. A: Attentive, loving family. P: Cont to\nsupport and educate family.\n\n4. DEV\nO: is /active with cares. Occ waking for\nfeeds this shift. Sleeping well b/w care times. Temps stable\nin OAC. A: AGA. P: Cont to provide dev appropriate care.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-12 00:00:00.000", "description": "Report", "row_id": 1997157, "text": "NPN 1900-700\n\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get bm or pe 26 with\npromod, 49 cc q4h po/pg. Infant bottled x1 on this shift\ntook 25cc. Infants abdomen benign, voiding and . No\naspirates or spits. Sleepy with bottling. A: Tolerating\nfeeds. P: Continue to encourage po feeds.\n\n#3 Parenting S/O: No contact with this shift. A:\nUnable to assess. P: Continue to support.\n\n#4 DEV S/O: Infant maintaining temps in OAC. Infant \nand active with cares. Sleepy with bottling. Sucking on\npacifier. A: AGA P: Continue to support dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-12 00:00:00.000", "description": "Report", "row_id": 1997158, "text": "Neonatology note\n25 d.o\n\nIN RA, no spells\nwt= gm +70\n150 cc/kg/d with EBM 26 po/pg\n\n, pink\nRR with soft intermittent murmur\nclear lungs\nAbdoment soft\n\nA: ex32 wk GA, growing preemie\nP: coontinue current management, will need Hep B vaccine.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-12 00:00:00.000", "description": "Report", "row_id": 1997159, "text": " PHysical Exam\n\nPE: pink, , breath sounds clear/equal with easy WOB, very softmurmur audible left lung fields, normal pulses, abd soft, non distended, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-12 00:00:00.000", "description": "Report", "row_id": 1997160, "text": "NPN 0700-1900\n\n\n2. FEN\nO: TF 150cc/kg/d of PE26/BM26 + PM. Alt feeds po/pg.\nBottling up to 42cc of 51cc requirement this shift. Abd\nsoft, +BS, no loops. A/G stable. No spits. Min asps. Voiding\nand (heme-). A: Tolerating feeds. P: Cont to\nmonitor nutritional status, encourage po intake.\n\n3. \nNo contact w/family thus far this shift. Scheduled for CPR\nclass today @ 1630.\n\n4. DEV\nO: is /active with cares. Occ waking for\nfeeds. Temps stable in OAC. , . Sleeping well b/w\ncare times. Calms w/pacifier. A: AGA. P: Cont to provide dev\nappropriate care.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-29 00:00:00.000", "description": "Report", "row_id": 1997112, "text": "Neonatology note\n12 d.o\nin RA\n\nWT= 1540 gm (+5) 140 cc/kg/d with EBM 30 PG\n\nAFOF\nclear lungs\nRR with no murmur\nAbdomen soft\n\nA: ex 32 wks GA, growing preemie, anemia\nP: continue current management\n" }, { "category": "Nursing/other", "chartdate": "2159-06-29 00:00:00.000", "description": "Report", "row_id": 1997113, "text": "NPN 0700-\n\n\n2. TF 150cc/k/d BM30PM or PE30PM. Abd benign. Voiding and\nheme negative stool. Attempted to bottle this AM and infant\nable to suckle a few times and not swallowing. Infant tired\neasily with bottle attempt. Tolerating feeds without spits\nand min. aspirates. Not interested in bottle at this time.\nMom planning to visit at 1730 and will attempt to breast\nfeed. Cont to encourage PO's as tolerated.\n\n3. Mother called and updated on plan of care. Mother\nstated that she will try to visit today at 1730 and would\nlike to breast feed infant. Cont to support, update, and\neducate .\n\n4. Temp stable in OC. Awake and quiet with\ncares. Resting well inbetween cares. Attempted to bottle\nfeed this AM as noted above. MAE, suckles on pacifier at\ntimes. Umbilicus dry. Cont to promote G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-30 00:00:00.000", "description": "Report", "row_id": 1997114, "text": "NICU nursing note\n\n\n2. FEN=O/Current wt=1570g (^30g). TF cont at 150cc/k/d of\nBM30PM/PE30PM gavaged over 40 min. Abd benign. (Please\nrefer to flowsheet for assessment.) Voiding/. Cont\non iron. A/Tolerating current regime. P/Cont to monitor\nfor feeding intolerance.\n\n3. =O/Mom in to visit. Updated by this RN.\nParticipating in all care. Held baby for 2100 feed and read\na story. A/Appropriate and actively involved. P/Cont to\nsupport and educate .\n\n4. G&D=O/Temp stable with hat in open crib. \nand active with cares. Sleeping well between feeds. A/Alt\nin G&D. P/Cont to monitor and support G&D.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-07 00:00:00.000", "description": "Report", "row_id": 1997139, "text": "NPN Days 7am-7pm\n\n\n#2 O: Remains on TF of 150cc/k/day of BM or Pe 28 cals. Abd\nremains softly round, +bs, no loops, no spits and minimal\naspirates. Voiding adeq amt. Has attempted to bottle X 2\nthus far this shift - has taken 20 and 30cc (of needed q 4\nhrs volume of 45cc)- seems to \"loose interest\" in bottling\nrather that appearing to be tired. A: doing some\nbottling/working on po feeding skills. P: Continue to\nmoniter.\n#3 O: Infant's mom in this afternoon. She is independ with\ncares and bottling. She spent time at the bedside holding\nher infant and to her. Discussed availablity of\nCPR classes for to take and encouraged her to\nsign-up for a class. Mom plans to visit again this evening.\n A: involved and invested mom. P: Continue to support,\n#4 O: Infant and active with cares, needing to be\nawakened for feeds. Temp stable in open crib. Ant font\nsoft and flat. A: AGA, working on po feeding skills. P:\nContinue to moniter for milestones.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-08 00:00:00.000", "description": "Report", "row_id": 1997140, "text": "NPN 1900-0700\n\n\n2. FEN\nO: Current wgt 1870g (+75). TF 150cc/kg/d of PE28/BM28 + PM.\nAlt feeds po/pg. Offering bottles x2/shift. Bottling\n23-30cc of 47cc min when offered. Abd exam benign, +BS, no\nloops. A/G stable @ 26-27cm. Min asps, no spits. Voiding and\n. A: Tolerating feeds. P: Cont to monitor\nnutritional status, encourage po intake.\n\n3. \nO: Mom in for 2100 care. Participated in bath and\nbottled infant. Stated she plans on beginning to put infant\nto breast tomorrow. Scheduled for CPR class on Thurs @ 1630.\nScheduled for LC on Wed @ 1330. Bulb syringe teaching done.\nA: Loving, involved family. P: Cont to support and educate\nfamily.\n\n4. DEV\nO: is /active with cares. Not yet waking for\nfeeds this shift. Temps stable in OAC. Sleeping well b/w\ncare times. , . A: AGA. P: Cont to provide dev\nappropriate care.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-26 00:00:00.000", "description": "Report", "row_id": 1997102, "text": "NPN\n\n\n#2F/N O- Infant had promod added to feeds today.\n(BM26cal/PE26cal at 150cc/kg. No spits or aspirates noted.\nVoiding and passing soft stool. A- . feeds well. P-\nFollow wts. Trial bottle in awake.\n#3Family No contact from Mom today.\n#4Dev. change.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-26 00:00:00.000", "description": "Report", "row_id": 1997103, "text": "NURSING NOTE\nMOM IN TO VISIT FOR 1730 FEED. MOM ABLE TO TAKE TEMP AND CHANGE DIAPER. MOM UPDATED WITH PLAN OF CARE. MOM HELD INFANT WHILE OTHER SIBLINGS VISITED.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-27 00:00:00.000", "description": "Report", "row_id": 1997104, "text": "NPN 1900-0700\n\n\n2. F&N: TF remain at 150cc/k/d of PE30 with promod. Feeds\ngavaged in over 40 minutes. Abd benign. BS+. A/G stable.\nMax asp was 6 cc of nonbilious, partially digested formula.\nVoiding and . Weight gain 50 grams.\n\n3. PAR: No contact from so far this shift.\n\n4. DEV: is active and during her cares.\nTemp stable in air isolette. Putting hands to\nface.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-06 00:00:00.000", "description": "Report", "row_id": 1997134, "text": "Neonatology Attending\nDOL 19 / CGA 35-2/7 weeks\n\nRemains in room air with no cardiorespiratory events.\n\nNo murmur. BP 72/47 (58).\n\nWt 1755 (+30) on TFI 150 cc/kg/day PE30PM/BM30PM. Bottling two-three full volumes per shift, but slowly. Voiding and normally.\n\nTemperature stable. Auditory screen passed.\n\nA&P\n32-4/7 week GA infant with resolving feeding immaturity\n-We will wean caloric density in anticipation of discharge home (28 kcal/oz today and 26 kcal/oz on Sunday)\n-Anticipate discharge on early next week\n" }, { "category": "Nursing/other", "chartdate": "2159-07-06 00:00:00.000", "description": "Report", "row_id": 1997135, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get pe 28 with promod.\nInfant needs 44cc q4h, bottled 44ccx2 today so far. Infants\nabdomen benign, voiding and . Infant has had no\nspits or aspirates. A: Tolerating po feeds. P: Continue to\nencourage po feeds.\n\n#3 Parenting S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#4 DEV S/O: Infant maintaining temps in OAC. with\ncares, sleepy in between. Good tone. A: AGA P: Continue to\nsupport dev.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-07 00:00:00.000", "description": "Report", "row_id": 1997136, "text": "NPN NIGHTS\n\n\nALT IN NUTRITION R/ : FULL VOLUME FEEDS WELL ON\n150CC/K/D OF BM28 W/PROMOD, 45CC Q4HRS. ABD EXAM BENIGN, NO\nLOOPS, NO SPITS. GIRTH 23-25. ASP. 0.2-0.4CC. VOIDING WELL,\nNO STOOL TONIGHT. WGT UP 40 TO 1795 TONIGHT. BABY WAS ALL\nBOTTLES EARLIER TODAY. AT 9:30PM SHE BOTTLED 25CC AND THE\nREST GAVAGED. AT 1:30AM SHE BOTTLED 40CC, AND THE LAST 5CC\nGAVAGED. SHE NEEDS MUCH ENCOURAGMENT TO BOTTLE. SHE IS \nBUT PASSIVE WHEN SHE BOTTLES. WILL GAVAGE HER LAST FEEDING\nTO GIVE HER A REST. CONTINUE CURRENT FEEDING PLAN. BOTTLE AT\nLEAST QOF, AND MORE IF SHE SEEMS INTERESTED.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIVEW\nITHCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN\nCRIB. CONTINUE DEVELOPMENTAL CARES.\n\nALT IN PARENTING:NO CONTACT FROM THIS SHIFT.\nCONTINUE TO SUPPORT AND UPDATE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-07 00:00:00.000", "description": "Report", "row_id": 1997137, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. pink and well perfused. ABd benign, no HSM. Umbi hernia soft, easily reduced. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-07 00:00:00.000", "description": "Report", "row_id": 1997138, "text": "Neonatology Attending\nDOL 20\n\nIn room air with no cardiorespiratory events.\n\nNo murmur.\n\nWt 1795 (+40) on TFI 150 cc/kg/day PE28PM/BM28PM, tolerating well. Bottled exclusively yesterday, but quite slowly, with requirement for gavage feeds overnight. Voiding and normally. Abdomen benign.\n\nTemperature stable in open crib.\n\nA&P\n32-4/7 week GA infant with feeding immaturity\n-Continue to await maturation of oral feeding skills\n-Wean caloric density tomorrow\n-Discharge planning in progress\n" }, { "category": "Nursing/other", "chartdate": "2159-07-08 00:00:00.000", "description": "Report", "row_id": 1997141, "text": "Neonatology\nContinue to be in RA. No spells. Comfortable appearing. No murmur.\n\nWt 1870 up 75. feeds at 150 cc/k/d of 28 cal. Good weight gain over time. Abdomen benign. STill requiring gavage,. Approx 4-6 bottles/day taking ~ volumes. Will dcerease to 26 cal and monitor growth over time.\n\n\nCOntinuing to await maturation of feeds.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-08 00:00:00.000", "description": "Report", "row_id": 1997142, "text": "#2 O: Infant remains on TF of 150cc/k/day of Pe28 cals, with\nplan made to decrease to 26 cals later today. Abd remains\nsoft, +bs, no loops, Ag stable, min aspirates and no spits.\nInfant bottled X thus far this shift and took 30cc,\notherwise tolerating gavage feeds well. Voiding adeq\namounts. A: tolerating feeds well, doing some bottling. P:\nContinue to moniter.\n#3 No contact with thus far this shift.\n#4 O: Infant and active with cares, needing to be\nawakened for feeds. Temp stable in open crib. Taking some\nfeeding volume by bottle. A: AGA. P: Continue to moniter\nfor milestones.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-27 00:00:00.000", "description": "Report", "row_id": 1997105, "text": "Neonatology note\n10 d.o wt= 1495 gm (+50)\n150 cc/kg/d with PE26 PG\nin RA, no episodes\n\nAFOF\nclear lungs\nRR with no murmur\nAbdomen soft\n\nA: ex 32 , growing preemie on Fe\nP: advancing calorie\n" }, { "category": "Nursing/other", "chartdate": "2159-06-27 00:00:00.000", "description": "Report", "row_id": 1997106, "text": "NPN 0700-\n\n\n2. TF 150cc/k/d. Calories increased to BM/PE 28 with PM.\nAbd benign. Voiding and no stool thus far. Girth stable at\n20.5cm. Tolerating increased cals without emesis and min.\naspirates. Cont to monitor tolerance to increased cals and\nattempt bottle/ breast feed when moms visits.\n\n3. No contact from thus far.\n\n4. Temp 99.5 in low air isolette. Isolette turned off and\ntemp 99.3, . Infant awake and active with cares,\nresting well inbetween. MAE. Umbicutis draining scant\namount of NP aware. Cont to\npromote G&D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-28 00:00:00.000", "description": "Report", "row_id": 1997107, "text": "NPN 1900-0730\n\n\n1. WT. 1.535GMS, UP 40GMS FROMYESTERDAY. TF CONT. AT\n150CC/K/D OF BM OR PE 28 WITH PROMOD. TOLERATING WELL . ABD\nSOFT, N LOOPS, +BS. VOIDING WELL, NO STOOL. NO SPITS OR\nASPIRATES NOTED. MOM IN FOR 2130 CARES. HOLDING INFANT TO\nBREAST. INFANT LATCHING AND ATTEMPTING TO SUCK. PLAN; CONT.\nTO TRY BF WHEN MOM IN. ASSESS TOLERANCE TO INCREASE IN\nFEEDS.\n\n3. MOM IN FOR 2130 CARES. INDEPENDANT WITH DIAPER CHANGE AND\nTEMP TAKING. HOLDING INFANT VERY LOVING AND CARING. ASKING\nALL APPROPRIATE QUESTIONS. PLAN; CONT. TO SUPPORT AND\nEDUCATE .\n\n4. REMAINS IN OFF ISOLLETE WITH TEMPS STABLE. INFANT VERY\nCALM, A/A WITH CARES. ATEMPTING TO BF BUT MAINLY A GAVAGE\nFEEDER. PLAN; CONT. TO SUPPORT G/D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-28 00:00:00.000", "description": "Report", "row_id": 1997108, "text": "Neonatology note\n11 d.o\nwt= 1535 gm (+40) 150 cc/kg/d with EBM/PE 28\nin RA, no spells.\n\nAFOF\nRR with no murmur\nclear lungs\nAbdomen soft, umbilical cutis\n\nA: ex 32 wks, growing preemie\nP: continue current management, advance to 30 cal/oz\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997058, "text": "Admission Note\n1605 gram infant female delivered at 1535 hours by NSVD at 32 4/7 weeks gestation to a 38 yo G6P4-5 A+/Ab neg/RPR NR/RI,HepbsAg neg/GBS unknown with an EDC of . ROM on at 1145 hours. Mother received antibiotics on at 1250 hours.\n\nPregnancy complicated by IUGR, HTN rx'd with labetolol. Mother received on .\n\nCalled by L&D staff at 3 minutes of life for precipitous delivery and prematurity. Apgar scores 4, 7 at 1 and 5 minutes. CPAP in DR poor air entry. Centrally pink with HR > 100.\n\nInfant wrapped and held briefly by mother. To NICU uneventfully.\n\nPE:\nVS as RN; First BP: 56/33 (41)\n\nWeight: 1605 grams, 3#9 oz\nLength: 16 in, 42 cm\nHC: 29 cm\n\nNCAT, AF o/F/s\nRRR no m\nDecreased BS, + retractions\nAbd soft min BS\n+ pulses\nnl female GU\nnon-focal neuro exam, but notably lethargic and hypotonic\n\nA/P: Preterm infant with poor resp effort. Respiratory signs/symptoms c/w poor lung compliance.\n\nREsp: intubated by with 3.0 ETT; will obtain CXR and give surfactant if clinically appropriate\n\nCVR: Stable; will follow BP's closely\n\nID: Send CBC and blood culture and consider antibiotics\n\nMetab: Follow D-sticks in light of risk of prematurity and maternal use of labetolol.\n\nSocial: Parents updated in DR.\n\nPrimary care MD is Dr. at CHB\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997059, "text": "Neonatal NP-Procedure Note\n\nProcedure: Intubation\nIndication: Airway management\n\nUnder direct visualization #3.0 ETT placed through vocal cords without difficulty. Auscultated bilateral equal breath sounds. Awaiting xray confirmation of tube placement. Infant toleratead procedure well.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997060, "text": "Respiratory Care Note\nThis 32 wga baby was brought to the NICU after receiving CPAP in DR. see admit note for further details. Intubated in NICU by for minimal resp. efforts. Placed on vent on SIMV 24, 20/5, 21% O2. BS clear. CXR showed tube in good position, lung fields clear and overexpanded. Decreasded to 18/5, RR 20, 25% O2. CBG pending.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-17 00:00:00.000", "description": "Report", "row_id": 1997061, "text": "Admission Note\nBaby Girl admitted to nicu s/p nvd at 32 weeks to a g6 p4 mom.\n above admission note for delivery room details. on arrival to nicu infant placed on servo controlled warmer initial temperature was 96.5 rectally. see flow sheet for other v.s .Infant warmed nicely and has maintained temp. on servo warmer. CBC,BC sent Plts repeated and wnl. Antibiotics started. D/s initially 71 then 104 at 6pm. Presently NPO on IV of D10W at 80 cc/k/d. Cxray looked wnl. Infant is presently vented on 18/5 rate of 20.cbg 7.32/51/42/27/0 which was on 25% fio2.Aiming to keep sats >92%. Shallow breaths initially with a bit more effort over the last hour. Tone is decreased with minimal response to painful stimuli.B/P maintained with means >30.No boluses given at this time.Will continue to monitor response to interventions. expect to see increased activity soon.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-18 00:00:00.000", "description": "Report", "row_id": 1997070, "text": "NURSING\n#1 SEPSIS\ns/o: Remains on IVAB- blood cx neg to date. Active with care\nA: R/o sepsis. P: Cont IVAB while awaiting final cx result\n#2 FEN\ns/o: 24 hr lytes= 146/4.2/114/24. TF increased to 100cc/k/d\nPresently feeding 30cc/k of PE20 with remainder PIV of D10W\ninfusing well. DS- 73 x1. Abd soft, no loops.+BS bilaterally\nurine output this shift=tapered to 2cc/k/hr. A: Tol enteral\nfeeds. Diuresis tapering off. P: Likely adv enterals\ntomorrow. Cont to assess PIV and mtr DS .\n#3 PARENT\ns/o: Dad and extended family visiting. Mom remains in ICU-\ninfant taken for visit to ICU and held by mom. A: \nupdated yet struggling with separation P: Cont to support\n#4G&D\ns/o: Nested in sheepskin with ext softly flexed. TOne good.\nAFOF. MAE. Alert with handling. Temp stable on servo. A: Dev\nappropriate for 32-4/7 wk P: cont dev supp cares.\n#5 RESP\ns/o:Desat x1--86, no lower yetsustained and not recovering\non own. BBO2 required. A: Occ spell. P: cont to mtr closely\nand document frequency/severity.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-19 00:00:00.000", "description": "Report", "row_id": 1997071, "text": "NPN:\n\nRESP: Sats 91-95% in RA. RR=50-70 w/SC retraction. BBS =/clear. Occasional brief sat-drifts w/quick recovery. No A&Bs thus far tonight; sustained desat x 1 which required BB02 over past 24 h.\n\nCV: No murmur. BP=67/32 (45). HR=130-140's. Color pink w/good perfusion.\n\nFEN: Wt=1505g (- 100g). TF=100cc/kg/d. Enteral feeds at 30cc/kg/d; tolerating 8cc PE-20 q 4 h via NG. IV of D-10-W at 70cc/kg/d. Dx=92. Abd benign. No spits. U/O=5.5cc/kg/h yesterday; voiding well tonight. No stool since mec at birth.\n\nID: CBC/diff last eve: WBC=6.1, Hct=48, Plat=151, N=45, B=1, L=50. Remains on Amp & Gent.\n\nG&D: CGA~32 wk. Temp stable in servo-controlled isolette. Active and alert w/cares. Occasional fussy periods. Nested in sheepskin.\n\nSOCIAL: No contact w/. Mother still a patient in ICU.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-19 00:00:00.000", "description": "Report", "row_id": 1997072, "text": "Neonatology Attending\n\nDay 2\n\nRemains in RA. RR 50-70s. Sats 91-95%. Occasional drifts. Mild retractions. No apnea. HR 140-150s. BP mean 45. On ampicillin and gentamicin. Weight 1505 gms (-100). TF at 100 cc/kg/d. Enteral feeds at 30 cc/kg/d. Tolerating feeds well. On IV dextrose. Blood glucose 92. Benign abdomen. No spits. Bilirubin 7.6/0.4. Mother in ICU. Baby visited with mother yesterday.\n\nMild respiratory control immaturity. Will continue to monitor closely. Tolerating feeding advance. Will continue. Following bilirubin.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-13 00:00:00.000", "description": "Report", "row_id": 1997161, "text": " 7p-7a\n\n\nFEN:\n TF:150cc/kg/D of bm26wpm. Alt PO/PG. Pt is bottling \nvolumes, while the remiander is being gavaged. Total voume\nis being gavaged over 40minns. Min aspirates and no spits so\nfar this shift. Pt's abd is benign w/active BS. Pt is\nvoiding w/each diaper chg. Remains on Vit E and Fe. Please\nrefer to Pt's chart for additional FEN data. Continue to\nsupport and encourage PO feeds.\n\nDEV:\n Pt's temp remains stable while in an OAC. Pt is\n and active w/cares. She is waking for feeds and\nsleeping well in between. Contiue to monitor and support\ndevelopmental status.\n\nPARENTING:\n No contact w/ by this co-worker so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-13 00:00:00.000", "description": "Report", "row_id": 1997162, "text": "I have examined this infant and agree with above documentation by , PCA.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-09 00:00:00.000", "description": "Report", "row_id": 1997143, "text": "NPN 1900-0700\n\n\n2. FEN\nO: Current wgt 1890g (+20). TF 150cc/kg/d of PE26/BM26 + PM.\nBottling x2/shift. Bottling up to 33cc of 47cc req. Abd exam\nbenign, +BS, no loops. A/G 24-25cm. No spits. Min asps.\nVoiding and (heme-). A: Tolerating feeds. P: Cont\nto monitor nutritional status, encourage po intake.\n\n3. \nO: Mom in @ beginning of shift, holding infant. Plans to\nreturn tomorrow. Scheduled for LC Wed @ 1330. Scheduled for\nCPR Thurs. A: Attentive, loving family. P: Cont to support\nand educate family.\n\n4. DEV\nO: is /active with cares. Temps stable in\nOAC. Not waking for feeds this shift. Settles easily after\ncares. , . A: AGA. P: Cont to provide dev appropriate\ncare.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-09 00:00:00.000", "description": "Report", "row_id": 1997144, "text": "Neonatology note\ncorrection:\nheart: soft systolic murmur anterior chest, bilaterally in the axillary as well as in the back probably PPS.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-09 00:00:00.000", "description": "Report", "row_id": 1997145, "text": "Neonatology note\n22 d.o\nin RA, no spells\nwt= 1890 gm +20\n150 cc.kg/d with PE 26 po/pg\n\n\nRR with no murmur\nclear lungs\nabdomen soft\n\nA: ex 32 wks GA, growing preemie\nP: continue current management\n" }, { "category": "Nursing/other", "chartdate": "2159-07-09 00:00:00.000", "description": "Report", "row_id": 1997146, "text": "NPN days 7am-7pm\n\n\n#2 O: Remains on TF of 150cc/k/day of BM26/Pe26 cals.\nTolerating gavage feeds well with minimal aspirates and no\nspits. Infant has bottled X 1 thus far this shift and took\n24cc (of needed 47cc q 4 hrs) - episode of paleness and mild\nduskyness noted while bottling and therefore O2 sat\nmonitering was resumed. Abd remains soft, +bs, no loops, Ag\nstable. Voiding adeq amts, stool heme neg. A: tolerating\nfeeds well, doing some po feeding. P: Continue to moniter\nand encourage po feeds as tolerated.\n#3 No contact with infant's mom thus far this shift.\n#4 O: Infant and active with cares, needing to be\nawakened for feeds. Temp stable in open crib. Had an\nepisode of paleness/mild duskyness with bottling. A: AGA,\nworking on po feeding skills.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-10 00:00:00.000", "description": "Report", "row_id": 1997147, "text": " 7p-7a\nAddendum: I have examined this infant and agree with the above note by A. .\n" }, { "category": "Nursing/other", "chartdate": "2159-07-10 00:00:00.000", "description": "Report", "row_id": 1997148, "text": " 7p-7a\n\n\nFEN:\n TF:150cc/kg/D of BM/PE26w/pm. Pt is alt PO/PG feeds.\nTotal Feeds are being gavaged over 45 mins. Mom was in for\n1st care this shift, infant BF well for >20 mins, and PO'd\nfull feed after. Pt's abd is benign w/active BS. min asp,\nand no spits. Pt is voiding w/ each diaper chg. No stools\nthis shift. PLease refer to PT's chart for additional FEN\ndata. Contiue to support and encourage PO feeds.\n\nPARENTING:\n Mom was in for 1st care this shift shift. She is\nindependent w/temps, feedings and and diaper chgs. Mom \nthe baby and BF for 20 mins. MOm is very patient and\naffectionate toward the infant. Continue to update and\nsupport.\n\nDEV:\n Pt's temp remains stable while in OAC. Pt is \nand active w/cares. SHe is begining to wake for feeds, and\nsleeps well in between them. Continue to monitor and\nsupport developmental milestones.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-24 00:00:00.000", "description": "Report", "row_id": 1997094, "text": " PHysical Exam\n\nPE: pink, AFOF, breath sounds clear/equal with mild intercostal retracting, no murmur, normal pulses, abd soft, slightly full, + bowel sounds, quiet , good tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-24 00:00:00.000", "description": "Report", "row_id": 1997095, "text": "Neonatology Attending\n\nDOL 7 CGA 33 4/7 weeks\n\nStable in RA. No A/B.\n\nBP 61/39 mean 47.\n\nOn 150 cc/kg/d BM/PE 22 pg. Aspirates 2-4 cc. Voiding. Stooling (heme neg). DS 76. Wt 1435 grams (up 15).\n\nBili 4.8/0.3 (rebound).\n\n visiting. Had family meeting yesterday.\n\nA: Stable. No spells. Tolerating feeds. Hyperbili resolved.\n\nP: Monitor\n Advance to 24 cals\n Start ferinsol\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-24 00:00:00.000", "description": "Report", "row_id": 1997096, "text": "NICU NURSING PROGRESS NOTE\n\nNUTRITION\nO: Advanced to 24 cals/oz BM or PE by gavage over 40 minutes\nevery 4 hrs. Abd exam benign. Voiding and passing heme neg\nstool.\nA: No evidence of intolerance to feeds.\nP: Assess.\n\nBILI\nO: Serum bili rebound 4.8/0.3.\nA: Problem resolved.\nP: D/C problem./\n\nDEVELOPMENT\nO: Active and with cares. Sleeps between. Sucking on\npacifier.\nA: Appropriate behavior.\nP; Support development.\n\nPARENTING\nO: Mom and Dad and siblings in to visit. Mom held infant.\nUpdated regarding infant's status and plan of care.\nA: Invovled .\nP: Support and keep informed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-25 00:00:00.000", "description": "Report", "row_id": 1997097, "text": "NURSING PROGRESS NOTE\n\n6 alt in bili\n\n2 - FEN - TF=150CC/K OF PE24. PT TOIL NG FEEDS OVER 40 MIN.\nNO SPITS, MIN ASPIRATES. ABD SOFT, +BS, NO LOOPS.\nAG=22-24CM. PT VOIDING, , GUIAC-. WT=1.445(+10)\n\n3 - parent - no family contact thus far tonight\n\n4 - DEV - TEMP STABLE IN SRVO MODE ISOLETTE. PT , EYES\nOPEN W/ CARES. AFOF\n\n\n\nREVISIONS TO PATHWAY:\n\n 6 alt in bili; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-25 00:00:00.000", "description": "Report", "row_id": 1997098, "text": "Neonatology note\n8 d.o wt=1445 gm (+ 10)\n150 cc/kg/d with EBM\\PE 24\nin RA, no episodes.\n\nAFOF.\njaundice.\nrrr with no murmur.\nclear lungs.\nAbdomen soft.\nA: ex 32 wks, jaundice, growing preemie, on Fe\nP: advancing calorie density.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-25 00:00:00.000", "description": "Report", "row_id": 1997099, "text": "NPN\n\n\n#2F/N O- infant remains on feeds of PE24cal at 150cc/kg. No\nspits or aspirates noted. Voiding well. Passed small stool\nx1. Gavages given over 45 minutes. A- Tol. feeds well P-\nIncrease to 26cal this PM.\n#3Family No contact during day shift.\n#4Dev. O- Infant with stable temp on servo heated isolette.\nInfant awake at cares and making some sucking attempts on\npacifier. A- AGA P- Support dev. be ready for air\nisolette /dressed and swaddled.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-13 00:00:00.000", "description": "Report", "row_id": 1997163, "text": "Neonatology note\n26 d.o\nin RA, no spells\nwt= 2055 gm +25\n150 cc/kg/d with EBM 26\n\n, pale pink\nRR with soft murmur\nclear lungs\nabdomen soft\n\nA: ex 32 wks GA, growing preemie\nP: continue current management.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-13 00:00:00.000", "description": "Report", "row_id": 1997164, "text": "Co-worker note 7a-7p\n\n\n#2. FEN: Wt 2055, ^25g. TF: 150cc/k/d of BM/PE 26 with PM=\n51cc q4hr. Infant alt PO/PG. PO'ed 25cc at 1330. Requires\nfrequent burbing and encouragement, tires easily with\nbottling. No spits, min asp. Abd, benign, no loops, +BS. ABD\ngirth stable at 27.0-27.5cm. V&S, guaic neg.\n\n#3. PAR: Mom in to visit today after 1330 cares. Very\nloving, asked appropriate questions. Mom stated she may be\nin for the 2130cares.\n\n#4. G&D: Infant remains in an OAC with stable temps\n(98.1-98.8). AFSF, PFSF. Wakes for feeds and is quietly\n with cares. AGA. Will continue to monitor and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-13 00:00:00.000", "description": "Report", "row_id": 1997165, "text": "Co-worker note 7a-7p\nI examined infant and agree with Patient Care Assistant's note for this shift.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-14 00:00:00.000", "description": "Report", "row_id": 1997166, "text": "NPN 1900-0700\n\n#2 Alt. in Nutrition\nO: TF=150cc/kg=53cc BM26/PM or PE26/PM Q 4 hrs. Abd. is round, soft, with + BS, no loops. Girth 26-27 cms. .1-.2cc aspirates. No spits. Voiding QS, no stools. Breastfed X 1 with mom and took full volume by bottle after. Attempted to PO another feeding and took only 25cc. Gavage fed remainder of bottle and other feeding. Wt. 2100 gms. up 45gms.\nA: Tolerating feeds, learning to PO, gaining wt.\nP: Continue with present feeding plan, alternating PO/PG. Follow daily wts.\n\n#3 Alt. in Parenting\nO: Mom in for 2130 feeding. Updated. She is independent with infant's care and feeding.\nA: Involved, loving mom\nP: informed and support.\n\n#4 Alt. in Development\nO: Maintaining temp in open crib, , positioned on side with boundaries in place. Not waking for feeds, but with cares. Taking some POs. Still needs some gavage. No spells.\nA: Appropriate for GA\nP: Continue to support developmental needs.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-14 00:00:00.000", "description": "Report", "row_id": 1997167, "text": "Neonatology\nDoing well RA. No spells. Comfortabel appearing.\n\nWT 2100 up 45. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen bneign. Await5ing maturation of feeds. Still erquiring sig amounts of gavage. PO improving slowly\n\nTemp stable in open crib.\n\nContinue to await maturation of feeds\n" }, { "category": "Nursing/other", "chartdate": "2159-07-14 00:00:00.000", "description": "Report", "row_id": 1997168, "text": " Physical Exam\n\nPE: pale pink, , breath sounds clear/equal with easy WOB, no murmur, abd soft, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-26 00:00:00.000", "description": "Report", "row_id": 1997100, "text": "NURSING PROGRESS NOTE\n\n\n2 - FEN - TF=150CC/K OF BM/PE26. PT NG FEEDS OVER 40\nMIN. SPITS, MIN ASPIRATES. ABD SOFT, +BS, NO LOOPS.\nAG=21CM. PT VOIDING, NO STOOLS. WT=1.445 (NO CHANGE)\n\n3 - PARENT - MOM IN TO VISIT AND HOLD. ASSISTING W/ CARES.\nUPDATED\n\n4 - G/D - TEMP STABLE IN AIR MODE ISOLETTE - WEANING. PT\n. PASSIVE, EYES OPEN W/ CARES. AFOF\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-26 00:00:00.000", "description": "Report", "row_id": 1997101, "text": "Neonatology note\n9 d.o wt= 1445 gm\n150 ml/kg/d with 26 cal/oz, pg\nin RA, no spells.\n\nAFOF.\nClear lung\nRRR with no murmur.\nAbdomen soft with no mass palpable, umbilical cutis\n\nA: ex 32 wks GA,\nP:add promod, continue current management.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-22 00:00:00.000", "description": "Report", "row_id": 1997087, "text": "Case Management Note\nFor d'c planning purposes, if baby requires home care, can use Care Group VNA as this VNA is following mom as well. Mother was in agreement w/Care Group (). I will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-22 00:00:00.000", "description": "Report", "row_id": 1997088, "text": "Rehab/OT\n\n seen today for care plan. Observational eval completed and posted at the bedside. Please refer to for details and recommendations. Met mom to review plan and discuss the role of OT. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-23 00:00:00.000", "description": "Report", "row_id": 1997089, "text": "Nursing progress note\n\n\n#2 O: Wgt down 15 gms. Total fluids remain 150cc/k/d. PG\nfeeds advanced to 150cc/k/d at 2AM. IV is now hep locked.\nAbd soft with active bowel sounds & no loops. Stool is\nguaiac neg. UOP is 2.7cc/k/h. DS to be done. A: Tolerating\nfeeds. P: Cont to assess.\n#4 O: Temp stable in servo isolette. with cares. Sucks\non pacifier. A: AGA. P: Cont to assess.\n#6 O: Remains sl jaundiced, under single phototx with eye\npatches on. A: Resolving hyperbili. P: Cont to assess.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-23 00:00:00.000", "description": "Report", "row_id": 1997090, "text": "Neo attending\nDOL 6 for this infant delivered at 32 week infant.In RA.\nWeight: 1420 grams on TF of 150 cc/kg/day of PE20\nContinues on phototx for physiologic jaundice with a bili of 7.4/0.5 today.\n\nRRR + m\nClear BS\nSoft abdomen\n+ 2 pulses\n\nA/P: Preterm infant with physiologic jaundice. Immature feeding skills. Will d/c phototx and recheck bili on Sunday\n" }, { "category": "Nursing/other", "chartdate": "2159-06-23 00:00:00.000", "description": "Report", "row_id": 1997091, "text": " Note\n\nFamily Meeting\n\nMet with in the family room today. See Family meeting checklist for issues discussed. Asked appropirate questions. Still seem overwhelmed. Pediatrician is .\n" }, { "category": "Nursing/other", "chartdate": "2159-06-23 00:00:00.000", "description": "Report", "row_id": 1997092, "text": "NICU Nursing Progress Note\n\nNUTRITION\nO: Remains on full feeds (150cc/kg/day) of 20cal BM/PE by\ngavage every 4 hrs. Abd exam benign. Voiding and passing\nheme neg stool. Dextrostix=65. Spitting small amt\nnon-bilious occasionally.\nHeparin lock d/c'd.\nA: No evidence of intolerance to feeding advancement.\nP: Assess.\n\nBILI\nO: Bili light stopped at 1300. Infant is slightly jaundiced.\n\nA: Hyperbili of prematurity.\nP: Check serum bili in a.m.\n\nDEVELOPMENT\nO: Temp stable in servo isolette. Active and with\ncares. Sucking on pacifier.\nA; Appropriate behavior.\nP; Support development.\n\nPARENTING\nO: in to visit. Family meeting held as note\nabove. verbalize comfrot level with infant's plan of\ncare and progress. Mom is pumping and obtaining BM. Tote bag\ngiven to her.\nA: Involved .\nP: Support and keep informed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-24 00:00:00.000", "description": "Report", "row_id": 1997093, "text": "Nursing progress note\n\n\n#2 O: Wgt up 15 gms. Remains on 150cc/k/d. Inc to 22 cal\nformula at 9:30PM. Abd soft with active bowel sounds & no\nloops. Voiding & stooling. Stool was guaiac neg. Max\naspirate was 4cc. A: tolerating feeds & gaining wgt. P: Cont\nto assess.\n#3 O: No contact this shift.\n#4 O: Remains in servo isolette nested in sheepskin. Quietly\n with cares. Sucks on pacifier. A: Stable. P: Cont to\nassess.\n#6 O: Phototherapy was d/c'd yesterday. Sl jaundiced. A:\nResolving hyperbili. P: Rebound bili to be drawn this AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-18 00:00:00.000", "description": "Report", "row_id": 1997184, "text": "Nursing Discharge note\n\n\n1. FEN: TF remain at min of 130 cc/kg/day of E24 or BM24\nwith enfamil powder. Infant was bottling between 50-55 cc q\n4 hours with good coordination. Tolerating feedings well;\nabd exam benign, no spits, AG stable, and min asp. Voiding\nqs and heme neg. Infant remains on ferinsol.\nProblem resolved.\n\n2. G/D: Temps stable in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. Problem resolved.\n\n3. /Discharge: Mom in for 1300 cares. Mother\nindependently fed infant and performed cares. Excited that\ninfant was coming home today. Discharge teaching was\ncompleted including; when to call pedi, protecting from\ninfection, feeding and bowel/bladder patterns, back to\nsleep, and car seat safety. Recipe for BM24 and E24 was\nreviewed with mother and she verbalized understanding.\nMother gave infant dose of ferinsol appropriately. Pedi\nappt is scheduled with Dr. of Pediatrics\non Friday at 1100. Caregroup VNA was contact and will see\ninfant tomorrow. Referral was completed and faxed.\nDischarge order was written. Tags were checked with mother.\nMother placed infant in car seat. Infant was discharged home\nwith at 1550.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-21 00:00:00.000", "description": "Report", "row_id": 1997083, "text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable in room air. Breath sounds clear and equal. NO spells over last 24 hours. She is tolerating advancing feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Bili today 13.7 /0.5. Started under double phototherapy today. Stable temp in heated isolette. Mom in to visit this afternoon. Held . Will plan for family meeting today or tomorrow. Please refer to neonatology attending note or detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-21 00:00:00.000", "description": "Report", "row_id": 1997084, "text": "nursing note\n\n\n#2 FEN O: Received child on TF of140cc/k. today child\nincreased to 150cc.k. Currently child receiving 105cc/k of\npe 20 and 45cc/k of d10w with lytes as ordered. Child\nincreased feeds 15cc/k at the 1200/2400 feeds.\nTolerating feeds well over 30 minutes. No spits, residuals\nnoted. Girth remains stable. No loops noted. Child voiding\nand stooling well. NG secure and placement verified. P: Will\ncontinue to increase feeds as tolerated. Will continue with\nplan.\n#3 Parenting O: mom in today to visit with the child. Given\nupdate. Talked with a little, held the child. Talked\nwith SW and received discount parking slip. Mom interacted\nwell with child while holding her. P: Will continue to\nsupport their coping skills.\n#4 G+D O: Child continues in isolette on servo temp. Temp\nslightly increased this am due to bili lights. Reset servo\ntemp and temp now WNL. Child and active with cares.\nCalms with the pacifier. P: Will continue to support the\nchild's coping skills.\nBili O: Child under double PTX as ordered. Eyes remain\ncovered. P :Will obtain bili level in the am. Keep eyes\ncovered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-22 00:00:00.000", "description": "Report", "row_id": 1997085, "text": "NURSING PROGRESS NOTE\n\nRESP/CV: INFANT REMAINS IN RA WITH 02 SATS >95%. RR 40-60'S WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. BS CL&= WITH GOOD AERATION AND CHEST MOVEMENT. NO A&B'S TONIGHT. HR 130-160'S WITHOUT AUDIBLE MURMER. COLOR SL JAUNDICE/PALE/PINK WITH ADEQUATE PERFUSION.\nBP 72/41-52.\n\nFEN: WEIGHT 1435GMS, DOWN 15GMS TONIGHT. TOTAL FLUIDS MAINTAINED AT 150CC/KG/D. ENTERAL FEEDS ADVANCED TO 120CC/KG/D OF PE20CAL AND PIV DECREASED TO 30CC/KG/D. ABD SOFT, PINK WITH STABLE GIRTH AND +BS. VOIDING AND STOOLING WNL. NO EMESIS OR RESIDUALS NOTED TONIGHT.\n\nBILI: REMAINS UNDER DOUBLE PHOTOTHERAPY AND BILI PNDING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-22 00:00:00.000", "description": "Report", "row_id": 1997086, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nFEN\nO: TF of 150cc/k/d. PIV D10w with 2 meq NaCl, 1 meq KCl\ninfusing at 15cc/k/d. Enteral feeds are at 135cc/k/d of PE\n20 gavaged over 40\". Abd. pink, no loops, active bs.\nVoiding/ stooling heme (-). No spits. min asp. A: Stable. p:\ncont to follow and adv feeds 15cc/k as tolerated.\nGD\nO: Temp stable in servo controlled isolette, active and\n with cares. MAE. Font soft, flat. Calms with\ncontainment and pacifier. A: AGA p: cont to support dev.\nmilestones.\nBili\nO: Under single photo tx. with eye shields on. P: cont to\nprovide photo tx as ordered. Probable d/c of photo tx when\nreaches full feeds with rebound bili on Monday.\nParenting\nNo contact from thus far today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-20 00:00:00.000", "description": "Report", "row_id": 1997077, "text": "Case Management Note\nMet w/mom who is on 5 Stonemen following MICU stay. D'c goal is home. Mom wants to breast feed & a breast pump was ordered for mom today Medical . For home services can use Care Group or VNA . Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-20 00:00:00.000", "description": "Report", "row_id": 1997078, "text": "Neonatology Attending\n\nDay 3\n\nRemains in RA. RR 40-70s. Saturations in mid 90s. Occasional drifts. No bradycardia. No murmur. HR 140-160s. BP mean 42. Bilirubin 7.6/0.4. Weight 1495 gms (-10). TF at 120 cc/kg/d. IV dextrose with lytes at 60 cc/kg/d. Enteral feeds at 60 cc/kg/d. Stable temperature. Mother transferred out of MICU.\n\nMild immaturity of breathing control. Will continue to monitor. Tolerating feeding advance well. Will continue. Will keep family up to date.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-20 00:00:00.000", "description": "Report", "row_id": 1997079, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\naFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. pink, ruddy and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-20 00:00:00.000", "description": "Report", "row_id": 1997080, "text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nFN\nO: is on TF of 140cc/k/ d of IV: 65cc/k/d D10 2meq\nof NaCl, 1 meq of KCl. infusing through PIV. PO: 75cc/k/d of\nPe 20 gavaged over 30\". Abd. pink, no loops, active bs.\nVoiding/ stooling mec stool. No spits,min asp. A: Stable. P:\ncont to adv. feeds 15cc/k as tolerated.\nGD\nO: Temp stable in servo controlled isolette, active and\n with cares. Font soft, flat. MAE. Calms with\ncontainment and pacifier. A: AGA P: cont to support\ndev.milestones.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-21 00:00:00.000", "description": "Report", "row_id": 1997081, "text": "NICU NPN 1900-0700\n\n\nFEN O: Tf remain at 140cc/k/d. Tolerating advancing feeds of\npe20 well. currently at 90cc/k/d. IVF of d10 with lytes,\ninfusing through new piv well. Voiding and stooling,\nabdominal exam benign, no spits, min ngt aspirates. Weight\n1450g, down 45g.\n\nParenting O: No contact from overnight.\n\n#4 G&D O: temps are stable nested on sheepskin, in servo\nisolette. baby is and active with cares, sleeps well\nin between cares. Fontanells are soft and flat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-21 00:00:00.000", "description": "Report", "row_id": 1997082, "text": "Neonatology Attending Progress Note\nNow day of life 4 for this 32 week gestation infant.\nCardiorespiratory status stable in RA with RR 50-70s.\nHR 120-160s\nBP 57/37 44\nNo apnea and bradycardia.\n\nWt. 1450gm down 45gm on 140cc/kg/d of TF - feedings up to 90cc/kg/d of PE are well tolerated thus far.\nNormal urine and stool output.\nDS 70.\n\n\nBili 13.7/0.5 - on double phototherapy.\nMother is A pos.\nHeme - plats 151,000 follow-up\n\nAssessment/plan:\n32 week gestation female with steady progress - will continue with advancement of feedings.\nFU bili planned for tomorrow.\nWill need to set up a family meeting when mother is well enough.\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-17 00:00:00.000", "description": "Report", "row_id": 1997181, "text": "NPN 0700-1900\n\n\n1. FEN: TF remain at min of 130 cc/kg/day of BM/E24. Infant\nis adlib bottling q 4 hours. Infant has bottled between\n40-50 cc thus far with good coordination. Tolerating\nfeedings well; abd exam benign, no spits, AG stable, and min\nasp. Voiding qs and no stool noted thus far. Infant\ncontinues on ferinsol. P: Cont. to support nutritional\nneeds.\n\n2. : Mom visited in between cares and held infant.\nUpdated at bedside on infant's condition and plan of care.\nAsking appropriate questions. Excited about potential\ndischarge tomorrow. Informed mother that infant would be\nretested in her car seat tonight. Reviewed ferinsol\nadministration and the recipe for 24 calorie\nbreastmilk/enfamil with mom. Mother verbalized\nunderstanding. VNA was contact and page 1 and 2\nwere started. Loving, involved . P: Cont. to support\nand update .\n\n3. G/D: Temps stable in open crib. and active\nwith cares. Settles well in between cares. Appropriately\nbrings hands to face and sucks on pacifier to comfort self.\nWakes for feedings q 4 hours. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-18 00:00:00.000", "description": "Report", "row_id": 1997182, "text": "NPNP11P-7A\n\n\n#2: TFMIN130CC.KG.D, INFANT TOOK IN 129CC/KG/D. WAKING VERY\n4-4.5HRS TO FEED, TKAING 40-50CC. ABDOMEN I BENINGN, VOIDING\nNAD . WT UP20GMS. NO PITS. A:TOLERATING FEEDS. P:\nCONT WITH PLAN.\n#3: TEMP STABLE IN OPEN CRIB, FONTNAELLES ARE SOFT AND FLAT.\n AND ACTIVE WITH CARES, SLEEPING WELL. INFANT BRINGS\nHANDS TO FACE, LIKES PACIFIER. PASSED CAR SEAT TEST THIS\nEVENING. A: AGA> P: CONT TO SUPPORT.\n#4: NO CONTACT FROM AT THIS WRITING.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-18 00:00:00.000", "description": "Report", "row_id": 1997183, "text": "Neonatology note\n31 d.o\nin RA, no spells\nwt= 2220 gm + 20\n128 cc/kg/d with EBM 24\n\n, clear lung\nrr with no murmur\nabdomen soft\n\nA: ex 32 wks GA, SGA\nP: may consider d/c home if mother can demonstrate that she can feed infant with the minimum amount required.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-16 00:00:00.000", "description": "Report", "row_id": 1997176, "text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 29\nWt: 2175 g (+35)(~10th to 25th %ile); birth wt: 1605 g. Average wt gain over past wk ~19 g/kg/d.\nHC: 31.5 cm (~25th %ile); last: 31.25 cm\nLN: 44 cm (~10th to 25th %ile); last: 42.5 cm\n noted.\nNutrition: 150 cc/kg/d BM/PE 24, po x past 24 hrs. Average of past 3 d intake ~141 cc/kg/d. Feeds just decreased yesterda. Based on average intake, projected intake for next 24 hrs ~113 kcal/kg/d, and ~3.1 to 3.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range except slightly elevated Ca++ to 11.1; discussed w/ team and not felt to warrant any action in adjusting feeds. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is meeting recommendations for wt gain. HC gain is not meeting recommended ~0.5 to 1 cm/wk, and LN gain is exceeding recommended ~1 cm/wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-16 00:00:00.000", "description": "Report", "row_id": 1997177, "text": "NPN DAYS\n\n\nFEN: TF min decreased to 130cc/kg/day=47cc q4hrs. Taking all\npo's. Has taken 52cc, 40cc po so far this shift. Voiding, no\nstool. No spits. Belly benign. Soft umbilical hernia. Will\ncontinue to encourage po feeds to meet minimum intake.\n\nAlt in Parenting: No contact so far this shift.\n\nGrowth and Dev: Temp stable in open crib while . Not\nwaking on her own prior to feeds. Quietly with cares.\nMom is to bring in the baby's carseat for test.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-17 00:00:00.000", "description": "Report", "row_id": 1997178, "text": "npn 1900-0700\n\n\n2: fen\ncurrent weight 2200gms up 25. total fluids remain at\n130cc/kilo/day of bm/pe 24. no breast milk at this time.\ntolerating feeds well. all po feeds. infant taking 45 and\n50cc thus far this shift. infant requies 47cc q 4 hours.\nno spits. abd soft with no loops. voiding, no stool thus far\nthis shift. umbilical hernia soft. continue to encourage all\npo feeds.\n\n3: parenting\nno contact this shift thus far with .\n\n4: g/d\ntemps stable in an open crib. and active with cares.\nsleeps well inbetween. wakes for feeds this shift. sucks\nvigorously on pacifier. brings hands to face. aga. continue\nto monitor for developmental milestones.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-17 00:00:00.000", "description": "Report", "row_id": 1997179, "text": "Neonatology note\n30 d.o\nin RA, no spells\nwt= 2200 gm +25\nEBM 24 at 135 cc/kg/d\n\n\nRR with no murmur\nmild retraction, clear lungs\nAbdomen soft\n\nA: ex 32 wks GA, SGA, growing preemie\nP: may consider d/c home soon\n" }, { "category": "Nursing/other", "chartdate": "2159-07-17 00:00:00.000", "description": "Report", "row_id": 1997180, "text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, in an open crib, , sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-19 00:00:00.000", "description": "Report", "row_id": 1997073, "text": "Clinical Nutrition\nO:\n32 wk CGA BG on DOL 2.\nBirth wt: 1605 g (~25th to 50th %ile); current wt: 1505 g (-100)\nHC: 29 cm (~25th %ile)\nLN: 42 cm (~25th to 50th %ile)\nLabs not due\nNutrition: 120 cc/kg/d TF. IVF of D10 W infusing via PIV. EN started on DOL 1; currently on 30 cc/kg/PE 20, advancing 15 cc/kg/. Projected intake for next 24 hrs ~30 kcal/kg/d, 0.9 g pro/kg/d, and 1.5 g fat/kg/d.\nGI: Abdomen benign; passing meconium stool.\n\nA/Goals:\nTolerating feeds so far without GI problems; advancing slowly and monitoring closely for signs of feeding intolerance. Labs not due. Tolerating IVF w/ good BS control. Initial goal for feeds is ~150 cc/kg/d PE/BM 24, providing ~120 kcal/kg/d and ~3.3 to 3.6 g pro/kg/d. Appropriate to add Fe supps when feeds reach initial goal. Further increases in feeds as per growth and tolerance. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-19 00:00:00.000", "description": "Report", "row_id": 1997074, "text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures overriding. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. infant active with exam.\n" }, { "category": "Nursing/other", "chartdate": "2159-06-19 00:00:00.000", "description": "Report", "row_id": 1997075, "text": "Nursing Progress Note\n\n1 Infant with Potential Sepsis\n5 Respiratory-32+ weeks\n\n#1 O: 48h blood cx neg, antibiotics dc'd. P: resolve issue\n#2 O: TF inc to 120cc/k/d enteral and IV. Presently 45cc/k/d\nPE20/BM20 tol well on pump over 30mins w/o spits or asp. IV\nnow D10W w/lytes at 75cc/k/d via PIV, infusing well. Abd\nbenign, vdg per flow sheet, no stool this shift. A: tol inc\nfeeds well so far P: adv 15cck/ as tol.\n#3 O: mom called for update, feeling better and being\ntransfered to post-partum floor. will be up to visit later.\n#4 O: temp stable on servo in heated isolette. intermittent\npacifier use, nested w/sheepshin, boundries A: AGA P: cont\nto assess and support developmentally\n#5 O: sats 94-100% in room air, mild SCR, RR 40's-50's. no\napnea or bradycardias noted this shift. P: monitor and\ndocument any episodes of apnea/bradys. resolve resp issue.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n 5 Respiratory-32+ weeks; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2159-06-20 00:00:00.000", "description": "Report", "row_id": 1997076, "text": "NICU NPN 1900-0700\n\n\nFEN O: Tf remain at 120cc/k/d. Tolerating advancing feeds of\npe20 well, currently at 60cc/k/d. Iv of d10 with lytes\ninfusing into piv at 60cc/k/d. Abdomen is soft, and flat, bs\nare active, d sticks are stable, no ngt aspirates or spits.\nWeight 1495g, down 10g.\n\nParenting O: Dad in to visit x1.\n\nG&D O: temps are stable, nested on sheepskin, in servo\nisolette. Baby is and active with cares, sleeps well\nin between cares. Fontanells are soft and flat. She takes\npacifier and brings hands to face.\n\nResp O: o2 sats 92-100%, lungs are clear, rr 40-70's, mild\nsc/ic retractions. No bradys to time this shift, no murmur,\nbp's stable.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-14 00:00:00.000", "description": "Report", "row_id": 1997169, "text": "NPN 0700-1900\n\n\n#2 FEN S/O: TF 150cc/k/d. Infant to get pe26 with promod,\n53cc q4h po/pg. Infant bottled 53cc so far this shift.\nAbdomen is benign, no aspirates or spits. Infant is voiding\nand . A: Stable P: Continue to encourage po feeds.\n\n#3 Parenting S/O: No contact with yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#4 DEV S/O: Infant maintaining temp in OAC. and active\nwith cares. Stirring before feeds. Sucks on pacifier. A: AGA\nP: Continue to support development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-15 00:00:00.000", "description": "Report", "row_id": 1997170, "text": "NPN\n\n\n#2\nInfant continues on TF=150cc/k of PE26 with promad q4 hours.\nInfant has bottled her first two feedings tonight and has\ntaken the entire volume. No spits noted. Abd is soft and\nround; voiding/no stools noted. Wt is up 40gms-2140.\n\n#3\nNo contact tonight thus far from the .\n\n#4\nInfant remains in an open crib with boundaries.\nInfant is with cares and her temp has been stable.\nInfant is waking for some feeds; bottling appears to be\nimproving.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-15 00:00:00.000", "description": "Report", "row_id": 1997171, "text": " Physical Exam\n\nPE: pale pink, , breath sounds clear/equal with easy WOB, soft SEM mid alSB, normal pulses, abd soft, non distended, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-15 00:00:00.000", "description": "Report", "row_id": 1997172, "text": "Neonatology Attending Progress Note\n\nNow day of life 28, CA .\nCurrently in RA with RR 50-60s\nNo apnea and bradycardia.\nHR 150s\nBP 77/40 61\n\nWt. 2140gm up 40gm on 150cc/kg/d of PE26 with Promod\nFeedings are well tolerated by bottle.\nNo gavage feedings needed in past day.\n\nDischarge teaching/screenine is in progress.\n\nAssessment/plan:\nVery nice progress continues - will continue to monitor feeding maturity.\nWill continue with discharge preparations.\nFeeding caloric density to be decreased to PE24 without Promod.\n" }, { "category": "Nursing/other", "chartdate": "2159-07-15 00:00:00.000", "description": "Report", "row_id": 1997173, "text": "NPN 0700-1900\n\n\n#1 FEN S/O: TF 150cc/k/d. Infant to get pe 24 now, 54 cc q4h\npo/pg. Infant bottled 45, and 50cc today. Abdomen benign,\nvoiding, no stools today. Minimal aspirates, no spits. A:\nTolerating po feeds. P: Continue to encourage po feeds.\n\n#3 S/O: No contact with yet this shift. A:\nUnable to assess. P: Continue to support.\n\n#4 DEV S/O: Maintaining temps in OAC. and active with\ncares. Waking for feeds. To have hepb at next care today. A:\nAGA P: Continue to support dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-16 00:00:00.000", "description": "Report", "row_id": 1997174, "text": "NURSING PROGRESS NOTE\n\n\n2 - FEN - TF=150CC/K OF BM/PE24. PT TAKING 55-60CC PO, \nFEEDS, NO SPITS. WAKING FOR FEEDS./ ABD SOFT, +BS. PT\nVOIDING, NO STOOLS. WT-=2.175(+35)\n\n3 - PARENT - MOM IN TO VISIT AT BEGINNING OF NIGHT.\nUPDATED. SIGNING CONSENT FOR HEP B VACCINE\n\n4 - TEMP STABLE. IN OPEN CRIB. AND ACTIVE.\nHEP B GIVEN IN LEFT THIGH\n\n\n" }, { "category": "Nursing/other", "chartdate": "2159-07-16 00:00:00.000", "description": "Report", "row_id": 1997175, "text": "Neonatology note\n29 d.o\nin RA, no spells\nwt= 2175 gm +35\n150 cc/kg/d with EBM/PE 24, all po nippling\n\n, pink\nRR with intermittent murmur\nClaear lungs\nabdomen soft\n\nA: ex 32 wks GA, SGA\nP: continue to monitor for feeding\n" } ]

[ { "category": "Radiology", "chartdate": "2161-08-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969520, "text": " 2:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval ET tube position\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB s/p endotracheal intubation\n\n REASON FOR THIS EXAMINATION:\n please eval ET tube position\n ______________________________________________________________________________\n FINAL REPORT\n Chest single view on .\n\n HISTORY: Shortness of breath.\n\n FINDINGS: The ET tube tip is 3 cm above the carina. There is blunting of the\n left CP angle suggesting a small effusion or volume loss in this region.\n There is right IJ line with tip in the SVC. Otherwise, the lungs are clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969663, "text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for changes\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated\n REASON FOR THIS EXAMINATION:\n eval for changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: Chest pain, shortness of breath.\n\n REFERENCE EXAM: .\n\n FINDINGS: The IJ line has been removed, the ET tube is 2.5 cm above the\n carina. There is dense opacity in the retrocardiac region that is new\n compared to the prior study that probably represents some volume\n loss/effusion/infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969815, "text": " 10:06 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval PICC placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated s/p PICC placement\n\n REASON FOR THIS EXAMINATION:\n eval PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest, \n\n Comparison to previous study of earlier the same date.\n\n INDICATION: PICC line placement.\n\n A left PICC line courses from the axilla to terminate below the medial third\n of the left clavicle, probably within the proximal left subclavian vein, but\n difficult to fully assess due to marked patient rotation. This finding has\n been communicated to the venous access nurse caring for the patient on the\n date of the study.\n\n New in the interval are bilateral perihilar opacities suggestive of pulmonary\n edema, as well as increasing small left and right pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969764, "text": " 2:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Intubation. Chest pain and shortness of breath.\n\n Endotracheal tube tip remains in standard position terminating about 3 cm\n above the carina, but the cuff appears overdistended. Cardiac and mediastinal\n contours are stable in appearance allowing for positional differences. Basilar\n opacities, likely a combination of atelectasis and effusion, show slight\n improvement on the left and slight worsening on the right.\n\n" }, { "category": "Radiology", "chartdate": "2161-08-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970264, "text": " 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated, with PNA, to be\n extubated in AM\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Pneumonia and intubation.\n\n Endotracheal tube is 3 cm above carina. Distal end of NG tube overlies distal\n body of stomach. Subclavian CV line probably in distal SVC but overlies spine\n and difficult to accurately localize on this film. Compared with the prior\n study of there has been significant reduction in the r\n ightsidedsided pulmonary opacity probably due to a combination of layering\n pleural effusion and pulmonary consolidation. There is some persistent right\n perihilar opacity. In addition there is opacity at the left lung base\n consistent with atelectasis and/or consolidation in the left lower lobe,\n essentially unchanged since the previous film of . Cannot rule\n out a small left pleural effusion. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2161-08-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970548, "text": " 4:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for edema, infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated, with PNA, volume\n overload\n REASON FOR THIS EXAMINATION:\n eval for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n INDICATION: Chest pain, shortness of breath.\n\n A single AP view of the chest is obtained on at 04:50 hours and\n compared with the prior morning's radiograph. There appears to be improvement\n in the appearance of the mild pulmonary edema since the prior examination.\n Persistent increased retrocardiac density on the left side likely represents\n superimposed airspace disease/atelectasis. Layering bilateral pleural\n effusions are a possibility. Right-sided subclavian line is unchanged in\n position.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969934, "text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for changes\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated\n REASON FOR THIS EXAMINATION:\n eval for changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:44 A.M. .\n\n HISTORY: Chest pain and shortness of breath. GI bleed.\n\n IMPRESSION: AP chest compared to through 16:\n\n Right perihilar consolidation continues to increase, consistent with\n progressive aspiration pneumonia. Atelectasis at the left base developed\n between and 15 and is subsequently stable. Heart size is top normal.\n Pulmonary vascular engorgement suggests cardiac decompensation. Small\n bilateral pleural effusions are stable. ET tube is in standard placement,\n though the cuff distends the trachea locally and should be evaluated to see if\n this is the desired situation. Nasogastric tube ends in the stomach. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969897, "text": " 6:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval position of the oGT placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated , s/b OGT\n placement\n REASON FOR THIS EXAMINATION:\n please eval position of the oGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Previous study of earlier of the same date.\n\n INDICATION: Orogastric tube placement.\n\n Orogastric tube terminates below the diaphragm with sideport in the body of\n the stomach. Endotracheal tube remains in standard position, but there is\n persistent overdistension of the cuff. Perihilar and basilar opacities appear\n slightly improved as well as bilateral effusions. Left PICC line has been\n withdrawn and now terminates in the left axilla.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-07-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969506, "text": " 8:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for acute cardiopulm process\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB\n REASON FOR THIS EXAMINATION:\n please eval for acute cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old female with chest pain, shortness of breath and GI\n bleed. Evaluate for cardiopulmonary process.\n\n Comparison is made to prior chest radiograph dated , and CT\n examination dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: The lungs are clear. Cardiomediastinal silhouette and hilar\n contours are within normal limits with unchanged appearance to a slightly\n tortuous calcified thoracic aorta. No evidence of pulmonary edema,\n pneumothorax or pleural effusion. A right internal jugular central venous\n catheter terminates within the right brachiocephalic confluence. Please note\n overall examination is slightly limited due to patient rotation.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 969577, "text": " 10:27 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with h/o CAD presented with GI bleeding in the setting of\n anticoagulation, now hypertensive, bradycardic, facial droop\n REASON FOR THIS EXAMINATION:\n eval for bleed\n CONTRAINDICATIONS for IV CONTRAST:\n not needed\n ______________________________________________________________________________\n WET READ: JWK SAT 11:41 AM\n Equivocal mild loss of sulcal differentiation in left frontal/parietal lobes\n should be correlated with clinical symptoms as no localizing information was\n provided.\n\n MRI should be performed to further evaluate for possible left frontal/parietal\n lobe infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with history of CAD, presenting with GI\n bleeding in the setting of anticoagulation. The patient is now hypertensive\n and bradycardic.\n\n NON-CONTRAST HEAD CT SCAN.\n\n FINDINGS: There is no hemorrhage, mass effect, or shift of the normally\n midline structures. Equivocal loss of the sulci within the left\n frontal/parietal lobe may represent early infarction. Minimal periventricular\n white matter hypodensity is consistent with chronic microvascular ischemia.\n There is no hydrocephalus. The overlying soft tissues and osseous structures\n are unremarkable.\n\n Visualized paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION:\n\n 1. Equivocal loss of focal differentiation in the left frontal/parietal lobes\n may signify early infarction. The findings are subtle and therefore, this\n should be correlated with the patient's clinical symptoms as no localizing\n history was provided. If there are localizing signs, MRI with diffusion can\n help.\n\n 2. No hemorrahge or mass efffect.\n\n" }, { "category": "Radiology", "chartdate": "2161-08-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970094, "text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:47 a.m., \n\n HISTORY: Chest pain. GI bleed. Intubated.\n\n IMPRESSION: AP chest compared to through 17:\n\n Consolidation predominantly in the right lung, which developed after ,\n continues to progress accompanied by increasing moderate right pleural\n effusion. There may also be left perihilar consolidation, and borderline\n interstitial edema. The heart is moderately enlarged but unchanged. ET tube\n is in standard placement, right subclavian line ends in the mid-SVC and a\n nasogastric tube passes below the diaphragm and out of view. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 970055, "text": " 5:25 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate SCL placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated, RSCL placed\n\n REASON FOR THIS EXAMINATION:\n please evaluate SCL placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female with chest pain, shortness of breath, and GI\n bleed, now status post placement of right subclavian line. Please evaluate\n line placement.\n\n FINDINGS: Single portable semi-upright chest radiograph is reviewed and\n compared to same day, 4:44 a.m.\n\n There has been interval placement of right subclavian approach central venous\n catheter, with tip projecting over the mid SVC. Endotracheal tube is roughly\n 2.6 cm above the carina, and the cuff continues to locally distend to the\n trachea. Nasogastric tube extends below the diaphragm and out of view.\n Diffuse opacity within the right lung is slightly worse, and there remains a\n small left pleural effusion and adjacent atelectasis. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. Interval placement of right subclavian approach central venous catheter,\n with tip projecting over the mid SVC.\n 2. Slight interval worsening of right airspace opacity, could be consistent\n with either evolving aspiration pneumonia, or asymmetric pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2161-08-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970633, "text": " 5:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PT.DO NOT HAVE PICC LINE. CXR FOR CVL POSITION\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman pulled PICC\n REASON FOR THIS EXAMINATION:\n PICC position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Central venous line placed, check position.\n\n CHEST\n\n The tip of the right subclavian line lies in the upper SVC. No pneumothorax\n is present. Bilateral pleural effusions are again seen.\n\n IMPRESSION: Tip of PICC line in upper SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-09 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 970687, "text": " 6:51 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: stroke?\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with dysarthria, rt arm weakness 2-3 days after extubation\n and large GIB.\n REASON FOR THIS EXAMINATION:\n stroke?\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE MRI OF THE BRAIN WITHOUT GADOLINIUM. ROUTINE MRA OF THE BRAIN USING\n 3D TIME-OF-FLIGHT TECHNIQUE.\n\n HISTORY: Dysarthria and right arm weakness after extubation and large GI\n bleed, question stroke.\n\n FINDINGS:\n\n Comparison is made with CT head from .\n\n There is no acute stroke noted on the diffusion-weighted imaging. There are\n moderate small vessel ischemic sequela in the subcortical and periventricular\n white matter. There is age-appropriate volume loss.\n\n Xanthogranulomatous changes of the choroid plexus are seen bilaterally.\n\n Mild scattered bilateral mastoid opacification is noted. There is mild\n sphenoid sinus mucosal thickening.\n\n Evaluation of the MRA demonstrates patency of the anterior and posterior\n circulations. There is no aneurysm or stenosis within limits of this\n examination.\n\n\n Impression:\n\n No acute infarct. Small vessel ischemic disease.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-10 00:00:00.000", "description": "PICC W/O PORT", "row_id": 970721, "text": " 7:36 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with enterococcal bacteremia, needs longterm antibiosis.\n has difficult peripheral access\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. , and performed the procedure. Dr.\n , the attending radiologist, was present and supervised throughout the\n entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single-lumen PICC line measuring 46 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4F single-\n lumen PICC line placement via the left brachial venous approach. Final\n internal length is 46 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-08-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970407, "text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrate, edema\n Admitting Diagnosis: CORONARY ARTERY DISEASE;CHEST PAIN;DYSPNEA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with chest pain, sob, with GIB, intubated, with PNA, volume\n overload\n REASON FOR THIS EXAMINATION:\n eval infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:39 A.M., \n\n HISTORY: Chest pain, shortness of breath, pneumonia volume overload.\n\n IMPRESSION: AP chest compared to through 19:\n\n Mild pulmonary edema persists but right-sided perihilar consolidation and\n right pleural effusion are improving. Heart size is normal. ET tube is in\n standard placement, nasogastric tube passes below the diaphragm and out of\n view, and a right subclavian line ends in mid SVC. The cuff on the\n tracheostomy tube distends the trachea and should be evaluated clinically to\n see if this is necessary.\n\n Dr. was paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Echo", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 76185, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 67\nWeight (lb): 226\nBSA (m2): 2.13 m2\nBP (mm Hg): 155/55\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 15:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Physiologic TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with hypokinesis of the basal inferior and inferolateral\nwalls (c/w left circumflex coronary artery disease). The remaining segments\ncontract normally (LVEF = 50 %). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No masses or vegetations are seen on the\naortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. No mass or vegetation\nis seen on the mitral valve. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: No valvular vegetations or significant regurgitant valve disease\nseen. Mild regional left ventricular systolic dysfunction, c/w CAD. Mild\npulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "Echo", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 76186, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function. Coronary artery disease.\nHeight: (in) 65\nWeight (lb): 191\nBSA (m2): 1.94 m2\nBP (mm Hg): 174/64\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:57\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\nventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with severe hypyokinesis of the basal half of the\ninferior and inferolateral walls. The remaining segments contract well (LVEF =\n50 %). Right ventricular chamber size and free wall motion are normal. The\nascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets and supporting structures are mildly thickened. No\nmitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of the severity of\nmitral regurgitation is now reduced and mild pulmonary artery systolic\nhypertension is now seen. Left ventricular systolic function is similar (was\nunderestimated on review of the prior study).\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-07 00:00:00.000", "description": "Report", "row_id": 1346873, "text": "NPN 1900-0700:\nNeuro: pt is lightly sedated with propofol 10 mcg/kg/min, at times agitated needed Haldol 5 mg PRN, opening eyes to verbal stimuli, following commands by grimacing to pain questions (denied any pain), grasping hands, easily arousable, PERRL.\n\nCV: NSR HR 63-84, BP 120-154/37-55, with central line and a PIV, CVP 7-11, maintained on antihypertensive drugs and IV antibiotics, peripheral pulses dopplerable, with edema over extremities, elevated over extremities, upper extremities leaking serous secretions.\n\nGI/GU: with OGT in place, NPO, abdomen obese, BS positive, passing stool in mushroom cath, on Lasix and received a single dose at 2100, opened up to polyuria throgh foley cath, FS 122-128.\n\nInteg: T max 100.1, cold compresses applied, T decreased to 98.2, pt is restrained with upper ext. soft restraints for tubes safety.\n\nSocial: DNR, daughter called and updated on .\n\nPlan: continue antibiotics, monitor FS and cover with insulin per sliding scale, wean mechanical ventilation and ? extubation today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-07 00:00:00.000", "description": "Report", "row_id": 1346874, "text": "Respiratory Care:\n\nPatient remains intubated on PSV. Current vent settings PSV 5, Peep 5, Fio2 40%. Spont vols 360-400's with RR mid 20's. BS clear bilaterally. Sx'd for sm amounts of thick white and blood tinged secretions. RSBI 82 this morning. Pt. appears comfortable on above settings.\nPlan: SBT later this morning. ? Extubation.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-07 00:00:00.000", "description": "Report", "row_id": 1346875, "text": "7am-7pm nursing progress notes\n\n88 y/o female with h/o CAD presented to her PCP with CP,developed GI bleed in settings of anti coagulation for cardiac cath,intubated for hypoxia and airway compromise during EGD and delerious and in need of multiple procedures in view of GI bleed.\n\nEXTUBATED AT 1545 hrs.\n\nCVS;HR 70-100 NSR occasional pvc,s noted EKG taken at AM,lytes repleted this AM. RSC remains patent.Pedal pulses are doppled both upper and lower extrimities are edematous.NBP 120- 150/70-90.\n\n\nRESP;Extubated at 1545 hrs 0n 50% cool neb SPO 2 maintained 96-100 suctioned for mod- large thick tan secretion LS are coarse to dim bibasilar.RR 16-20\n\nNeuro;Propofol was off since 7000 for extubation pt is more awake but unable to asses MS follows commands and moves all extrimities in bed.\n\nGI;Abdomen obese BS+ NG tube pulled out for extubation Still remains NPO.Mushroom catheter in place draining yellow coloured liquid stool.\n\nGU;Diuresing with 40 mg lasix BD PM dose was given early in view of extubation.Goal is to keep her negative.\n\nID;On antibiotics for PNA blood culture reports are pending.\n\nENDO; Blood sugars are controlled on sliding scale insulin.\n\nSKIN;Both upper extrimities are edematous and oozing serous drainage,back is intact.\n\nSOCIAL;Visited by her daughter and updated.\n\nPLAN;Daily EKG\nSpeech and swallow test\nMonitor vitals sxn as needed\ncrit to be done BD and transfusion if low\nFollow PM labs.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-08 00:00:00.000", "description": "Report", "row_id": 1346876, "text": "NPN-MICU\nMrs developed some stridor s/p extubation but has been maintaining her sats.\n\nResp:pt noted to have some stidor upon initial , amt of wheezes and some air mvmt in the airways and pt denied any SOB or dyspnea. Her O2 sats cont to be >97% and RR 20-28. She has been developing a more forceful cough through the night and looks to be clearing her airway. She has been giving x2 racemic epi treatment with some noted improvement but by mn she still had some stridor, so she was placed on steroids.\n\nNeuro:Pt was more lethargic at the beginning of the shift, unsble to take po pills. She is now waking up and talking more as night has progressed. She is asking where she is and that she hqas to go to the bathroom. She is following commands more and more and cont to MAE.\n\nCV: pt has been maintaining HR in the 90-105 SR/ST (up to 110 s/p racemic epi) and her BP has been 120-160. She has been unable to take her po captopril(or any po pills for now) due to her MS and ?inability to swallow. Her K+ was replaced\n\nGI:pt NPO for now as she was not awake enough to take her pills and than she had some stridor so her po pills have been held(captopril & lipitor). She cont to pass liq stool, mushroom cath in place. Her Blood sugars are controlled on SS insulin.\n\nGU: pt was 3l neg at 12mn. she u/o has fallen off through the night but she cont on laix doses. She is still very puffy with fluid.\n\nHeme:her hct is stable at 34\n\nID: pt with low grade fever and finishing up with her Ampicillin course.\n\nA/P:Will cont to eval her stridor and asses rsp to steroids\n Follow O2 sats and CXR this am\n If pt more awake and interactive, eval swallowing ability at bedside otherwise, pt needs FT in IR.\n Note BP and Hr off meds / switching to IV meds if needed.\n Note hct and replace lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2161-07-31 00:00:00.000", "description": "Report", "row_id": 1346846, "text": "Events: Endoscopy for brisk brbpr while pt in cath lab. Tranfused 2units prbc\nAdmit note: 84yr old female admitted to MICU 7 for brbpr. She orginally was admitted to cath lab from where she developed cp during none excersize stress test. Please see admit data, H&P, cath lab notes.\n\nNeuro: Very hoh, does not where hearing aides tinitus. Initially oriented to , answering questions and following commands appropriately. Became restless and confused as evening lengthened, currently sleeping in naps s/p sedation for endocscopy procedure.\n\nCV: Sr with HR in 60s', dropped to 47 during endoscopy with relative drop in BP to 115/40's. Current HR 52 with bp 141/41.\n\nPulm: RA sat 98%, placed on 70% face mask while sedated mouth breathing and drop in 02 sat 88%. Lungs clear bilaterally, respitory effort unlabored.\n\nGU: Foley draining clear yellow urine to gravity.\n\nGI: Abd soft, bs present, no stool/bleeding since arrival.\n\nSkin: Surfaces grossly intact with mulitple areas of echymosis at bilateral scapula areas and lower arms. Small echymotic area at inner aspect of right shin. Pulses present by doppler. Right femoral A/V sheaths and dual lumen d&i, knee imobilizer in place to maitain integrity of same.\n\nSoc: Pts grandaughter at bedside since admission, pts daughter is listed as hcp. Pt code status is DNR but intubation would be acceptable for short term if necessary.\n\nP: Orient/reassure prn, follow serial hcts/hemodynamics, transfuse as ordered/indicated. Observe for recurring chest pain, further bleeding. Femoral sheaths to remain in place at present in the event of need to return to cath lab. Keep family up to date on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 1346847, "text": "Resp Care\nABG showing Met acidosis. RR increased in attempt to compensate for acidosis. FIO2 weaned to 40%. Suctioning moderate amounts of thick blood tinged secretions. Pt to and from Nuclear Med without complications.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 1346869, "text": "NPN 1900-0700:\nEvents: pt has been prepared for colonoscopy with Golytely (this is the third bottle of 4 L Golytely).\n\nROS:\n\nNeuro: sedated with propofol 10 mcg/kg/hr, opens eyes to verbal stimuli, localizes pain, PERRL, agitated at times, MAEs, pt is HOH.\n\nResp: intubated on vent CPAP with PS 5/5, 40%, suctioned with moderated thick tan secretions, LS CTA, SPO2 99-100%, RR 14-28.\n\nCV: NSR HR 60-88, BP 104-173 on captopril, with a RSC line and a PIV line, on D5.45NS at 75 cc/hr, Mid line pulled out and tip sent for cx, peripheral pulses dopplerable, received Lasix 40 mg with good effect, potassium repleted, on Ampicillin IV.\n\nGI/GU: OGT in place, receiving 3rd bottle of golytely, stool is liquidy with greenish to brownish color, abdomen obese, BS present, with Foley adequate U/O.\n\nInteg: T max 98.7, all washed up, on universal precautions, FS 98-100.\n\nSocial: DNR, daughter called at night and updated on POC.\n\nPlan: wean vent (spontaneous breathing trial in am), ? extubation, colonoscopy in am, monitor electrolytes and replete as ordered, FS monitoring and sliding scale as indicated, continue antibiotics.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 1346870, "text": "Respiratory care:\nPatient remians intubated and mechanically vented. Vent checked and alarms functioning. Please see flow sheet for data. Breathsounds are clear. No abg this am. RSBI 200. Please see respiratory section of carevue for further data.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-05 00:00:00.000", "description": "Report", "row_id": 1346866, "text": "NURSING PROGRESS NOTE 0700-1900\nEVENTS: GI ATTEMPTED COLONOSCOPY THIS AFTERNOON, HOWEVER PT CONTINUES TO HAVE STOOL. CONTINUE WITH GOLYTELY OVERNIGHT AND GI WILL ATTEMPT TO PERFORM COLONOSCOPY TOMMORROW.\n\nNEURO: SEDATION D/C'D TO ATTEMPT TO FULLY WAKE PT AND POTENTIAL FOR EXTUBATION-PT HAS PRN ORDERS FOR IVP VERSED AND FENTANYL BOLUSES FOR AGITATION. CURRENTLY OPENS EYES TO VOICE, PERRL 3MM/BRISK BILATERALLY. MAEX4, HOWEVER DOES NOT FOLLOW COMMANDS. BILATERAL SOFT WRIST RESTRAINTS MAINTAINED FOR SAFETY OF TUBES/LINES. AFEBRILE.\n\nRESP: OETT SECURE AND PATENT, VENT SETTINGS ARE CPAP/40%/ WITH TV'S 350-400'S AND RR TEENS-20'S. SPO2 97-100%. LUNG SOUNDS ESSENTIALLY CLEAR THROUGHOUT, BILATERAL CHEST EXPANSION NOTED. SUCTIONED FOR SAMLL TO MODERATE AMTS OF THICK TAN SECRETIONS.\n\n\nCV: HR 50'S-80'S SB/NSR WITH RARE PVC'S NOTED. SBP 130'S-160'S, MAPS >60. WEAKLY PALPABLE RADIALS AND DP PULSES AUDIBLE WITH DOPPLER. HCT STABLE 32.5, NO SIGNS OF ACTIVE BLEEDING. CVP'S . RSC LINE PATENT, LEFT BRACHIAL MIDLINE PATENT.\n\nGI/GU: ABDOMEN SOFT AND DISTENDED, BOWEL SOUNDS PRESENT X4. PT HAS REMAINED NPO FOR COLONOSCOPY. OG TUBE PATENT. FLEXISEAL D/C'D BY GI THIS AFTERNOON FOR PROCEDURE, FOUND TO HAVE FORMED BROWN STOOL UPON DIGITAL EXAM BY MD. INDWELLING FOLEY CATHETER SECURE AND PATENTLY DRAINING YELLOW SEDIMENT URINE. RECEIVED LASIX 20MG IVP WITH BRISK EFFECT.\n\nINTEG: NO SIGNS OF BREAKDOWN, ALOE VESTA CREAM APPLIED. PT HAS MULTIPLE AREAS OF ECCHYMOSIS.\n\nENDO: FSBS MONITORED EVERY 4 HOURS, COVERED PRN WITH SS INSULIN.\n\nSOCIAL: DAUGHTER CALLED TODAY, WAS UPDATED BY THIS RN.\n\nPLAN: CONTINUE WITH GOLYTELY UNTIL STOOL CLEARS. GI TO PERFORM COLONOSCOPY TOMORROW. BOLUS WITH PRN IVP MEDS FOR AGITATION, MONITOR MS POTENTIAL TO EXTUBATE. REPLETE ELECTROLYTES PRN. PT HAS AN ORDER FOR EKG TOMORROW AM.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-05 00:00:00.000", "description": "Report", "row_id": 1346867, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 23@lip) and on vent support. No vent changes were made t/o shift. Lung sound were clear t/o. Suctioned for sm thk tan secretions. No ABG's were drawn. Care plan is to continue to wean as tol, ? of extubation in AM. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-05 00:00:00.000", "description": "Report", "row_id": 1346868, "text": "ADDENDUM\nPT NOTED TO BECOME INCREASINGLY AGITATED AND TACHYPNEIC WITHOUT SEDATION. NOT FOLLOWING COMMANDS, MOD AMTS OF THICK TAN SECRETIONS WHEN SUCTIONED. STARTED ON PROPOFOL GTT 10MCG/KG/MIN WITH THERAPEUTIC EFFECT. PT APPEARS TO BE COMFORTABLE AT THIS TIME WITH RR 15. PLAN IS TO TURN OFF PROPOFOL IN AM FOR WAKE UP TO RE- FOR POSSIBLE EXTUBATION.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 1346871, "text": "7am-7pm nsg progress notes\n\nEVENTS; EKG,ECHO;COLONOSCOPY.\n\nCVS;HR 60-80 NSR no ectopy NBP 130-150/50-60 Captopril dose increased.CVP linepatent with sharp waves.EKG and ECHO done this AM.Crit remains stable.Lytes repleted this AM.\n\nRESP;Recieved this AM cpap/ps 40/5/5 no changes are made LS are coarse to dim bibasilar suctioned copious amounts of blood stained secretion.Sats are maintained 100%.Tried SBT since no plan to extubate today put back to previous settings.\n\nNEURO;Propofol was off since 0600 pt was not fully awake and was unable to follow commands at the begninning of the shift and to keep her awake sedations were not restarted until afternoon and found to be more awake following all commands, and moving all limbs off the bed.Sedation restarted to keep pt comfortable since no plan to extubate today,to be turned off at AM.Both upper extrimity restrained for safety of invasuve lines.\n\nGI;Prepared her with 4 bottles of Golytelly back flow was clear enough and procedure was performed at 1600 verbally reported as no active bleeding.Mushroom catheter still in place.Abdomen obese BS+.OGT in place and feeds not restarted.\n\nGU;Voiding via foley catheter,diuresing with lasix 40 mg /BD with good effect.\n\nENDO; on insulin sliding scale.FS 90-120.\n\nID;Afebrile, on antibiotics.Blood and sputum cultures are done.\n\nSKIN;Both upper extrimity has edema and redness and on rt hand has oozing DSD in site.Back care given.\n\nPLAN;Monitor vital signs\nDiuresis to continue\nCrit and PM labs to follow up.\nFor extubation At AM\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 1346872, "text": "Respiratory Care\nPt remains intubated (#7.5ETT 23@lip) and on vent support. Vent changes were SBT at start of shift to PSV, holding off on extubation till AM. Lung sounds were course with rhonchi, suctioned for Q2-3 HRS for blood tinged secretions (sample sent to lab). No ABG's were drawn t/o. Care plan is to continue to wean as tol, ? of extubation in AM. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-04 00:00:00.000", "description": "Report", "row_id": 1346861, "text": "Respiratory Care:\nPatient with tachypnea and decreased Sp02 lastnight. changed over to CMV mode to rest overnight. Temp 102, cultures sent including thick, tannish sputum specimen. Changed to a heated wire circuit to thin viscous secretions. She has since been suctioned for moderate amounts. BS=bilat, no wheezing. CXR noted for increasing infiltrates in RML and RLL. RSBI was 33 with tidal volumes of 180cc and a rate of 6 on sedation. Plan is to lighten sedation and continue with weaning as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-04 00:00:00.000", "description": "Report", "row_id": 1346862, "text": "Respiratory Care: Pt remains orally intubated and vented. Weaned to PS 5, PEEP 5. Lung sounds clear. Suctioned for small thick yellow secretions. Plan is to extubate after GI scope tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-04 00:00:00.000", "description": "Report", "row_id": 1346863, "text": "NURSING PROGRESS NOTE 0700-1900\nEVENTS: PT STARTED PREP FOR COLONOSCOPY IN AM. HAD EPISODE OF LGE AMT OF MAROONISH RED BLOOD PER RECTUM THIS EVENING THAT LEAKED AROUND FLEXISEAL TUBE. HR STABLE IN 50'S-60'S AND SBP STABLE IN THE 1TEENS. DR. IN TO SEE PT, FELT THIS WAS MOSTLY OLD BLOOD AND ORDERED HCT TO BE CHECKED AT . RIGHT SC CVL PLACED THIS EVENING.\n\nNEURO: LIGHTLY SEDATED ON FENTANYL GTT 10MCG/HOUR AND VERSED GTT 0.5MG/HOUR. OPENS EYES TO VOICE AND STIMULATION, AT TIMES SPONTANEOUSLY. PERRLA 3MM/BRISK BILATERALLY. PT IS NOTED TO BE HOH PER DAUGHTER, INCONSISTENTLY FOLLOWS COMMANDS AND HAS PURPOSEFUL MOVEMENTS. NO SEIZURE ACTIVITY NOTED, TMAX 99.1. BILATERAL SOFT WRIST RESTRAINTS MAINTAINED FOR SAFETY OF TUBES/LINES.\n\nRESP: OETT SECURE AND PATENT, RECEIVED PT ON VENT SETTINGS AC/40%/500/14/5, HAS SINCE BEEN WEANED TO CPAP/40%/. RR 15-20'S WITH REGULAR EFFORT, SPO2 > OR = 95% THROUGHOUT THE SHIFT. LUNGS CLEAR THROUGHOUT ALL FIELDS, SUCTIONED FOR SCANT TO SMALL AMTS OF THICK TAN BLOOD TINGED SECRETIONS. BILATERAL CHEST EXPANSION NOTED.\n\nCV: HR 40'S-80'S THROUGHOUT THE SHIFT NSR/SB WITHOUT ECTOPY NOTED. SBP 100'S-130'S, NOTED TO INCREASE TO 160'S WITH STIMULATION. WEAKLY PALPABLE RADIALS, BILATERL DP PULSES AUDIBLE WITH DOPPLER. LAST HCT AT 1400 WAS STABLE AT 34.\n\nGI/GU: ABDOMEN SOFT, BOWEL SOUNDS PRESENT X4. PT HAS BEEN NPO EXCEPT MEDS AND GOLYTELY FOR PREP FOR SCOPE IN AM. OG TUBE PATENT, PLACEMENT VERIFIED BY INSTILLING AIR. FLEXISEAL PATENT DRAINING MAROONISH RED BLOOD/STOOL. INDWELLING FOLEY CATHETER SECURE AND PATENT WITH 15-35ML/HOUR YELLOW SEDIMENT URINE. UA AND C&S SENT TODAY.\n\nINTEG: SKIN HAS MULTIPLE AREAS OF ECCHYMOSIS. SKIN ON BACK AND BUTTOCKS INTACT.\n\nENDO: FSBS MONITORED EVERY 4 HOURS, COVERED WITH SS INSULIN.\n\nSOCIAL: DAUGHTER CALLED TODAY, ALL QUESTIONS ANSWERED APPROPRIATELY. PT IS DNR.\n\nPLAN: PT IS DUE FOR 3RD OF 3 DOSES OF NEUTRA PHOS AT MN TONIGHT. CONTINUE GOLYTELY PREP FOR COLONOSCOPY IN AM. HCT DUE AT . WEAN VENT AS TOLERATED BY PT.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-05 00:00:00.000", "description": "Report", "row_id": 1346864, "text": "Resp Care\nPt remained intubated and ventilated on psv 5/5 40%. Breath sounds are mostly clear. Suctiioned for small amounts of thick tan sputum. Et tube rotated and retaped. RSBI this morning = 60.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-05 00:00:00.000", "description": "Report", "row_id": 1346865, "text": "Nursing Note: 1900-0700\nSignificant events:\n\nReceived one unit packed cells for Hct 27.\n\n\nNEURO: Sedation increased for agitation with any stimulus. Currently on Fentanyl gtt @ 30mcg/hr and Versed gtt @ 2.5 mg/hr and still easily responsive to any stimuli. Moving all extrems requiring use of bilat soft wrist restraints to maintain safety and integrity of lines. No commands.\n\nRESP: Continues on PSV 5/5/.4 maintaining sats at or near 100% LS cta; RR 10s-teens. Sx for mod amt thick sputum.\n\nC/V: HR 40s-60s, sinus; NBP 120s-150s. Hct 27; received one unit prbc with appreciable increase to 32. INR 1.2. Elytes pnd.\n\nID: Afebrile; covered with Vanco and Levofloxacin for MSSA in sputum.\n\nGI/GU: Completed Golytly prep for colonoscopy though stool still not clear. U/O marginal at times. Flexiseal intact for maroon/brown liquid stool.\n\nENDO: Covered Q4 hrs with sliding scale.\n\nACCESS: Fem line pulled after right scl line placement confirmed.\n\nDISPO/PLAN: DNR; colonoscopy today; no contact from family overnight.\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-03 00:00:00.000", "description": "Report", "row_id": 1346859, "text": "Respiratory Care\nPt remains intubated (#7.5 ETT 23@lip) and on vent support. Vent changes were from SBT to PSV. Pt received on SBT and passes, no ABG was drawn (no a-line) no plan to extubate pt today. Lung sounds were course w/rhonchi. Suctioned for sm-mod thk tan secretions, Q2-3 hrs. No ABG's were drawn (last on ). Care plan is to continue on PSV, SBT in AM, ? of extubation if able to maintain secretions. Will continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-04 00:00:00.000", "description": "Report", "row_id": 1346860, "text": "NURSING PROGRESS NOTE:\nDNR, will intubate for short periods\n\nEVENTS: midline placed, unable to place PICC; spiked temp to 102 and as pan cultured\n\nNEURO: pt lightly sedated on 12.g mcg/hr fent and versed 1mg/hr; arouses to verbal stim, follows commands, denies pain, grimaces with activity; moves all extremities; PERL, pupils 3mm and brisk bilaterally; prior to intubation, pt sundowns, very confused and agitated\n\nCV: cont on nitro gtt, will attempt to wean off this am; SBP 163-114; HR NSR to SB 98-51, this am now HR remaining in 40's, no ectopy, has brady'd down to 30's during admission; cont on metoprolol IV q6h; 2+ pitting edema LE's; +radial/pedalpulses to palpation; HCT stable, no S+S bleeding; to be repleted with 20meq KCl this am\n\nRESP: pt cont vented changed to AC from CPAP 40/5/5 when she desatted to 92% and became tachypneic; now AC 500/14/40%/5; suctioned q 1-2hrs for copious amt thick tan to blood tinged secretions; satting 95-100%; frequent cuff leak present; cont on levaquin for ? pna, probable asp during scope\n\nGI: +BS, +flatus, small amt liquid black stools via flexiseal; abd soft obese, appears non-tender; umb hernia present; no TF at this time, on d5 @75 continuous; no further bleeding\n\nGU: foley in place draining clear yellow urine, 5-60 cc/hr, rec'd 20mg lasix and put out 700cc in 1 hr, then tapered off, no order for additional lasix; pt 4.8L+ LOS\n\nACCESS: unable to advance PICC line, so pt has midline with catheter tubing coiled under dsg; right fem sheath with TLC in place; if pt remains on gtts, will needs new CL before fem sheath is pulled\n\nSKIN: multiple ecchymotic areas throughout, small skin tears LE's; otherwise intact\n\nPOC: no red tag scan as pt no longer has active bleeding; transfuse for HCT <30; no anticoagulation; plan for colonoscpy after cleared by cards, to start prep today; cont vent suppot and frequent suctioning; maintain intubation for procedures\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 1346848, "text": "Resp Care\nPt intubated s/p becoming unresponsive and desaturating into 60's during endoscopy. Pt intubated with 7.5 ETT placed at 23 @ lip. BS heard bilaterally post intubation. BS slightly coarse in upper aw's, otherwise clear bilaterally. Pt currently on full vent support with no changes made at this time. SpO2=100%. See CareVue for details and specifics.\nPlan: Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 1346849, "text": "Nursing 19-07\nEvents:\n-Bright red bloody stools\n-Upper GI scope\n-Intubation\n\nNeuro: Initially withdrawn / lethargic, as time went on became more alert but restless and confused. Attempting to get out of bed, threatening femoral sheaths. Oriented to self, rarely hospital, speaking in garbled non-sensical terms. Treated with haldol sparingly (prolonged QTc), then ativan with no notable decrease in agitation. For endoscopy, moderate sedation was used however pt required a total of 3mg midaz and 100mcg fentanyl; was still swatting at physician operator and moving around in the bed; was then intubated for acute desat to 64% and thereafter midaz / fentanyl gtts were initiated.\n\nPain: Prior to intubation was complaining of non-descript mild abdominal pain only with palpation. Now on 50mcg fentanyl / hr gtt, and is deeply sedated, remains hypertensive but with no other signs of pain.\n\nResp: Lungs coarse -> clear, equal bilaterally, diminished at the bases. Productive cough prior to intubation, but pt swallowed sputum before it could be orally suctioned. Post-intubation ABG reveals metabolic acidosis with hyperoxia, SPO2 100% on current vent settings. Now suctioned for thick brown sputum in moderate amounts. Awaiting portable CXR.\n\nCV: Sinus / sinus brady rhythm with occasional PVC's and ventricular bigeminy. Extremities cool and dry, oral mucosa very dry. Dopplerable distal pulses. Right femoral arterial line transducing sharply, and right femoral venous sheath in place. Right IJ CVL also in place. Tranfused with 3 units PRBC's this shift, awaiting post-transfusion HCT. Has been very hypertensive despite adequate sedation, with SBP>190 at times; nitroglycerin gtt to begin shortly.\n\nGI: Abdomen becoming increasingly distended this shift. Bowel sounds are hyperactive. Pt remains NPO and on a protonix gtt at 8mg/hr. Began having dark liquid stools with mixture of bright red blood in early evening, increasing amounts through shift. Flexiseal device placed for incontinence management; other methods (external bag) had failed and stooling nearly continuously. Upper GI scope done, then paused for intubation, then resumed. Plan now for red blood cell scan tonight.\n\nGU: Foley to gravity with marginal clear yellow urine output.\n\nEndo: RISS ordered, latest glucose 223 to be covered.\n\nLytes: Ionized calcium 1.11\n\nSkin: Intact with eccyhmotic areas on arms and legs. Abrasion on LLE with mild sanguenous drainage intermittently, DSD applied.\n\nSocial: Granddaughter visited in evening, went home and family plans to return in am. updated by phone overnight by GI doctors.\n\nPlan: Maintain safety. Pain / sedation management. Pulmonary toileting. Serial hcts. Nitro gtt to reduce SBP 140-160. Red blood cell scan to be completed imminently. NPO. Do not place gastric tube; pt has ulceration at esophageogastric junction. Logroll for femoral lines. Notify team of acute changes.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 1346850, "text": "Resp Care\n\nPt remains intubated; mode of ventilation changed to cpap/psv. MV being maintained in the 6-8L range with rr's in the mid teens to low 20's. Bs with occ rhonchi and suctioning thick brown sputum\n" }, { "category": "Nursing/other", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 1346851, "text": "Nsg.notes 0700-1900hrs\n\nEvents:EKG,CAT SCAN HEAD,ECHO,FLUID BOLUS,Rt.IJV came out.\n\nNeuro:sedated with fentanyl 50 and versed 2mg/hr.eye opens to pain and speech,following commands like squeezing hands when asked to do so.CAT scan head done in am,while transferring the pt to CAT Scan bed Rt.IJV came out ,immediately pressure applied for 5-10min and then pressure dressing applied informed to Dr. in MICU.And shifted all infusions to Rt femoral 3 lumen venous access as MD.incident report documented .CT head report:equivocal loss of focal differentiation in the left frontal/parietal lobes may signify early infarction,no haematoma or mass effect.\n\nResp:Intubated and ventillated ,mode CPAP +PS ,PEEP 5 ,PSupport 10,Fio2 40%.suctioned moderate thick secretions.lungs on auscultation clear in upper lobe and diminished on base.sats 100%\n\nCVS:HR 40-80/min,SB to NSR.no ectopics noted.BP 130-180/50-70 mm of hg,nitroglycerine restarted am 0.2mcg/kg/hr and increased upto 0.35mcg.kg/hr and running same.peripheral pulse present with doppler.multiple echymotic briuse on both hands and back present.check crit q4h,last sent at 6pm.and 2pm report is 35.echo done ,verbal report same as previous echo,low EF.\n\nGU/GI:NPO.Abdomen soft distended,bowel sounds present.flexi seal in place,drained 100ml maroon coloured liquid .NO gastric tube ,ulceration at esophago gastric junction.on foley cath,urine output low in am ,good effect with 250ml R/lactate.\n\nIntegu:no pressure sores,having multiple echymotic bruises and LLE abrasion,DSD intact.T max 98.7.bath given and positioned.\n\nIV access:22g and 20g PIV on Lt.hand,3 lumen venous acces on Rt femoral,A line on Rt femoral.all lines patent and site looks clean,dressing intact.Rt IJV came out.pressure dressing intact.plan to remove Rt femoral A line by cardiologist and to keep Femoral venous access till tomorrow.as IV nurse and icu Dr for a PIV and failed.\n\nSocial:sedated,visited by family and updated with MD.DNR.\n\nEndo:On sliding scale insulin Q4H,Not covered this shift.\n\nPlan:IV access.follow up with ECHO report.wean off and extubate tomorrow.HCT q4h.titrate nitroglcerine according to blood pressure.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-02 00:00:00.000", "description": "Report", "row_id": 1346852, "text": "Nursing Progress Note:\nDNR, but will intubate for short periods\n\nALLERGIES: asa,sulfa,dilt,pepcid, levaquin\n\npt admitted to night of after dev 10/10 chest pain during stress test; taken to , given nitro, plavix,integrelin; tranferredto Cath Lab, but procedure stopped b/c dev BRBPR; transferred to MICU for further ngt and scope; red scan unable to be completed d/t pt already having radioactive isotopes in system d/t stress test; intubated for desatting to 60's during scope, found oozing ulcer at esophagus and esophagitis,EGD findings not explaining blood loss; unable to place OGT d/t ulceration at esophageal gastric junction; also sundowning while in MICU requiring haldol; head ct yesterday negative\n\nNEURO:pt currently sedated on fent 50mcg/hr and versed 2mg/hr, daily wake up in evening for possible extubation, sedation off for 1 hr (pt becomes hypertensive to 190's when off sedation), pt alert and appropriate, following commands; cont follow commands denies pain, moves all extremities; PERL, pupils 4mm and brisk bilaterally\n\nCV: cont on nitro gtt @ .40mcg/kg/min; aline d/c'd, now NBP 125-148; HR NSR with PVC's 88-63; +pedal/radial pulses; 2+ pitting edema in lower extremities; approx 3L+ LOS @ MN; rec'd lasix 40mg IVx1, lg u/o following; see Careview for pending am labs; dropped HCT from 31.1 to 29.4, transfused 1 unit PRBC's, 4a HCT pending\n\nRESP: pt intubated on CPAP 40%/; team attempted to extubated during but will hold off until am d/t secretions; LS coare at apices and dim at bases; suctioned for small amt bloody sputum q2hrs; bilateral breath sounds and chest expansion present; satting 100-99%\n\nGI/GU: pt NPO, no OGT as described above; abd obese non-tender non-distended; flexiseal in place, draining small amount maroon liquid\nstools; foley inplace; draining clear yellow urine, diuresing well with lasix; on protonix gtt 8mg/hr; ARF resolved\n\nACCESS: TLC fem line via sheath;fem artery/aline sheath pulled by cards tonight; two PIV patent and WNL; RIJ accidentally d/c'd while at CT yesterday\n\nSKIN: multiple ecchymotic areas throughout and intact; small skin tears on LE's\n\nPOC: cont serial HCT, transfuse <30; if rebleeds may go to angio/surgery; possibleextubation tomorrow,although md note says to cont intubation if further procedures are anticipated; pt may return to cath lab after GIB stable; daily ekg's; prn haldol for agitation\n\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-02 00:00:00.000", "description": "Report", "row_id": 1346853, "text": "Resp Care\nPt remains intubated on PSV. PS weaned to 5 and tolerating well with TV 400-500. BS coarse bilaterally and diminished at lung bases. Suctioning for small amounts of thick bloody secretions this morning. Morning RSBI=22. See CareVue for details and specifics.\nPlan: Wean to extubate this morning.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-02 00:00:00.000", "description": "Report", "row_id": 1346854, "text": "NURSING PROGRESS NOTE 0700-1900\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS CURRENTLY OFF OF ALL SEDATION GTTS- HOWEVER, HAS FENTANYL ORDERED PRN FOR ANY SIGNS OF DISCOMFORT, HALDOL FOR AGITATION. PT HAS BEEN EASY TO AROUSE- WILL OPEN EYES SPONTANEOUSLY, FOLLOWS COMMANDS WITHOUT DIFFICULTY. ATTEMPTS TO MOUTH WORDS BUT IS DIFFICULT TO UNDERSTAND. AFEBRILE. NO SEIZURE ACTIVITY NOTED. BILATERAL WRIST RESTRAINTS APPLIED FOR SAFETY AS PT WILL ACTIVELY ATTEMPT TO GRAB ETT.\n\nRR: REMAINS INTUBATED. PLAN IS FOR EXTUBATION TOMORROW AS PT HAS HAD COPIOUS AMOUNTS OF THICK, TAN, BLOOD TINGED SECRETIONS- HAS BEEN REQUIRING Q 1 HR SUCTIONING. SPUTUM CULTURE SENT- PLAN TO INITIATE ANTIBIOTICS. PT HAS BEEN TOLERATING 5/5 CPAP/PS. TV 400'S, SP02 > OR = TO 95%. RR 12-18 WITH NO SOB OR INCREASED WOB NOTED. BILATERAL CHEST EXPANSION NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 70-90'S WITH NO SIGNS OF ECTOPY NOTED. SBP 120-140'S- GOAL FOR SBP IS 130-140. UNABLE TO WEAN NITRO GTT- SUPPLEMENTAL IV LOPRESSOR ORDERED. WEAKLY PALPABLE PULSES NOTED TO BILATERAL DORSALIS PEDIS AND RADIALS. PT HAS SECURE AND PATENT RT FEMORAL VENOUS SHEATH- PLAN IS TO KEEP IN UNTIL ABLE TO SECURE PICC PLCMT. CONTINUING TO MONITOR CRIT- PLAN TO TRANSFUSE FOR < 30.\n\nGI: ABD IS SOFT, SLIGHTLY DISTENDED. BS X 4 QUADRANTS. D5 1/2 NS INITIATED FOR NUTRITION AS PT IS UNABLE TO HAVE TF- OGT DEFERRED IN LIGHT OF BLEEDING ULCER AND AS PER GI. FLEXI SEAL IS SECURE AND PATENT, VERY SMALL AMOUNTS OF MAROON STOOL NOTED. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nINTEG: BACK AND BUTTOCKS ARE GROSSLY INTACT. UPPER EXTREMITIES ARE VERY BRUISED.\n\nSOCAIL: THREE DAUGHTERS IN TO VISIT- ALL QUESTIONS ANSWERED. NO ISSUES.\n\nPLAN: INITIATE ABX. EXTUBATE TOMORROW. MONITOR CRIT, TRANSFUSE FOR < 30. IVP FENTANYL PRN. PICC PLCMT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "Nursing/other", "chartdate": "2161-08-02 00:00:00.000", "description": "Report", "row_id": 1346855, "text": "Resp Care\n\nPt remains intubated and on cpap/psv. MV is being maintained in the 5-6L range. Extubated held due to large amts of thick brown sputum. Possible am extubation.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-03 00:00:00.000", "description": "Report", "row_id": 1346856, "text": "Nursing Progress Note:\nDNR, will intubate for short periods\n\nALLERGIES: , , SULFA, DILT, PEPCID\n\npt admitted from Hosp night of ; had stress test @ and dev 10/10 chest pain; sent to their ED where she recieved ntg, integrillin, plavix; transferred to cath lab; pt in cath lab when procedure had to be stopped as pt developed GIB abd started to put lg amounts liquid maroon stools; transfer to MICU for further mgt; pt prior to intubation very confused, has baseline dementia and sundowns; was scoped here, desatted to 60's and was emergently intubated; found ucleration at esophageal-gastric junction, but GI does not feels this accounts for amt of bleeding to red tag scan, where red scan could not be completed d/t pt already having radioactive materials in her system; unable to extubate or as pt was having increased amt bloody sputum, now very thick and tan sputum requiring frequent suctioning; also, md notes, will keep pt intubated for further procedures, and pt will go to IR today for PICC, and maybe repeat red cell scan\n\nNEURO: sedation off during day and was recieving fent bolus, now back on fent 50mcg/hr and versed 2mg/hr overnight as pt becoming agitated during nursing care; pt arouses easily, follows commands, all extremities; c/o pain x1 tonight but location NI, now appears to be comfortable on gtt\n\nCV: cont on nitro gtt, unable to wean off, also on metoprolol IV q6; SBP 128-146; HR 57-84, rare PVC's; 2+ pitting edema LE's; HCT stable; see careview for am labs; on d2 @75 continuos b/s not able to recieve ant nutrition\n\nRESP: pt intubated on CPAP 40%/; lg amt thick tan secretions suctioned q2hrs; RR 15-23; pulling inadequate tidal volumes; RSBI this am 33, and SBT this am\n\nGI: +BS, flexiseal in place draining small amt maroon liq stools; abd soft obese, non-tender, non-distended; NPO, no OGT b/c of ulceraton at esophageal-gatric junction\n\nGU: foley in place, draining sm amt of clear yellow urine, md aware, U/O tapering off to 20cc/hr; no order to diurese, although pt 3L+ LOS and did recieve 40mg lasix last, put out very large amounts\n\nACCESS: right fem TLC in place via sheath; RIJ accidentally pulled at CT, fem art line pulled by cards; to hace PICC placed in IR in am\n\nSKIN: came in with many ecchymotic areas, and skin tears at shins\n\nPOC: cont vent support, ? extubation today, cont frequent suctioning, ? keep intubated for procedures; to IR for PICC, ? to NM for red cell scan; monitor for S+S bleeding, serial HCT\n\n" }, { "category": "Nursing/other", "chartdate": "2161-08-03 00:00:00.000", "description": "Report", "row_id": 1346857, "text": "Resp Care\nPt remains intubated on PSV 5/5. No vent changes made this shift. BS coarse bilaterally, suctioning for moderate amounts of thick tan secretions. Morning RSBI=33. No ABG's this shift. See CareVue for details and specifics.\nPlan: ? SBT/ extubation. Pt to go to IR and Nuclear medicine today, ? to remain intubated during these procedures.\n" }, { "category": "Nursing/other", "chartdate": "2161-08-03 00:00:00.000", "description": "Report", "row_id": 1346858, "text": "Nursing Progress Note: 0700-1900\n\nPt. is off sedation since 1600 and tolerating so far. Plan is to extubate pt. tomorrow if secretions aren't considered a deterrant.\n\nNeuro: Pt. awakens easily, follows commands (squeezes hand and attempts to wiggle toes although weakly), mouths that she wants water. She recognized daughter and grandaughter. Plan is give bolus meds if needed. Team would like cardiology service and GI to talk about a plan re: need for cardiac cath and colonoscopy.\n\nCV: HR 50s-60s SB/NSR with no ectopy, NBP 120s-140s/30s-40s with occasional jumps to 160 systolic with stimulation. Pt. remains on Nitro gtt at 0.2mcg/kg min. Ntg turned down to 0.15mcg/kg/min but pt's BP immediately rose into 160s systolic (goal is <160). Pt. also receiving 5mg IV Lopressor q 6 hours. Pt. needs cardiac cath but due to inabiltiy to anticoagulate (GI issues) this has not been done.\n\nResp: Pt. on CPAP+PS/40%/ with RR in teens and 02 sats 99-100%. Lungs are clear to course and require suctioning q 2 hours of small to moderate amounts of thick,tan secretions. Chest PT done with turns. Pt. did well on 2 hour SBT trial today, no ABG done (no arterial line), team aware.\n\nGI: Pt. remains NPO (GI issues not resolved, pt. still needs colonoscopy but not stable enough. Flex-seal still in place with minimal drainage BSX4. No plans for red-tag scan.\n\nGU: UO marginal but adequate, pt. bolused with 250cc D5W with continuous infusion at 75cc/hour of D5 1/2NS ordered. Per GI service, OK to drop OG tube so pt. can be prepped for colonoscopy tomorrow.\n\nEndo: Sliding scale in place.\n\nSocial: Daughter and grandaughter in to see pt.\n\n\nSkin: Intact\n\n" }, { "category": "ECG", "chartdate": "2161-08-12 00:00:00.000", "description": "Report", "row_id": 187916, "text": "Sinus bradycardia\nLow lead voltage\nSince previous tracing of , heart rate slower\n\n" }, { "category": "ECG", "chartdate": "2161-08-09 00:00:00.000", "description": "Report", "row_id": 187917, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of no\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2161-08-08 00:00:00.000", "description": "Report", "row_id": 187918, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of no\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2161-08-07 00:00:00.000", "description": "Report", "row_id": 187919, "text": "Ectopic atrial rhythm, new compared to the previous tracing of .\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2161-08-06 00:00:00.000", "description": "Report", "row_id": 188147, "text": "Sinus rhythm. Modest non-specific ST-T wave changes. Prominent early R wave\nprogression that is non-diagnostic. Compared to tracing of there is\nno significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2161-08-03 00:00:00.000", "description": "Report", "row_id": 188148, "text": "Sinus rhythm. Non-specific inferior ST-T wave changes. Early transition which\nis non-specific. Compared to the previous tracing the Q-T interval is now\nnormal and inferior ST-T wave changes are now present.\n\n" }, { "category": "ECG", "chartdate": "2161-07-31 00:00:00.000", "description": "Report", "row_id": 188149, "text": "Sinus bradycardia with A-V conduction delay. Compared to the prior tracing #1\nthe P-R interval is somewhat longer. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2161-08-01 00:00:00.000", "description": "Report", "row_id": 188150, "text": "Normal sinus rhythm. ECG within normal limits. Compared to the prior tracing\nof no diagnostic change.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2131-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 996779, "text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for resolution\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with PICC found to have L lung collapse on last CXR\n REASON FOR THIS EXAMINATION:\n eval for resolution\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old status post PICC with left lung collapse.\n\n AP SEMI-UPRIGHT PORTABLE CHEST: Compared to study of 12 hours prior. Patient\n is markedly rotated for today's study. Right-sided subclavian line tip\n appears unchanged in position at the atriocaval junction. The right-sided\n PICC tip cannot be visualized underlying this. NG tube courses off the\n inferior aspect of the image. Tracheostomy tube unchanged in position. There\n has been interval re-aeration of the left mid and upper lung with some\n residual perihilar and basilar collapse.\n\n IMPRESSION: Interval re-inflation of a majority of the left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 996580, "text": " 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for cardiopulmonary disease\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with encephalopathy\n REASON FOR THIS EXAMINATION:\n please evaluate for cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Encephalopathy, question cardiopulmonary disease.\n\n This is compared with the prior from . The ET tube is 7.4 cm from\n the carina. The NG tube is almost at the duodenum. The heart is not\n enlarged. There is some atelectasis at the left lung base without any focal\n pneumonia.\n\n IMPRESSION: No acute cardiopulmonary process. Lines and tubes in standard\n positions.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 996747, "text": " 6:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval placement\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman s/p PICC in R median at 43cm\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n WET READ: 10:10 PM\n New right PICC terminates in mid-SVC. Limited film, but near complete white\n out and volume loss of left lung compared to one day prior - concerning for\n LLL collapse and effusion.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:42 P.M., \n\n HISTORY: PICC line in a 44-year-old woman.\n\n IMPRESSION: AP chest compared to :\n\n New opacification of the left hemithorax and ipsilateral mediastinal shift\n indicates left lung collapse. Right lung hyperinflated and clear. Tip of the\n right PIC projects over the low SVC. Tracheostomy tube in standard placement.\n Nasogastric tube tip in the region of the pylorus unchanged. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997511, "text": " 5:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for NG tube placement\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with trach s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n evaluate for NG tube placement\n ______________________________________________________________________________\n WET READ: DMFj 10:05 PM\n NG tube in good position.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: at 07:39.\n\n HISTORY: Evaluate for NG tube placement for a 44-year-old woman with\n tracheostomy, status post NG placement.\n\n FINDINGS: A feeding tube is located in the left upper quadrant/i.e. stomach\n which needs to be advanced forward. There a new left retrocardiac atelectasis\n likely aspiration versus mucous plug. A tracheostomy tube is seen with distal\n tip projected above the carina bifurcation by 4.2 cm. The lungs are clear.\n\n IMPRESSION:\n\n 1. The feeding tube needs to be advanced by approximately 10/15 cm.\n\n 2. New left retrocardiac opacity, likely atelectasis or aspiration.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997286, "text": " 3:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? NGT placement.\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with anoxic brain injury, now with new NGT. Please evaluate\n for NGT placement prior to initiating tube feeds.\n REASON FOR THIS EXAMINATION:\n ? NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that extends to the antrum of the stomach. The left\n hemidiaphragm is now sharply seen and the haziness at the left base has\n substantially cleared. The right lung remains clear and the tracheostomy tube\n is again seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 997366, "text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? NGT placement.\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with anoxic brain injury, NGT replaced. Please assess prior\n to reinitiation of tube feeds.\n REASON FOR THIS EXAMINATION:\n ? NGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: NG tube placement.\n\n Portable AP chest radiograph compared to .\n\n The NG tube tip is in the stomach. The tracheostomy is at the midline with\n its tip 4.4 cm above the carina. The cardiomediastinal silhouette is stable.\n Left retrocardiac atelectasis is unchanged. The rest of the lungs are\n unremarkable.\n\n DL\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2131-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 996982, "text": " 8:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check line and tube position\n Admitting Diagnosis: CIRRHOSIS;S/P CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with anoxic brain injury now with NGT replacement\n REASON FOR THIS EXAMINATION:\n check line and tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check line and tube position.\n\n COMPARISONS: .\n\n AP SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: A tracheostomy tube is present.\n An NGT terminates in the stomach. A right-sided PICC line terminates at the\n cavoatrial junction. There is decreased opacity at the left lung base. There\n is no pneumothorax. The heart size is stable.\n\n IMPRESSION:\n 1. Improving left basilar opacity, most compatible with a small layering\n pleural effusion.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-01-03 00:00:00.000", "description": "Report", "row_id": 1670399, "text": "npn: 1600-1900\n44 y/o f, was at home with her fiance when she began to have resp difficulty. she used her inhaler and reportedly had some hemoptysis. pt then became unresponsive, emt's were called and was intubated in the and was resuscitated. she was brought to the er where a head ct was done that did not reveal any acute pathology but a chest xray showed bilateral infiltrates. pt was affebrile to 102. in osh pt has remained unresponsive and has only recieved 3mg of ativan since admission. pt was brought to per family---family is having trouble coping and to r/o hepatic encephalopathy???\n\nneuro: pt is alert. will not follow commands. no purposeful movement. pt will grimace to deep pain. pt will blink but does not focus. pt is posturing. pt has foot drop biulaterally. eeg at osh showed brain slowing anoxic brain injury.\n\ncv: nsr 90's. no ectopy noted. bp stable 108-130's. pt has been off pressors since . pt afebrile. generalized edema noted bilaterally on arms and feet. ppp bilaterally.\n\nresp: pt trached on 35% trach mask. satting 98-100%. coarse lungs sounds bilaterally. pt has strong productive cough. pt has not required any suctioning. pt rr 19.\n\ngi/gu: pt is npo at this time. pt had large bm upon arrival. pt has positive bowel sounds. foley draining clear yellow uop. 30-300cc/hr. uc/ua sent.\n\nskin: skin is intact, however, pt has a large purple blister on left heel and medium sized red/purple blister on right heel. pt has red rash/fungal rash on sacrum/perinum area.\n\nid: pt arrived on vacno. blood cultures sent to lab.\n\naccess: pt has r tlc.\n\nsocial: daughter and mother called/updated. pt is to remain full code.\n\nplan: c/o to floor, ? neurology consult\n" }, { "category": "Nursing/other", "chartdate": "2131-01-04 00:00:00.000", "description": "Report", "row_id": 1670400, "text": "Neuro;Pt openes eyes spontaneuosly but does n't follow commands didnot notice any movements of extrimities,upper extrimities are in flexion.\n\nLS are coarse throughout On 35% trach mask O2 sats are maintained upto975 on the above settings.Coughs up thcik yellow secretions through tracheostomy site.dressing changed.Breathing efforts are normal.\n\nHR 100-110 ST most of the shift,NBP 110-120/50-60.Positive pedal pulses.For access rt CVL in place.\n\nAbdomen softly distended with positive bowel sounds.NG tube in place NPO except meds.On bowel meds,no bowel movement during this shift.\n\nVoiding adequate amts via foley catheter.\n\nSkin-redness around lips,groin anti-fungal applied,ulcer on lt heel.M boots are on.\n\nAfebrile,vanco trough level 22.8 PM dose was held planning to repeat level at AM.\n\nNo contact from family at this shift.\n\nPlan;pulm toiletting\nHaemodinamic monitoring\n?To restart TF as tolerated\nSocial work consult/update with family.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-01-04 00:00:00.000", "description": "Report", "row_id": 1670401, "text": "RESP CARE NOTE\nPT REMAINED ON 35% COOL AEROSOL TM OVERNIGHT WITH RR IN 20'S AND SATS OF > 95%. BS COARSE BILATERALLY. SUCTIONED SMALL TO MOD AMTS OF THICK TAN SECRETIONS WITH BLOOD TINGED AT TIMES. INNER CANNULA IN PLACE AND PATENT. CLEANED AROUND TRACH SITE AND CHANGED DRESSING. CUFF PRESSURE 25CMH20. COOL NEB FILLED X 2. AMBU AT BEDSIDE. WILL CONT TO FOLLOW.\n" }, { "category": "Nursing/other", "chartdate": "2131-01-04 00:00:00.000", "description": "Report", "row_id": 1670402, "text": "Respiratory Care\nPatient remains on Trach Collar as documented in Carevue. Suction small amounts of tan secreations. Humidifier maintained.\n" }, { "category": "Nursing/other", "chartdate": "2131-01-05 00:00:00.000", "description": "Report", "row_id": 1670403, "text": "NURSING PROGRESS NOTE 1900-0700\nPT IS A 44 Y/O FEMALE WHO BEGAN HAVING RESP DIFFICULTY AT HOME. PER NOTES, THE PT USED HER INHALER AND REPORTEDLY HAD SOME HEMOPTYSIS. PT THEN BECAME UNRESPONSIVE AND EMS WAS ACTIVATED. INTUBATED AND RESUSCITATED FOR BRIEF PERIOD OF ASYSTOLE IN THE FIELD. CT AT OSH DID NOT REVEAL ANY ACUTE PATHOLOGY HOWEVER CXR SHOWED BILAT INFILTRATES. AN EEG WAS PERFORMED AND WAS SUGGESTIVE OF AN ENCEPHALOPATHY CONSISTENT WITH POST ANOXIC EMCEPHALOPATHY. PER NEUROLOGY AT OSH PT WAS IN PERSISTENT VEGITATIVE STATE, SO TX TO FOR ANOTHER OPINION. FULL CODE.\n\nEVENTS: PT WAS CALLED OUT TO THE FLOOR AND HAD A BED. CALLED BACK IN WORSENING CXR.\n\nNEURO: PT IS ALERT, NONVERBAL. DOES NOT TRACK TO VOICE. AT TIMES NOTED TO HAVE UPWARD GAZE. POSTURING. WITHDRAWS TO NAILBED PRESSURE. MINIMAL NONPURPOSEFUL MOVEMENT OF EXTREMITIES NOTED. PERRL.\n\nRESP: PT HAS TRACH, REMAINS ON TRACH COLLAR WITH FIO2 SET 35%. RR 20'S AND SATS REMAIN STABLE AT 95% OR HIGHER. PT SUCTIONED FOR MODERATE TO COPIOUS AMTS OF THICK YELLOW SECRETIONS. AT TIMES EXPECTORATES SECRETIONS. LUNG SOUND ON RIGHT ARE COARSE AND DIMINISHED AT THE BASE. CXR FOR LINE PLACEMENT REVEALED WHITE OUT OF LEFT LUNG. MICU RESIDENT AWARE. L LUNG SOUNDS ARE COARSE AND DIMINISHED THROUGHOUT.\n\nCV: HR 70'S-80'S NSR WITHOUT ECTOPY NOTED. SBP 100'S-1TEENS WITH MAPS >60. PALPABLE RADIAL/DP PULSES BILATERALLY. RSC REMAINS IN PLACE FOR NOW. PT ALSO HAS R SINGLE LUMEN PICC LINE.\n\nGI/GU: ABDOMEN DISTENDED, BOWEL SOUNDS PRESENT. PT PASSING AMTS OF LIQUID GOLDEN STOOL, SO MUSHROOM CATHETER PLACED. INDWELLING FOLEY CATHETER PATENTLY DRAINING CLEAR YELLOW URINE. UOP NOTED TO BE MARGINAL AT TIMES, SO STARTED ON MAINTENANCE FLUIDS OF D5 1/2 NS AT 75ML/HOUR FOR 1L.\n\nINTEG: SKIN ON BACK AND BUTTOCKS INTACT. MULTIPLE AREAS OF BRUISING NOTED. BILATERAL HEELS BRUISED-MULTIPODUS BOOTS REMAIN ON. BARRIER CREAM APPLIED.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: CONT ICU SUPPORTIVE CARE, ? C/O TO MEDICINE IN AM WITH NEURO CONSULT. MONITOR RESP STATUS, SUCTION PRN. CONTINUE LACTULOSE AND RIFAXIMIN FOR ANY COMPONENT OF HEPATIC ENCEPHALOPATHY POSSIBLY CONTRIBUTING TO MS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2131-01-05 00:00:00.000", "description": "Report", "row_id": 1670404, "text": "PT REMAINED ON 40% TC T/O THE NIGHT , she req frequent sx for thk tan to brown secr. IC changed x 1 this shift. Spo2 mid to high 90's\n" }, { "category": "Nursing/other", "chartdate": "2131-01-05 00:00:00.000", "description": "Report", "row_id": 1670405, "text": "Respiratory Care\nPatient remains on trach collar. Suctioning moderate amounts of thick maroon colored secreations.\n" }, { "category": "Nursing/other", "chartdate": "2131-01-05 00:00:00.000", "description": "Report", "row_id": 1670406, "text": "MICU 7: RN Note 0700-1900\n\nCalled out.\n\nFull Code.\n\nSOCIAL:\nPrimary contact is daughter ; MD updated her by phone this pm. Family meeting is planned for Monday; no time set yet.\nFiance's name is . Visited today for ~one hour. He stated that he would like to be present at meeting; his number is on board in room. mother called today; provided brief update; encouraged her to communicate with regarding the specifics of pt's care/condition.\n\nNEURO:\nPersistent Vegetative State per Neurology Team.\nEyes open, blinks. Does not track. Fiance states that she smiles for him; has done this at OSH. Does not follow commands. Decerebrating.\n\nCV:\nAfebrile. SR 70-80s. BP stable; see flowsheet. Bolus adm x1 for low UOP. Potassium 60 meq for K+ of 3.1 this morning. No ectopy. PICC at RAC. RSC TL still in place; recommendation is to DC immediately prior to the next CXR to ensure proper placement of PICC after slow withdrawal of RSC TL.\n\nINTEG: No skin breakdown noted at coccyx; redness notes-Miconazole applied. Both heels have blisters; L>R; Multi-podus boots on/re-adjusted.\n\nRESP:\nTrached/mask 35%. Large amt thick, creamy yellow/tan/brown; darker than yesterday RRT. ; expectorates much of it but Sx required too. Lungs coarse and I/E wheezes. Clear after sx and RT Rx. CPT to both sides; concentrating on Left (whiteout on left last eve...apices improved today). Trached on . Large incision; team aware. Trach care done/inner cannula lined with secretions but not plugged.\n\nGU: Foley; UOP 30/hour with maintenance IV at 75/hour. Dropped to 15/hr then to 20/hour for 2-3 hours. NS bolus 250ml adm with + effect; 30/hr. Amber. Small amount of blood peri-area.\n\nGI: Mushroom valve; large vol liquid stool/no leaking around tube. See flowsheet. Abd soft/distended. NG placement verified by ausc. Meds adm; tol well.\n\nPLAN: Family meeting on Monday to discuss PEG/Transfer to Extended Care Facility. CPT/Suctioning/Nebs. Lactulose/Rifaximin/Nadolo. SS insulin. PPI/Heparin. Nutrition consult. Multi-podus boot re-adjustment as needed.\n" }, { "category": "Nursing/other", "chartdate": "2131-01-05 00:00:00.000", "description": "Report", "row_id": 1670407, "text": "RN Addendum 0700-1900\n\nStool out for shift: 800cc\n\nTF started at 1830 at 10/hour; Probalance; Nutrion consult still pending. Maintenance fluids off; UOP down again to 15cc in the last hour.\n" } ]

[ { "category": "Echo", "chartdate": "2105-01-16 00:00:00.000", "description": "Report", "row_id": 69044, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 62\nWeight (lb): 193\nBSA (m2): 1.88 m2\nBP (mm Hg): 139/76\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Moderate mitral annular calcification. Moderate\nthickening of mitral valve chordae. Calcified tips of papillary muscles. Mild\nfunctional MS due to MAC. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Ascites.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\nmasses or vegetations are seen on the aortic valve. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. No mass or vegetation is seen on the mitral valve. There is moderate\nthickening of the mitral valve chordae. There is mild functional mitral\nstenosis (mean gradient 8 mmHg) due to mitral annular calcification. Moderate\n(2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. No vegetation/mass is seen on the pulmonic valve. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and\nregional biventricular systolic function. Mild calcific mitral stenosis.\nModerate mitral regurgitation. Moderate pulmonary hypertension. No valvular\nvegetations seen.\n\nCompared with the prior study (images reviewed) of , there is more\nmitral regurgitation. Mild calcific stenosis is seen and pulmonary pressures\nare higher.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-01-12 00:00:00.000", "description": "RENAL U.S.", "row_id": 1225953, "text": " 2:13 PM\n RENAL U.S. Clip # \n Reason: ARF EVALUATE FOR OBSTRUCTION\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F with acute renal insufficiency in the setting of liver failure\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female with acute renal insufficiency in the setting\n of liver failure.\n\n COMPARISON: CT of .\n\n RENAL ULTRASOUND: The right kidney measures 10.5 cm, and the left kidney\n measures 13.3 cm. There is no hydronephrosis, stone, or mass. There is\n intra-abdominal free fluid compatible with ascites. The study was performed\n with an empty bladder.\n\n IMPRESSION: Normal renal ultrasound. Ascites.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-08 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1225424, "text": " 9:43 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: Please perform with dopplers to evaluate portal vasculature.\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with new onset ascites without known h/o cirrhosis. Has had\n prior US without evaluation of portal vasculature.\n REASON FOR THIS EXAMINATION:\n Please perform with dopplers to evaluate portal vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female with new onset of ascites without known\n history of cirrhosis.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: The liver is shrunken and very nodular and heterogeneous with an\n appearance suggestive of cirrhosis. No focal liver lesion is identified. No\n biliary dilatation is seen. There is a large amount of ascites within the\n abdomen. Numerous small shadowing gallstones are seen within the gallbladder.\n\n DOPPLER EXAMINATION: Color Doppler and spectral waveform analysis was\n performed. The main, right, and left portal veins are patent with hepatopetal\n flow. A large patent paraumbilical vein is again identified. The hepatic\n veins are patent. Appropriate arterial waveforms are seen in the main, right,\n and left hepatic arteries.\n\n IMPRESSION:\n 1. Shrunken nodular liver. Large amount of abdominal ascites. Recanalized\n paraumbilical vein. These son features are consistent with cirrhosis\n and portal hypertension.\n 2. Patent hepatic vasculature.\n 3. Cholelithiasis.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1226325, "text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change, consolidation - given recurrin\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67F with hepatic encephalopathy and fevers\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, consolidation - given recurring fevers\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Encephalopathy and fever, to assess for pneumonia.\n\n FINDINGS: In comparison with the study of , there is continuing moderate\n cardiomegaly with some decrease in the degree of mediastinal vascular\n congestion and increased pulmonary venous pressure. The right hemidiaphragm\n and heart border are more sharply seen and no definite acute consolidation is\n appreciated.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-01-11 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1225831, "text": " 3:01 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for ascites, intrabdominal abscess. Please o\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 F with HCV, DM2 presents with worsening ascities despite 2 months of PO\n lasix and with intermittent fevers.\n REASON FOR THIS EXAMINATION:\n Please evaluate for ascites, intrabdominal abscess. Please only use PO contrast\n (no IV).\n CONTRAINDICATIONS for IV CONTRAST:\n Increased creatinine\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old woman with hepatitis C, diabetes, presenting with\n increased ascites by two months of Lasix and intermittent fevers.\n\n TECHNIQUE: Axial MDCT images were acquired from the lung bases to the\n symphysis pubis following oral contrast. Intravenous contrast was withheld at\n the request of the referring physician.\n\n COMPARISON: CT thorax, abdomen, and pelvis, .\n\n CT ABDOMEN:\n\n There has been interval development of small bilateral pleural effusions.\n Otherwise, the lung bases appear clear. Visualized portions of the heart and\n pericardium are unremarkable. Some calcification of the mitral valve is again\n noted. Small pericardial effusion.\n\n There has been interval development of moderate amount of ascites. There is\n no loculated fluid collection seen, although assessment is somewhat limited\n due to lack of intravenous contrast. The liver is small and nodular in\n contour, consistent with the patient's known cirrhosis. Assessment of the\n hepatic vasculature and focal lesions is not possible in the absence of\n intravenous contrast. The gallbladder is moderately distended and contains\n dependent high-attenuation material, consistent with small gallstones. The\n spleen is not enlarged, measuring 10.5 cm. Non-contrast examination of both\n kidneys and both adrenal glands is unremarkable, no hydronephrosis.\n Non-contrast examination of the pancreas is grossly normal. No bulky porta\n hepatis or retroperitoneal lymphadenopathy. Oral contrast adequately\n opacifies the small and large bowel. No abnormal bowel dilatation is seen.\n There is mild thickening of the cecal pole (2:56), this was also seen on the\n prior CT of .\n\n CT OF THE PELVIS:\n\n The urinary bladder is decompressed with a Foley catheter. The uterus and\n rectum are unremarkable in appearance. Free fluid extends into the pelvis.\n No pelvic lymphadenopathy. There is diffuse anasarca of the subcutaneous\n tissues. The visualized osseous structures are unremarkable without lytic or\n sclerotic destructive bony lesions seen.\n (Over)\n\n 3:01 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for ascites, intrabdominal abscess. Please o\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. New moderate ascites without loculated fluid collections.\n 2. New small bilateral pleural effusions and small pericardial effusion.\n 3. Nodular cirrhotic liver incompletely evaluated on this non-contrast study.\n 4. Dependent gallstones within the gallbladder.\n 5. Diffuse anasarca.\n\n The pertinent findings were discussed with Dr. by telephone at 4\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2105-01-08 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1225504, "text": " 7:37 PM\n CHEST (PA & LAT) Clip # \n Reason: rule out pulmonary process\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with HCV cirrhosis and new onset fluid overload concern for\n secondary process.\n REASON FOR THIS EXAMINATION:\n rule out pulmonary process\n ______________________________________________________________________________\n WET READ: 9:08 PM\n No pneumonia. Possible small bilateral pleural effusions. Dilated tortuous\n thoracic aorta.\n ______________________________________________________________________________\n FINAL REPORT\n AP AND LATERAL CHEST ON .\n\n HISTORY: Cirrhosis. New fluid overload. Evaluate pulmonary process.\n\n IMPRESSION: AP frontal chest rotated rightward and a lateral view are\n compared to :\n\n Mild cardiomegaly is probably unchanged. Lungs are clear. Pulmonary and\n mediastinal vasculature are normal and there is no pleural abnormality or\n evidence of central adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-01-09 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1225547, "text": " 8:31 AM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate for intraperitoneal free air\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis s/p 2 taps.\n REASON FOR THIS EXAMINATION:\n please evaluate for intraperitoneal free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old female with cirrhosis status post two taps. Evaluate\n for intraperitoneal free air.\n\n COMPARISON: .\n\n FINDINGS: Single upright view of the abdomen was provided as the patient was\n not able to tolerate lying flat on her side. The bowel gas pattern is normal\n without gaseous dilatation of bowel loops. Evaluation of the abdomen is\n somewhat limited due to poor photon penetration, but no free air under the\n diaphragm is seen on the upright view. No pneumatosis. No radiopaque foreign\n bodies. No osseous lesions concerning for malignancy.\n\n IMPRESSION: No obstruction or free air.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-17 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1226668, "text": " 4:12 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: CIRRHOSIS ,RISING BILI,EVAL FOR BILIARY DILATATION\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis, rising bili\n REASON FOR THIS EXAMINATION:\n r/o e/o biliary dilatation\n ______________________________________________________________________________\n WET READ: GMSj SAT 4:47 PM\n -Cholelithiasis without acute cholecystitis\n -Cirrhotic liver - no focal lesion\n -No intra or extrahepatic ductal dilatation - CBD: 6 mm\n -Limited eval of pancreatic tail due to overlying bowel gas\n -Moderate ascites\n -Spleen measuring at the upper limits of normal at 12.4 cm\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old female with cirrhosis and rising bilirubin. Evaluate\n for ductal dilatation.\n\n COMPARISON: CT torso from and right upper quadrant\n ultrasound from .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates a shrunken nodular\n appearance, findings consistent with history of cirrhosis. No focal hepatic\n lesion is identified. The main portal vein is patent with hepatopetal flow.\n The gallbladder is filled with stones, however, demonstrates no distention,\n wall thickening or pericholecystic fluid to suggest acute inflammation. No\n intra- or extra-hepatic biliary ductal dilatation is identified. The common\n bile duct measures 6 mm and is normal. The pancreatic head, neck and body\n appear normal. Evaluation of the tail is limited by overlying bowel gas. The\n spleen measures at the upper limits of normal at 12.4 cm, similar compared to\n prior examinations. There is a moderate amount of intra-abdominal ascites.\n\n IMPRESSION:\n 1. Cirrhotic liver without focal lesion.\n 2. Cholelithiasis without evidence of acute cholecystitis. No intra- or\n extra-hepatic biliary dilatation.\n 3. Stable moderate ascites.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1225861, "text": " 11:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?new infiltrate\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with fever of unknown origin.\n REASON FOR THIS EXAMINATION:\n ?new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:43 P.M., \n\n HISTORY: Fever, suspect pneumonia.\n\n IMPRESSION: AP chest compared to .\n\n Moderate cardiomegaly has worsened and pulmonary and mediastinal vascular\n congestion have developed. There is no pulmonary edema. There is\n heterogeneous opacification of the right lung, partially obscuring the\n hemidiaphragm. Whether this is pneumonia or atelectasis is radiographically\n indeterminate.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-01-15 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1226359, "text": " 10:59 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Rule out free air or infectious source.\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with HCV cirrhosis multiple attempts on paracentesis\n yesterday also with persistent fevers no source of infection and also concern\n for possible stroke.\n REASON FOR THIS EXAMINATION:\n Rule out free air or infectious source.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HCV cirrhosis, status post multiple paracentesis, now with\n persistent fevers and no source of infection, rule out free air or infectious\n source.\n\n COMPARISON: CT abdomen and pelvis .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n pubic symphysis without IV or oral contrast. Coronal and sagittal\n reformations were provided and reviewed.\n\n DLP: 844.78 mGy-cm.\n\n CHEST: There are bilateral pleural effusions which have improved slightly\n since prior studies. There are no nodules, masses, or pneumothoraces. The\n heart size is large. The previously seen pericardial effusion has decreased\n in size. The wall of the descending aorta is clearly visualized, indicating\n anemia. Major airways are patent. There is no axillary, hilar, or\n mediastinal lymphadenopathy.\n\n ABDOMEN: The liver is nodular and atrophic consistent with cirrhosis. There\n are no focal lesions seen on this non-contrast enhanced study. Dependent\n gallstones are seen within the gallbladder without secondary signs of\n cholecystitis. The spleen is of normal size. The pancreas, adrenal glands,\n and kidneys are unremarkable. Assessment for vessel patency is limited by the\n lack of contrast. There is no free air to suggest perforation. Compared to\n prior study, the amount of ascites has increased slightly and appears to be\n dependently located in the right lower quadrant.\n\n PELVIS: There is air in the bladder from Foley catheter placement. The\n rectum and sigmoid are unremarkable. The uterus is normal for age. There is\n no inguinal lymphadenopathy.\n\n BONES AND SOFT TISSUES: There are no suspicious osseous lesions. Significant\n soft tissue stranding is seen around the right lower quadrant.\n\n IMPRESSION:\n 1. No perforation.\n 2. Dependent ascites, which has increased slightly since prior exam.\n 3. Improvement of the small bilateral pleural effusions and resolution of a\n (Over)\n\n 10:59 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Rule out free air or infectious source.\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small pericardial effusion.\n 4. Cholelithiasis without cholecystitis.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1226360, "text": " 10:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out acute infarct, brain edema or hemorrhage\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with HCV cirrhosis multiple attempts on paracentesis\n yesterday also with persistent fevers no source of infection and also concern\n for possible stroke.\n REASON FOR THIS EXAMINATION:\n rule out acute infarct, brain edema or hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of hepatitis C cirrhosis, persistent fevers, and concern\n for possible stroke.\n\n COMPARISONS: CT head, . MRI head .\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n infarction. The ventricles and sulci are prominent, suggesting age-related\n atrophy, which is unchanged from prior exams. There is no evidence of\n cerebral edema. Confluent hypodensities in the periventricular white matter\n suggests chronic small vessel ischemic disease. This is also unchanged from\n prior exams. The basal cisterns are patent. There is preservation of\n -white matter differentiation.\n\n No fracture is identified. Calcifications along the anterior falx and right\n tentorium are unchanged. Mild enlargement of the sagittal sinus is stable and\n likely a normal variant as confirmed with the previous MRI. No fracture is\n identified. The visualized paranasal sinuses, mastoid air cells, and middle\n ear cavities are clear. The soft tissues are unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Stable chronic small vessel ischemic disease.\n\n" }, { "category": "Radiology", "chartdate": "2105-02-03 00:00:00.000", "description": "PARACENTESIS DIAG/THERAP W IMAGING GUID", "row_id": 1228921, "text": " 9:20 AM\n PARACENTESIS DIAG/THERAP W IMAGING GUID; Clip # \n Reason: 3L Therapeutic paracentesis\n Admitting Diagnosis: ASCITES\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG/THERAP W IMAGING G *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with ascites, previously difficult paracentesis on floor\n REASON FOR THIS EXAMINATION:\n 3L Therapeutic paracentesis\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of HCV cirrhosis. Increasing ascites. Therapeutic\n paracentesis.\n\n FINDINGS: Limited ultrasound scan of the abdomen shows a large amount of\n ascites present. A site suitable for percutaneous aspiration was marked in\n the left lower quadrant under ultrasound guidance.\n\n TECHNIQUE: Written informed consent was obtained from the patient's proxy\n prior to the procedure, explaining risks and benefits. A timeout was\n performed prior to the procedure, confirming patient identity by three\n parameters and the procedure to be performed.\n\n The patient was prepped and draped in the usual sterile manner. The\n superficial tissues were infiltrated with 15 cc of 1% lidocaine. A 5 French\n catheter was inserted percutaneously. 3 liters of clear yellow fluid\n were aspirated. No significant complication occurred during the procedure. A\n sterile dressing was applied.\n\n The attending radiologist, Dr. , supervised the procedure.\n\n IMPRESSION: Successful ultrasound-guided percutaneous aspiration of 3 liters\n ascites.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-20 00:00:00.000", "description": "PARACENTESIS DIAG/THERAP W IMAGING GUID", "row_id": 1226978, "text": " 9:09 AM\n PARACENTESIS DIAG/THERAP W IMAGING GUID; Clip # \n Reason: 3L therapeutic paracentesis\n Admitting Diagnosis: ASCITES\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG/THERAP W IMAGING G *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis and tense ascites with previously very\n difficult paracentesis on floor\n REASON FOR THIS EXAMINATION:\n 3L therapeutic paracentesis\n CONTRAINDICATIONS for IV CONTRAST:\n acute kidney injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and ascites.\n\n PROCEDURE: Preliminary four-quadrant ultrasound demonstrates a large amount\n of intra-abdominal free fluid consistent with ascites. After discussion of\n the risks, benefits and alternatives of the procedure, written informed\n consent was obtained. A preprocedure timeout was performed using three\n patient identifiers per protocol.\n\n The right lower quadrant was selected and marked as it contained the largest\n pocket of free fluid. The skin was prepped and draped in the usual sterile\n fashion. Approximately 7 mL of buffered 1% lidocaine was infiltrated into the\n skin and subcutaneous tissues for local anesthesia. A 5 French catheter\n was passed into the peritoneum. The catheter was then attached to wall\n suction and 3 liters of clear yellow fluid was drained.\n\n The patient tolerated the procedure well and there was no immediate\n complication. The patient was transferred back to the daycare unit for\n observation and discharged.\n\n The attending radiologist, Dr. , was present for the critical\n portions of the procedure.\n\n IMPRESSION: Technically successful therapeutic paracentesis with removal of 3\n liters of clear yellow fluid.\n\n" }, { "category": "Radiology", "chartdate": "2105-01-22 00:00:00.000", "description": "PARACENTESIS DIAG/THERAP W IMAGING GUID", "row_id": 1227308, "text": " 1:08 PM\n PARACENTESIS DIAG/THERAP W IMAGING GUID Clip # \n Reason: 3L paracentesis (only 3L at a time because patient will not\n Admitting Diagnosis: ASCITES\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG/THERAP W IMAGING G *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis and previously difficult paracenteses on the\n floor\n REASON FOR THIS EXAMINATION:\n 3L paracentesis (only 3L at a time because patient will not get albumin)\n CONTRAINDICATIONS for IV CONTRAST:\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis with ascites.\n\n OPERATORS: Dr. (attending), Dr. (resident) and Dr. \n (resident).\n\n ANESTHESIA: 5 cc of buffered 1% lidocaine.\n\n SPECIMENS SENT: Culture, cell count, and chemistry.\n\n PROCEDURE: Preliminary four-quadrant ultrasound demonstrates a large amount\n of intra-abdominal free fluid consistent with ascites. After discussion of\n the risks, benefits and alternatives of the procedure, written informed\n consent was obtained. A preprocedure timeout was performed using three\n patient identifiers per protocol.\n\n The right lower quadrant was selected and marked as it contained the largest\n pocket of free fluid. The skin was prepped and draped in the usual sterile\n fashion. Approximately 5 mL of buffered 1% lidocaine was infiltrated into the\n skin and subcutaneous tissues for local anesthesia. A 5 French catheter\n was passed into the peritoneum. Approximately 20 mL of clear yellow fluid was\n removed for diagnostic evaluation. The catheter was then attached to wall\n suction and 3 liters of yellow fluid was drained.\n\n The patient tolerated the procedure well and there was no immediate\n complication.\n\n The attending radiologist, Dr. , was present for the critical portions of\n the procedure.\n\n IMPRESSION: Technically successful diagnostic and therapeutic paracentesis\n with removal of 3 liters of yellow fluid.\n (Over)\n\n 1:08 PM\n PARACENTESIS DIAG/THERAP W IMAGING GUID Clip # \n Reason: 3L paracentesis (only 3L at a time because patient will not\n Admitting Diagnosis: ASCITES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2105-01-27 00:00:00.000", "description": "PARACENTESIS DIAG/THERAP W IMAGING GUID", "row_id": 1227919, "text": " 8:56 AM\n PARACENTESIS DIAG/THERAP W IMAGING GUID Clip # \n Reason: therapeutic paracentesis for 3L please, thanks!\n Admitting Diagnosis: ASCITES\n ********************************* CPT Codes ********************************\n * PARACENTESIS DIAG/THERAP W IMAGING G *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with cirrhosis, ascites, needs tap\n REASON FOR THIS EXAMINATION:\n therapeutic paracentesis for 3L please, thanks!\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis with ascites.\n\n PROCEDURE: Preliminary four-quadrant ultrasound demonstrates a large amount\n of intra-abdominal free fluid consistent with ascites. After discussion of\n the risks, benefits and alternatives of the procedure, written informed\n consent was obtained. A preprocedure timeout was performed using three\n patient identifiers per protocol.\n\n The right lower quadrant was selected and marked as it contained the largest\n pocket of free fluid. The skin was prepped and draped in the usual sterile\n fashion. Approximately 5 mL of buffered 1% lidocaine was infiltrated into the\n skin and subcutaneous tissues for local anesthesia. A 5 French catheter\n was passed into the peritoneum. The catheter was then attached to wall suction\n and 3 liters of yellow fluid was drained.\n\n The patient tolerated the procedure well and there was no immediate\n complication.\n\n The attending radiologist, Dr. , was present for the critical portions of\n the procedure.\n\n IMPRESSION: Technically successful therapeutic paracentesis with removal of 3\n liters of yellow fluid.\n\n" }, { "category": "ECG", "chartdate": "2105-01-10 00:00:00.000", "description": "Report", "row_id": 154454, "text": "Sinus rhythm. Low QRS voltages in the limb leads. Otherwise, within normal\nlimits. Compared to the previous tracing QRS voltages in the limb leads are\nslightly lower. Consider changing body habitus, hypothyroidism, pericardial\neffusion or simply repositioning.\n\n" } ]

[ { "category": "Nutrition", "chartdate": "2151-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553381, "text": "Subjective\n Intub, sedated, paralyzed\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 140 kg\n ^8kg\n 44.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 186\n 91.5kg\n 132kg ()\n 106\n 106\n Diagnosis: Cardiac Arrest\n PMH :\n Ebstein's Anomaly s/p TV/ASD repair\n OSA\n Pulmonary HTN\n Obesity\n HTN\n Hyperlipidemia\n Pertinent medications: amiodarone, cisatracurium, fent, levo,\n lidoncaine, versed, vasopressin, colace, hep, protonix, abx, lasix,\n others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 03:01 AM\n BUN\n 30 mg/dL\n 03:01 AM\n Creatinine\n 2.6 mg/dL\n 03:01 AM\n Sodium\n 134 mEq/L\n 03:01 AM\n Potassium\n 5.2 mEq/L\n 07:36 AM\n Chloride\n 101 mEq/L\n 03:01 AM\n TCO2\n 22 mEq/L\n 03:01 AM\n PO2 (arterial)\n 109 mm Hg\n 09:16 AM\n PCO2 (arterial)\n 43 mm Hg\n 09:16 AM\n pH (arterial)\n 7.31 units\n 09:16 AM\n pH (urine)\n 6.5 units\n 02:56 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:16 AM\n Calcium non-ionized\n 8.5 mg/dL\n 03:01 AM\n Phosphorus\n 3.7 mg/dL\n 03:01 AM\n Ionized Calcium\n 1.09 mmol/L\n 03:25 AM\n Magnesium\n 1.7 mg/dL\n 03:01 AM\n ALT\n 400 IU/L\n 03:01 AM\n Alkaline Phosphate\n 68 IU/L\n 03:01 AM\n AST\n 448 IU/L\n 03:01 AM\n Total Bilirubin\n 1.2 mg/dL\n 03:01 AM\n WBC\n 13.4 K/uL\n 03:01 AM\n Hgb\n 14.2 g/dL\n 03:01 AM\n Hematocrit\n 42.9 %\n 03:01 AM\n Current diet order / nutrition support: NPO, TF c/s\n GI: abd firm, dist, hypo bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO, witnessed aspiration during intubation, ARF,\n CHF\n Estimated Nutritional Needs ( per adj BW)\n Calories: 1830- (BEE x or / 20-22 cal/kg)\n Protein: 119-137 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Specifics:\n 39M presented to ED with unstable ventricular tachycardia, s/p\n resuscitation with return to sinus tachycardia, now intubated, with\n hypoxic and hypercarbic respiratory failure. Pt currently with\n decreased urine output, like ATN d/t hypoperfusion. Nutrition c/s for\n TF, pt not appropriate for enteral feed at this time given the\n amounts/types of gtts he is on, per chart, pt also with very distend\n abd, ? paralytic ilesu. Consider holding off nutrition support for\n 2-3days given pt is well nourished prior to adm, and acutely ill at\n this time. TPN rec below if plan to start nutrition support today.\n Medical Nutrition Therapy Plan - Recommend the Following\n TPN: start day 1 (150des/70aa), lytes pending am chem. 10\n Check chemistry 10 panel daily, adj TPN prn\n Check triglycerides, if <400, can give lipid\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Provided TG , 400 and Bg <150, goal TPN will be 80kg 3-in -1 to\n provide 2000kcal/120g pro\n If prefer to trial TF: Vivonex TEN at 10ml/hr, monitor tol. Hold for\n residual >100\n Other: f/u re poc, please page if has ?\n" }, { "category": "Echo", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 78220, "text": "PATIENT/TEST INFORMATION:\nIndication: Ebsteins anomaly. S/p repair. Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 308\nBSA (m2): 2.56 m2\nBP (mm Hg): 102/67\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 09:00\nTest: Portable TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Systolic performance could not be assessed. The right\nventricular cavity is markedly dilated The free wall is hypokinetic. The\naortic and tricuspid valves are not well seen. The mitral valve is grossly\nnormal. No definite mitral regurgitation is seen.\n\n\n" }, { "category": "Echo", "chartdate": "2151-03-15 00:00:00.000", "description": "Report", "row_id": 78210, "text": "PATIENT/TEST INFORMATION:\nIndication: Ebstein' s anomaly, s/p surgical repair. S/p ASD repair. Reassess LV function s/p recent VF arrest\nHeight: (in) 72\nWeight (lb): 307\nBSA (m2): 2.56 m2\nBP (mm Hg): 120/69\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 17:01\nTest: Portable TTE (Congenital, focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Prominent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Low\nnormal LVEF.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall\nhypokinesis. Abnormal septal motion/position.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Tricuspid valve annuloplasty ring. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is low normal (LVEF 50%). The right ventricular cavity is markedly\ndilated with severely depressed free wall contractility. There is abnormal\nseptal motion/position. The aortic valve leaflets appear structurally normal\nwith good leaflet excursion. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. No mitral regurgitation is seen. A tricuspid\nvalve annuloplasty ring is present. The ring is well seated. The leaflets are\nnot well seen, but the gradient across the valve is increased (mean 6mmHg).\nThe pulmonary artery systolic pressure could not be quantified. There is no\npericardial effusion.\n\nIMPRESSION: Marked right ventricular cavity enlargement with free wall\nhypokinesis. Normal left ventricular cavity size with low normal systolic\nfunction. Well seated tricuspid annuloplasty ring with increased gradient.\n\n\n" }, { "category": "Echo", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 78211, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease with Ebstein's anomaly and strial septal defect s/p closure and tricuspid annuloplasty. ?intracardiac shunt\nHeight: (in) 72\nWeight (lb): 300\nBSA (m2): 2.53 m2\nBP (mm Hg): 97/67\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 14:18\nTest: Portable TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Depressed LAA emptying velocity (<0.2m/s)\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or thrombus in\nthe body of the RA or RAA. Depressed RAA ejection velocity (<0.2m/s). No ASD\nby 2D or color Doppler. Prominent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Depressed LVEF.\n\nRIGHT VENTRICLE: Dilated RV cavity. Severe global RV free wall hypokinesis.\n\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Normal aortic valve leaflets\n(3). No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: The septal insertion of the tricuspid valve is apically\ndisplaced, consistent with Ebstein's anomaly. Tricuspid valve annuloplasty\nring. Mild to moderate [+] TR. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the left atrium/left\natrial appendage or the right atrium/right atrial appendage. The left and\natrial and right appendage emptying velocities are depressed (<0.2m/s). The\nintra-atrial septum is thickened consistent with prior ASD closure surgery. No\nresidual atrial septal defect is seen by 2D or color Doppler. Left ventricular\nwall thickness and cavity size are grossly normal. The apex is heavily\ntrabeculated. Systolic function could not be adequately assessed. Th e\nsystolic function appears depressed. The right ventricular cavity is dilated\nwith marked free wall hypokinesis. There are simple atheroma in the descending\nthoracic aorta to 45cm from the incisors. The descending aorta is relatively\nsmall, but no coarctation or dissection is seen. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. No mass or vegetation is seen on the mitral\nvalve. The tricuspid annular ring is identified and appears well seated. Mild\nto moderate tricuspid regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: No atrial septal defect by 2D or color Doppler. Well seated\ntricuspid annular ring with mild-moderate tricuspid regurgitation. Severe\nright ventricular cavity enlargement with depressed biventricular systolic\nfunction.\n\n\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555139, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers. Wife stayed over noc. D5W maintenance\n for elevated NA levels d/c\nd (Na+ 140) PT on consult but did not get to\n see pt yet. Pt conts doing leg and arm lifts & assisting with turns.\n NPO p mn for EP study in AM, remained afebrile. Wore own bipap\n overnite.\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555140, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers. Wife stayed over noc. D5W maintenance\n for elevated NA levels d/c\nd (Na+ 140) PT on consult but did not get to\n see pt yet. Pt conts doing leg and arm lifts & assisting with turns.\n NPO p mn for EP study in AM, remained afebrile. Wore own bipap\n overnite.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553649, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Hemodynimic instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt has aspiration pneumonia , Pt having frequent PVC throughout\n shift. ABG have improved, plan to D/C Inovent/ NO when pt PVC can be\n evaluted . sedation has been reduced, paralytics are off. Last balloon\n measurements Transpulmonary low = -4,\n Transpulmonary high = 10. Should be noted that pt was making some\n disruptive inspiratory efforts during measurements.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553830, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: No spontaneous breathing\n efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol, Maintain PEEP at current\n level and reduce FiO2 as tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ABG remains WNL on 19 cm peep and 60% Fio2. Secretions are usually\n minimal. Cardiology attending is concerned about peep levels and wants\n to try to wean peep slowly, decreased from 20 cm to 19 cm this shift.\n Pt remains on 60% oxygen which\n Somewhat increase risk of ARDS developing. Plan is to discuss weather\n to wean more peep before weaning FiO2 . Esophageal balloon still in\n place but INO vent was D/C\nd yesterday.\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 555032, "text": "TITLE:\n Chief Complaint: VF arrest\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:01 AM\n INVASIVE VENTILATION - STOP 01:20 PM\n ARTERIAL LINE - STOP 04:50 AM\n FEVER - 102.8\nF - 09:47 AM\n .\n Patient was extubated yesterday with anesthesia and pulmonary present.\n Post extubation gas showed adequate oxygenation. Put patient in for\n speech and swallow evaluation given that NG tube removed and has been\n intubated for over a week. Patient interactive and responsive. Fever\n curve treding down. PM lytes showed increased Na to 149 so turned up\n D5W to 200 cc/hour. Now increasingly volume up but also persistently\n hypernatremic.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Midazolam (Versed) - 10:55 AM\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Other medications:\n No change to PMHX\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.2\nC (99\n HR: 58 (55 - 100) bpm\n BP: 99/66(70) {92/48(61) - 103/66(70)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,403 mL\n 1,455 mL\n PO:\n 120 mL\n 180 mL\n TF:\n 546 mL\n IVF:\n 3,907 mL\n 1,275 mL\n Blood products:\n Total out:\n 2,360 mL\n 675 mL\n Urine:\n 2,360 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,043 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (90 - 893) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.38/54/132/34/5\n Ve: 10.1 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.8 g/dL\n 405 K/uL\n 105 mg/dL\n 1.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 60 mg/dL\n 106 mEq/L\n 146 mEq/L\n 34.2 %\n 10.9 K/uL\n [image002.jpg]\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n WBC\n 12.2\n 10.9\n Hct\n 35.1\n 34.2\n Plt\n 458\n 405\n Cr\n 1.7\n 1.6\n 1.7\n 1.5\n TCO2\n 35\n 34\n 37\n 37\n 34\n 33\n Glucose\n 110\n 101\n 113\n 105\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:119/67, Alk Phos / T Bili:46/0.9,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.0 mg/dL, Mg++:3.1 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now extubated s/p a prolonged\n intubation for hypoxic and hypercarbic respiratory failure, persistent\n fevers now trending down and persistent hypernatremia.\n # Respiratory Failure now s/p extubation: Mixed hypoxemia and\n hypercarbia. Pt was extubated yesterday without complication. MS\n today alert and interactive. Sats stable on 4L, high flow. Likely a\n component of OSA contributing to patient\ns ongoing hypercarbia.\n - CPAP at night\n - cont. nebs\n - raise head of bed to relieve pressure from abdomen\n - Wean O2 as tolerated to maintain sats >92%\n - f/u am CXR\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - . BB to 25mg tid given bradycardia\n -Cont. Lisinopril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD. Will discuss timing with EP today\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed . Fevers now resolving after extubation.\n - ID following, appreciate their recs\n - f/u mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum pending given inc. secretions\n - Tylenol prn now given fevers resolving, d/c standing ASA\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis and insensible losses\n in setting of persistant fevers. Free water deficit initially 8L,\n improving with inc. free water flushes and D5. Na today improved to\n 146.\n -holding lasix\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair. TTE peri-arrest showed poor systolic function. Repeat on \n showed improved systolic function with EF 50%\n - holding digoxin\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n - Monitor I/O\n # ARF: due to ATN, Cr continues to improve daily.\n - d/ced lasix gtt\n - monitor UOP\n - Cont. to follow\n # Bowel motility/nutrition\n Now s/p extubation, moving bowels\n - Speech and swallow today\n - ADAT once cleared by S&S\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Medical Decision Making\n Doing well post extubation. Also now afebrile. Continue management for\n chronic hypoventilation syndrome. Will review with EP for continuation\n of amiodarone given young age and baseline pulmonary disease.\n Above discussed extensively with patient.\n Total time spent on patient care: 25 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:45 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555297, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, shocked into VF, requiring intubation\n and pressors. Pt\n CV - Pt has been without vea x 7 days, stable on Amiodarone and\n lopressor.\n Resp -Extubation , able to tolerate NP.\n Gi\n Abd obese w/ +bs. Tolerating NAS low chol diet. No stool\n GU\n foley cath patent to amber urine.\n ID\n afebrile. Last temp spike\n Access\n TLC placed.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains intubated & vented. Thick tannish secretions. Able to expel air\n & talk around inflated ETT cuff @ times. Sats decreasing when above\n occurring.\n Action:\n Sx as indicated. ETT cuff pressure cked-35mmhg. Vent settings chged to\n CMV/AC. Sedation increased & bloused w Versed 2mg iv x2. Freq. position\n changes, HOB 30-45deg. On IVF in addition to free water via OGT for\n elevated Na+.\n Response:\n Stable sats w increased sedation. Without recurrence of leak with\n increased sedation. Adeq U/O-remains overall positive approx 4l.\n Plan:\n Place back on CPAP/PS as tolerated. Contin vent wean as tolerated.\n Maint adeq sedation.^ ^\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Continues febrile. Off abx. Contin to receive ASA & Tylenol tid. All\n cultures to date-neg. Last cultured .\n Action:\n Tylenol 2gm/day and ASA contin.\n Response:\n Remains febrile. Off cooling blanket.\n Plan:\n Follow with ID recs. Contin present rx.\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone & Lopressor po.\n Action:\n Maint Potassium >4.0.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Responsive. Appropriate @ times. Very restless @ times. Will attempt to\n reach for ETT if able.\n Action:\n Fent. Gtt increased due to forceful coughing (freq) resulting in\n leakage around ETT cuff & decreased sats.\n Response:\n Improved sats w increased fentanyl gtt. Remains easily\n arousable-following simple commands.\n Plan:\n Decrease sedation as tolerated. Adeq safety measures. Reorient freq.\n Ineffective Coping\n Assessment:\n Patients wife & mother encouraged with patients progress. Becomes\n easily concerned when vent/monitor alarms.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation.\n Plan:\n Contin support pt/family asindicated.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Balance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Muscle Performace, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Transfers, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2151-03-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554188, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment:\n :\n Comments:\n Plan\n Next 24-48 hours: wean peep as tol\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2151-03-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554292, "text": "Demographics\n Day of mechanical ventilation: 0\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n :\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Bronchial\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1600\n no incident\n" }, { "category": "Nursing", "chartdate": "2151-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553819, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n EVENTS:R Femoral TLC d/c & tip sent for culture. Remains febrile with\n all cultures pending. Positive nasal swab for MSRA.\n ACCESS: RIJ TLC & R Radial Aline.\n Ventricular tachycardia, sustained\n Assessment:\n Short runs VT noted. Minimal perfusion with VT. Continues on Levophed\n gtt-0.120mcg/kg/min.\n Action:\n Amiodarone continues @ 0.5mg/min.\n Response:\n Continues with PVC\ns. Short runs VT noted. Pressor dependent.\n Plan:\n Con\nt amio gtt. Ck AM Labs-replace as indicated. Contin Levophed\n gtt-wean as tolerated.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lasix gtt @ 20mg/hr. LS diminished throughout. Remains intubated-PEEP\n decreased to 19 with stable ABG. Fentanyl gtt up @ 50mcg/hr.\n Action:\n Lasix gtt. Fentanyl gtt.\n Response:\n Diuresing to Lasix gtt, but remains approx 4L positive over all.\n Stable Sats/ABGs. Comfortable on low dose fentanyl gtt-easily arousable\n to noxious stimuli/presently not following commands. Not requiring\n Versed IV.\n Plan:\n Cont diuresis. Contin low dose Fentanly gtt. ?Wean FiO2 or PEEP as\n tolerated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile despite cooling blanket, Tylenol/ASA, & Abx.\n Action:\n Cooling blanket. Abx. Antipyretics. Vanco trough sent.\n Response:\n Remains febrile.\n Plan:\n Con\nt cooling blanket. Con\nt to monitor temps. Con\nt Abx &\n antipyretics.\n" }, { "category": "Physician ", "chartdate": "2151-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554016, "text": "CCU Intern Progress Note:\n Chief Complaint:\n 24 Hour Events:\n - vanc dose increased to 1000mg q12h\n - amiodarone IV --> 400 PO TID\n - fever curve improving (100s)\n - on fentanyl gtt, lasix gtt\n - levophed gtt weaned for most day, but restarted at 4am on for\n SBP in low 80s.\n - attempted weaning PEEP, but pt not tolerating well\n - hiccup episode resulting in desat to 80s, resolved without\n intervention\n - diarrhea started --> flexiseal tube placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:15 AM\n Piperacillin/Tazobactam (Zosyn) - 04:17 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Furosemide (Lasix) - 20 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:17 PM\n Fentanyl - 05:15 PM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.2\nC (100.7\n HR: 96 (81 - 97) bpm\n BP: 109/69(79) {84/50(61) - 120/70(84)} mmHg\n RR: 28 (25 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 22 (21 - 22)mmHg\n Total In:\n 2,380 mL\n 477 mL\n PO:\n TF:\n 495 mL\n 306 mL\n IVF:\n 1,655 mL\n 171 mL\n Blood products:\n Total out:\n 3,560 mL\n 505 mL\n Urine:\n 3,560 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,180 mL\n -28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 30 cmH2O\n SpO2: 94%\n ABG: 7.40/43/86/27/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 156\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 132 mg/dL\n 2.9 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 85 mg/dL\n 99 mEq/L\n 139 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 04:42 PM\n 04:58 PM\n 08:18 PM\n 04:12 AM\n 04:26 AM\n 02:54 PM\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n WBC\n 11.4\n 18.9\n Hct\n 36.4\n 36.1\n 37.2\n Plt\n 269\n 307\n Cr\n 2.5\n 2.3\n 2.1\n 2.9\n TCO2\n 27\n 25\n 29\n 30\n 28\n Glucose\n 141\n 130\n 147\n 132\n 132\n Other labs:\n PT / PTT / INR:18.4/31.3/1.7,\n CK / CKMB / Troponin-T:4046/9/0.30,\n ALT / AST:765/267,\n Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200,\n Differential-Neuts:86.6 %, Lymph:10.8 %, Mono:2.4 %, Eos:0.1 %,\n Fibrinogen:546 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677\n IU/L,\n Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP for today is 15\n per pulm recs.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n - wean sedation, off midazolam\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Attempt to d/c levophed to improve ectopy, tolerate MAP >60.\n - Consider trail of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - wean levophed as tolerated\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased.\n Cultures negative thus far. Fem line removed and sent for culture. ?\n drug fever given persistant fever and no pos. cx data.\n - Cultures from peripheral and from line pending\n - fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 6, plan for 8-day course for VAP to\n complete on \n - Cont. vanc, dosed by levels given renal function improving\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued and now improving, 2.4 today.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd yesterday, new IJ placed . Fever curve\n decreasing, will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553853, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CBC with diff showed increased\n neutrophils, leukocytosis improving\n - Dr. placed right IJ line\n - femoral line removed, sent for cx, after holding pressure for 5\n minutes, groin bled small amound after pt coughing; then hemostasis\n acheived with 15 minutes of groin pressure\n - blood cx form fem and art line\n - increased lactulose, BS now positive\n - increased ectopy in AM, with 7-8 runs NSVT, was dropping SBP with\n these episodes to 70s, therefore restarted amio at noon gtt with 300mg\n bolus, then 1mg for 6 hours and 0.5 afterwards\n - FIO2 weaned to 60%, PEEP weaned from 20 to 19, Nitric oxide was\n stopped\n - nutrution recs for tube feeds placed, orders placed\n - PM lytes stable\n - negative 596ml\n - vanco level 10.3\n Medications\n Unchanged\n Physical Exam\n General appearance: vent setings- CMV/Assist VT 450, RR 28, PEEP 19,\n FIO2 60%\n BP: 102 / 57 mmHg\n HR: 85 bpm\n Tmax C last 24 hours: 39.4 C\n Tmax F last 24 hours: F\n T current C: 38.6 C\n T current F: 101.4 F\n O2 sat: 95 % on Supplemental oxygen: FIO2 60\n Previous day:\n Intake: 2,111 mL\n Output: 2,700 mL\n Fluid balance: -589 mL\n Today:\n Intake: 440 mL\n Output: 725 mL\n Fluid balance: -285 mL\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 269\n 12.3\n 130\n 2.3\n 27\n 3.6\n 70\n 102\n 138\n 36.1\n 11.4\n [image002.jpg]\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n 04:42 PM\n 04:58 PM\n 04:12 AM\n WBC\n 14.4\n 11.4\n Hgb\n 12.9\n 12.3\n Hct (Serum)\n 38.0\n 36.4\n 36.1\n Plt\n 249\n 269\n INR\n 1.9\n 1.7\n PTT\n 35.1\n 34.8\n Na+\n 132\n 135\n 137\n 138\n K + (Serum)\n 4.6\n 4.1\n 4.1\n 3.6\n Cl\n 96\n 99\n 100\n 102\n HCO3\n 23\n 25\n 26\n 27\n BUN\n 55\n 60\n 68\n 70\n Creatinine\n 3.1\n 2.5\n 2.5\n 2.3\n Glucose\n 137\n 143\n 141\n 130\n O2 sat (arterial)\n 94\n 89\n 94\n 97\n 98\n 94\n ABG: 7.42 / 43 / 112 / / 2 Values as of 04:26 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - wean Fi02 preferentially over PEEP as tolerated. Consider decreasing\n PEEP once Fi02 <50%.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy yesterday and amiodarone restarted.\n - Appreciate electrophysiology input\n - Cont. amiodatrone gtt\n - Attempt to d/c levophed to improve ectopy, tolerate MAP >60. If\n tolerates stopping pressors and has room on BP with persistent ectopy,\n increase BB and consider dialing down on PEEP to leave BP room for BB.\n Trial of IV lopressor 2.5-5mg IV Q4 hours\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today, decreaseing PEEP if necessary. Attempt to add BB\n as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - fem line out, consider PICC once afebrile vs CVL line under fluoro/\n in cath lab.\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 5, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low, next\n level tonight\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - Discontinued amiodarone\n - monitor liver function\n -got vitamin K yesterday\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: right femoral line, art line. Fever curve decreasing, will\n monitor femoral blood cultures. Fem line out , attempt CVL\n placement today.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553855, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CBC with diff showed increased\n neutrophils, leukocytosis improving\n - Dr. placed right IJ line\n - femoral line removed, sent for cx, after holding pressure for 5\n minutes, groin bled small amound after pt coughing; then hemostasis\n acheived with 15 minutes of groin pressure\n - blood cx form fem and art line\n - increased lactulose, BS now positive\n - increased ectopy in AM, with 7-8 runs NSVT, was dropping SBP with\n these episodes to 70s, therefore restarted amio at noon gtt with 300mg\n bolus, then 1mg for 6 hours and 0.5 afterwards\n - FIO2 weaned to 60%, PEEP weaned from 20 to 19, Nitric oxide was\n stopped\n - nutrution recs for tube feeds placed, orders placed\n - PM lytes stable\n - negative 596ml\n - vanco level 10.3\n Medications\n Unchanged\n Physical Exam\n General appearance: vent setings- CMV/Assist VT 450, RR 28, PEEP 19,\n FIO2 60%\n BP: 102 / 57 mmHg\n HR: 85 bpm\n Tmax C last 24 hours: 39.4 C\n Tmax F last 24 hours: F\n T current C: 38.6 C\n T current F: 101.4 F\n O2 sat: 95 % on Supplemental oxygen: FIO2 60\n Previous day:\n Intake: 2,111 mL\n Output: 2,700 mL\n Fluid balance: -589 mL\n Today:\n Intake: 440 mL\n Output: 725 mL\n Fluid balance: -285 mL\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 269\n 12.3\n 130\n 2.3\n 27\n 3.6\n 70\n 102\n 138\n 36.1\n 11.4\n [image002.jpg]\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n 04:42 PM\n 04:58 PM\n 04:12 AM\n WBC\n 14.4\n 11.4\n Hgb\n 12.9\n 12.3\n Hct (Serum)\n 38.0\n 36.4\n 36.1\n Plt\n 249\n 269\n INR\n 1.9\n 1.7\n PTT\n 35.1\n 34.8\n Na+\n 132\n 135\n 137\n 138\n K + (Serum)\n 4.6\n 4.1\n 4.1\n 3.6\n Cl\n 96\n 99\n 100\n 102\n HCO3\n 23\n 25\n 26\n 27\n BUN\n 55\n 60\n 68\n 70\n Creatinine\n 3.1\n 2.5\n 2.5\n 2.3\n Glucose\n 137\n 143\n 141\n 130\n O2 sat (arterial)\n 94\n 89\n 94\n 97\n 98\n 94\n ABG: 7.42 / 43 / 112 / / 2 Values as of 04:26 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP for today is 15\n per pulm recs.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n - wean sedation, off midazolam\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy yesterday and amiodarone restarted\n with decreased ectopy ovenight.\n - Appreciate electrophysiology input\n - Cont. , switch to PO 400mg tid\n - Attempt to d/c levophed to improve ectopy, tolerate MAP >60.\n - Consider trail of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today if able, decreaseing PEEP as tolerated. Attempt\n to add BB as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased.\n Cultures negative thus far. Fem line removed and sent for culture. ?\n drug fever given persistant fever and no pos. cx data.\n - Cultures from peripheral and from line pending\n - fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 6, plan for 8-day course for VAP to\n complete on \n - Cont. vanc, dosed by levels given renal function improving\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued and now improving, 2.4 today.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd yesterday, new IJ placed . Fever curve\n decreasing, will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553859, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CBC with diff showed increased\n neutrophils, leukocytosis improving\n - Dr. placed right IJ line\n - femoral line removed, sent for cx, after holding pressure for 5\n minutes, groin bled small amound after pt coughing; then hemostasis\n acheived with 15 minutes of groin pressure\n - blood cx form fem and art line\n - increased lactulose, BS now positive\n - increased ectopy in AM, with 7-8 runs NSVT, was dropping SBP with\n these episodes to 70s, therefore restarted amio at noon gtt with 300mg\n bolus, then 1mg for 6 hours and 0.5 afterwards\n - FIO2 weaned to 60%, PEEP weaned from 20 to 19, Nitric oxide was\n stopped\n - nutrution recs for tube feeds placed, orders placed\n - PM lytes stable\n - negative 596ml\n - vanco level 10.3\n Medications\n Unchanged\n Physical Exam\n General appearance: vent setings- CMV/Assist VT 450, RR 28, PEEP 19,\n FIO2 60%\n BP: 102 / 57 mmHg\n HR: 85 bpm\n Tmax C last 24 hours: 39.4 C\n Tmax F last 24 hours: F\n T current C: 38.6 C\n T current F: 101.4 F\n O2 sat: 95 % on Supplemental oxygen: FIO2 60\n Previous day:\n Intake: 2,111 mL\n Output: 2,700 mL\n Fluid balance: -589 mL\n Today:\n Intake: 440 mL\n Output: 725 mL\n Fluid balance: -285 mL\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 269\n 12.3\n 130\n 2.3\n 27\n 3.6\n 70\n 102\n 138\n 36.1\n 11.4\n [image002.jpg]\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n 04:42 PM\n 04:58 PM\n 04:12 AM\n WBC\n 14.4\n 11.4\n Hgb\n 12.9\n 12.3\n Hct (Serum)\n 38.0\n 36.4\n 36.1\n Plt\n 249\n 269\n INR\n 1.9\n 1.7\n PTT\n 35.1\n 34.8\n Na+\n 132\n 135\n 137\n 138\n K + (Serum)\n 4.6\n 4.1\n 4.1\n 3.6\n Cl\n 96\n 99\n 100\n 102\n HCO3\n 23\n 25\n 26\n 27\n BUN\n 55\n 60\n 68\n 70\n Creatinine\n 3.1\n 2.5\n 2.5\n 2.3\n Glucose\n 137\n 143\n 141\n 130\n O2 sat (arterial)\n 94\n 89\n 94\n 97\n 98\n 94\n ABG: 7.42 / 43 / 112 / / 2 Values as of 04:26 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP for today is 15\n per pulm recs.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n - wean sedation, off midazolam\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy yesterday and amiodarone restarted\n with decreased ectopy ovenight.\n - Appreciate electrophysiology input\n - Cont. , switch to PO 400mg tid\n - Attempt to d/c levophed to improve ectopy, tolerate MAP >60.\n - Consider trail of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today if able, decreaseing PEEP as tolerated. Attempt\n to add BB as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased.\n Cultures negative thus far. Fem line removed and sent for culture. ?\n drug fever given persistant fever and no pos. cx data.\n - Cultures from peripheral and from line pending\n - fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 6, plan for 8-day course for VAP to\n complete on \n - Cont. vanc, dosed by levels given renal function improving\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued and now improving, 2.4 today.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd yesterday, new IJ placed . Fever curve\n decreasing, will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n Continued critically ill with pressor and ventilatory requirement.\n Weaning levophed, PEEP. Change Amiodarone to PO.\n Critical care time spent 60 minutes for hemodynamic instability and\n respiratory failure.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:33 ------\n" }, { "category": "Respiratory ", "chartdate": "2151-03-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553755, "text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated; and FiO2.Nitric oxide\n turned off this shift, pt tolerated well. FiO2 weaned to 50%, then\n needed to increase to 100% for line placement. Currently FiO2 60%, Spo2\n 93-94%, pt febrile, so no more fio2 weaning for now.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Homodynamic instability, Underlying\n illness not resolved\n Respiratory Care Shift Procedures\n Specialized Gas Therapy\n Nitric Oxide\n Nitric Oxide trial: Stopped\n Comments: Pt able to come off Nitric oxide without rebound effect.\n" }, { "category": "Physician ", "chartdate": "2151-03-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553811, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CBC with diff showed increased\n neutrophils, leukocytosis improving\n - Dr. placed right IJ line\n - femoral line removed, sent for cx, after holding pressure for 5\n minutes, groin bled small amound after pt coughing; then hemostasis\n acheived with 15 minutes of groin pressure\n - blood cx form fem and art line\n - increased lactulose, BS now positive\n - increased ectopy in AM, with 7-8 runs NSVT, was dropping SBP with\n these episodes to 70s, therefore restarted amio at noon gtt with 300mg\n bolus, then 1mg for 6 hours and 0.5 afterwards\n - FIO2 weaned to 60%, PEEP weaned from 20 to 19, Nitric oxide was\n stopped\n - nutrution recs for tube feeds placed, orders placed\n - PM lytes stable\n - negative 596ml\n - vanco level 10.3\n Medications\n Unchanged\n Physical Exam\n General appearance: vent setings- CMV/Assist VT 450, RR 28, PEEP 19,\n FIO2 60%\n BP: 102 / 57 mmHg\n HR: 85 bpm\n Tmax C last 24 hours: 39.4 C\n Tmax F last 24 hours: F\n T current C: 38.6 C\n T current F: 101.4 F\n O2 sat: 95 % on Supplemental oxygen: FIO2 60\n Previous day:\n Intake: 2,111 mL\n Output: 2,700 mL\n Fluid balance: -589 mL\n Today:\n Intake: 440 mL\n Output: 725 mL\n Fluid balance: -285 mL\n Labs\n 269\n 12.3\n 130\n 2.3\n 27\n 3.6\n 70\n 102\n 138\n 36.1\n 11.4\n [image002.jpg]\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n 04:42 PM\n 04:58 PM\n 04:12 AM\n WBC\n 14.4\n 11.4\n Hgb\n 12.9\n 12.3\n Hct (Serum)\n 38.0\n 36.4\n 36.1\n Plt\n 249\n 269\n INR\n 1.9\n 1.7\n PTT\n 35.1\n 34.8\n Na+\n 132\n 135\n 137\n 138\n K + (Serum)\n 4.6\n 4.1\n 4.1\n 3.6\n Cl\n 96\n 99\n 100\n 102\n HCO3\n 23\n 25\n 26\n 27\n BUN\n 55\n 60\n 68\n 70\n Creatinine\n 3.1\n 2.5\n 2.5\n 2.3\n Glucose\n 137\n 143\n 141\n 130\n O2 sat (arterial)\n 94\n 89\n 94\n 97\n 98\n 94\n ABG: 7.42 / 43 / 112 / / 2 Values as of 04:26 AM\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n" }, { "category": "Physician ", "chartdate": "2151-03-11 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553812, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CBC with diff showed increased\n neutrophils, leukocytosis improving\n - Dr. placed right IJ line\n - femoral line removed, sent for cx, after holding pressure for 5\n minutes, groin bled small amound after pt coughing; then hemostasis\n acheived with 15 minutes of groin pressure\n - blood cx form fem and art line\n - increased lactulose, BS now positive\n - increased ectopy in AM, with 7-8 runs NSVT, was dropping SBP with\n these episodes to 70s, therefore restarted amio at noon gtt with 300mg\n bolus, then 1mg for 6 hours and 0.5 afterwards\n - FIO2 weaned to 60%, PEEP weaned from 20 to 19, Nitric oxide was\n stopped\n - nutrution recs for tube feeds placed, orders placed\n - PM lytes stable\n - negative 596ml\n - vanco level 10.3\n Medications\n Unchanged\n Physical Exam\n General appearance: vent setings- CMV/Assist VT 450, RR 28, PEEP 19,\n FIO2 60%\n BP: 102 / 57 mmHg\n HR: 85 bpm\n Tmax C last 24 hours: 39.4 C\n Tmax F last 24 hours: F\n T current C: 38.6 C\n T current F: 101.4 F\n O2 sat: 95 % on Supplemental oxygen: FIO2 60\n Previous day:\n Intake: 2,111 mL\n Output: 2,700 mL\n Fluid balance: -589 mL\n Today:\n Intake: 440 mL\n Output: 725 mL\n Fluid balance: -285 mL\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 269\n 12.3\n 130\n 2.3\n 27\n 3.6\n 70\n 102\n 138\n 36.1\n 11.4\n [image002.jpg]\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n 04:42 PM\n 04:58 PM\n 04:12 AM\n WBC\n 14.4\n 11.4\n Hgb\n 12.9\n 12.3\n Hct (Serum)\n 38.0\n 36.4\n 36.1\n Plt\n 249\n 269\n INR\n 1.9\n 1.7\n PTT\n 35.1\n 34.8\n Na+\n 132\n 135\n 137\n 138\n K + (Serum)\n 4.6\n 4.1\n 4.1\n 3.6\n Cl\n 96\n 99\n 100\n 102\n HCO3\n 23\n 25\n 26\n 27\n BUN\n 55\n 60\n 68\n 70\n Creatinine\n 3.1\n 2.5\n 2.5\n 2.3\n Glucose\n 137\n 143\n 141\n 130\n O2 sat (arterial)\n 94\n 89\n 94\n 97\n 98\n 94\n ABG: 7.42 / 43 / 112 / / 2 Values as of 04:26 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO. Compliance improving.\n - NO down to 5 PPM, attempt to d/c today,wean Fi02 preferentially over\n PEEP as tolerated. Consider decreasing PEEP once Fi02 <50%.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy\n - Appreciate electrophysiology input, have signed off.\n - off amiodatrone\n - Agressively wean and attempt to d/c levophed to improve ectopy,\n tolerate MAP >60. If tolerates stopping pressors and has room on BP\n with persistent ectopy, increase BB and consider dialing down on PEEP\n to leave BP room for BB. Trial of IV lopressor 2.5-5mg IV Q4 hours\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today, decreaseing PEEP if necessary. Attempt to add BB\n as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - fem line out, consider PICC once afebrile vs CVL line under fluoro/\n in cath lab.\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 5, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low, next\n level tonight\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - Discontinued amiodarone\n - monitor liver function\n -got vitamin K yesterday\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: right femoral line, art line. Fever curve decreasing, will\n monitor femoral blood cultures. Fem line out , attempt CVL\n placement today.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553943, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n CONTACT PRECAUTIONS: Positive nasal swab for MSRA.\n ACCESS: RIJ TLC & R Radial Aline.\n SOCIAL: talked w/ wife\n encouraged her to go home tonite and rest and\n see her 3 children, that they needed her at home for reassurance. Pt\n told to call whenever she wanted and to come back whenever she wanted.\n Pt understanding that she really needs to do so and felt better about\n going home tonite as her husband is doing better. Wife to talk with\n patient\ns mother about going home too.\n Ventricular tachycardia, sustained\n Assessment:\n Short runs VT noted. Minimal perfusion with VT. Continues on Levophed\n gtt-0.120mcg/kg/min. Amiodarone gtt @ 0.5mg/min.\n Action:\n Amiodarone po started then turned off amio gtt. Weaning levo gtt.\n Response:\n Continues with PVC\ns. rare run of 4 PVcs. Levophed gtt weaned off at\n 5pm.\n Plan:\n Con\nt amio po .AM Labs-replace as indicated.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lasix gtt @ 20mg/hr. LS diminished throughout. Remains intubated-PEEP\n decreased to 19 with stable ABG. Fentanyl gtt up @ 50mcg/hr. scant\n secretions. Pt decompensates w/ turns (sats down to 89% then remain low\n for ~1h even w/ increased FIO2). Also developed some hiccups this\n evening which pt then desaturated to 89%, hiccups resolved on own and\n pt\ns sats increased back to 93%.\n Action:\n Lasix gtt. Fentanyl gtt. Decreased FIO2 to 55%, able to decrease peep\n to 18.\n Response:\n Diuresing to Lasix gtt, but remains positive 4+L LOS.. Stable\n Sats/ABGs. Comfortable on low dose fentanyl gtt-easily arousable to\n noxious stimuli/presently not following commands. Not requiring Versed\n IV.\n Plan:\n Cont diuresis. Contin low dose Fentanly gtt. ?wean peep in am, no\n changes planned for overnite.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile despite cooling blanket, Tylenol/ASA, & Abx. Tmax\n 101.7.\n Action:\n Cooling blanket. Abx. Antipyretics. Vanco increased to q12h.\n Response:\n Remains febrile. This evening temp 100.3\n Plan:\n Con\nt cooling blanket. Con\nt to monitor temps. Con\nt Abx &\n antipyretics.\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555138, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers. Wife stayed over noc. D5W for\n elevated NA levels d/c\nd. PT on consult\nbut did not get to see pt\n yet. Pt doing leg and arm lifts & assisting with turns.\n NPO p mn for EP study in AM, remained afebrile overnite. Wore own bipap\n overnite.\n" }, { "category": "Nursing", "chartdate": "2151-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554333, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554394, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Oxim. Sats 90-92%. ABG sat 96% (7.45/48/84).\n LS diminished bases. RR 14-18. spontaneous Tv 600\n Lasix at 15mg/hr. u/o 150-200cc/hr. neg. 1.4L for . (goal was\n neg. 1L).\n AM Na+ 155.\n Action:\n Peep decreased from 14-12. PS 12/FIO2 50% unchanged.\n Suctioned for small thick tan secretions.\n Lasix gtt decreased to 10mg/hr and then down to 5mg/hr at 0600. D5W\n at 100cc/hr started at 0600.\n Response:\n Oxim. Sats 94-96%. Repeat ABG 7.37/59/82. HO aware. AM ABG\n 7.44/50/81.\n Plan:\n Contin. To wean peep . goal PO2 >60. contin. freewater/IV. Monitor\n lytes.\n Ventricular tachycardia, sustained\n Assessment:\n HR 80-90\ns SR, increasing with more wakefulness. Occas. PVC, PAC. AM\n K+ 3.7\n Action:\n Amio 400mg po as ordered. K+ repleted at 0600.\n Lopressor dose increased to 25mg- for 0600 dose.\n Response:\n Stable rhythm. BP stable on lopressor. Off pressor x24hr.\n Plan:\n Monitor lytes and replete prn. Contin. Po amio. Monitor effect of\n lopressor.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open spontaneously and also to voice and/or pain. Will nod head\n when ask\ncan you hear me\n but will not squeeze hands or move toes to\n command. Also does not respond (stares at you) when asked about pain.\n Pt. appearing restless, uncomfortable in rotating bed- HR/BP\n elevated, pt. awake, coughing and appearing anxious. Wife stating that\n pt. does not\nlike\n the rotating bed.\n Action:\n Fent. Gtt was increased back to 100mcq/hr (in stages) and also given\n fent. Boluses 25-50mcq x2-3 during night. Versed 1mg x2.\n Also foot rest was dropped in the bari air bed so that pt. s feet could\n extend out and not be held up by the foot board.\n Pt. repositioned withpillows in the bed and continued to rotate side to\n side.\n Decreased fentanyl gtt to 80mcq/hr ~0500 in attempt to wean. HO\n aware.\n Response:\n Good response to increase fent. Dose. Pt. still able to open eyes and\n look around. Occas. will follow command. Appearing more comfortable\n in the bed now that legs are able to extend fully.\n Pt. did start to wake more ~ an hour after fent. Was decreased to\n 80mcq/hr. HR/BP up, moving around in bed more. Gave small bolus of\n versed and fent. With good effect.\n Plan:\n Attempt. To wean fent. Gtt as tolerated today.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.9po. CT prelim report was neg. for infectious source\n Action:\n Tylenol and ASA RTC. Vanco dose held at for supra therapeutic\n level. Cont. on zosyn\n Response:\n Vanco level to be drawn at 0600.\n Plan:\n Monoitor level. Contin. Zosyn , Tylenol and ASA.\n Still waiting for sinus film report.\n" }, { "category": "Nutrition", "chartdate": "2151-03-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 554041, "text": "Objective\n Pertinent medications: norepinephrine, lasix, abx, fentanyl, ssri,\n colace, lacutlose, others noted\n Labs:\n Value\n Date\n Glucose\n 132 mg/dL\n 04:36 AM\n Glucose Finger Stick\n 191\n 12:00 PM\n BUN\n 85 mg/dL\n 04:36 AM\n Creatinine\n 2.9 mg/dL\n 04:36 AM\n Sodium\n 139 mEq/L\n 04:36 AM\n Potassium\n 4.4 mEq/L\n 04:36 AM\n Chloride\n 99 mEq/L\n 04:36 AM\n TCO2\n 27 mEq/L\n 04:36 AM\n PO2 (arterial)\n 86 mm Hg\n 04:51 AM\n PCO2 (arterial)\n 43 mm Hg\n 04:51 AM\n pH (arterial)\n 7.40 units\n 04:51 AM\n pH (urine)\n 5.0 units\n 10:34 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 04:51 AM\n Albumin\n 3.2 g/dL\n 04:12 AM\n Calcium non-ionized\n 8.6 mg/dL\n 04:36 AM\n Phosphorus\n 5.2 mg/dL\n 04:36 AM\n Ionized Calcium\n 1.08 mmol/L\n 04:26 AM\n Magnesium\n 2.7 mg/dL\n 04:36 AM\n ALT\n 765 IU/L\n 04:36 AM\n Alkaline Phosphate\n 58 IU/L\n 04:36 AM\n AST\n 267 IU/L\n 04:36 AM\n Amylase\n 103 IU/L\n 04:12 AM\n Total Bilirubin\n 1.5 mg/dL\n 04:12 AM\n WBC\n 18.9 K/uL\n 04:36 AM\n Hgb\n 12.6 g/dL\n 04:36 AM\n Hematocrit\n 37.2 %\n 04:36 AM\n Current diet order / nutrition support: Nutren Pulmonary Full strength;\n Additives: Beneprotein, 40 gm/day\n Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n ( 1943kcal/116g pro)\n GI: very obese, + diarrhea\n Assessment of Nutritional Status\n 39M intub d/t respiratory failure, pt started on TF on , currently\n tolerating Nutren Pulm + Beneprotein at 40ml/hr, goal is 50ml/hr.\n Noted pt with +diarrhea, rec checking C-diff, if remains negative x 3,\n can add banana flake. Serum phos is elevated, cont to monitor closely,\n and rec phos biner.\n Medical Nutrition Therapy Plan - Recommend the Following\n Cont to adv TF to goal, monitor tol\n Hold off on all bowel regimens\n Check C-Diff x 3, if all negative, then give banana flakes\n Start phos binder\n Check chemistry 10 panel\n Cont Bg mgt\n Other: f/u re poc, please call if has ?\n" }, { "category": "Physician ", "chartdate": "2151-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554042, "text": "CCU Intern Progress Note:\n Chief Complaint:\n 24 Hour Events:\n - vanc dose increased to 1000mg q12h\n - amiodarone IV --> 400 PO TID\n - fever curve improving (100s)\n - on fentanyl gtt, lasix gtt\n - levophed gtt weaned for most day, but restarted at 4am on for\n SBP in low 80s.\n - attempted weaning PEEP, but pt not tolerating well\n - hiccup episode resulting in desat to 80s, resolved without\n intervention\n - diarrhea started --> flexiseal tube placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:15 AM\n Piperacillin/Tazobactam (Zosyn) - 04:17 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Furosemide (Lasix) - 20 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:17 PM\n Fentanyl - 05:15 PM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.2\nC (100.7\n HR: 96 (81 - 97) bpm\n BP: 109/69(79) {84/50(61) - 120/70(84)} mmHg\n RR: 28 (25 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 22 (21 - 22)mmHg\n Total In:\n 2,380 mL\n 477 mL\n PO:\n TF:\n 495 mL\n 306 mL\n IVF:\n 1,655 mL\n 171 mL\n Blood products:\n Total out:\n 3,560 mL\n 505 mL\n Urine:\n 3,560 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,180 mL\n -28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 30 cmH2O\n SpO2: 94%\n ABG: 7.40/43/86/27/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 156\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 132 mg/dL\n 2.9 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 85 mg/dL\n 99 mEq/L\n 139 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 04:42 PM\n 04:58 PM\n 08:18 PM\n 04:12 AM\n 04:26 AM\n 02:54 PM\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n WBC\n 11.4\n 18.9\n Hct\n 36.4\n 36.1\n 37.2\n Plt\n 269\n 307\n Cr\n 2.5\n 2.3\n 2.1\n 2.9\n TCO2\n 27\n 25\n 29\n 30\n 28\n Glucose\n 141\n 130\n 147\n 132\n 132\n Other labs:\n PT / PTT / INR:18.4/31.3/1.7,\n CK / CKMB / Troponin-T:4046/9/0.30,\n ALT / AST:765/267,\n Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200,\n Differential-Neuts:86.6 %, Lymph:10.8 %, Mono:2.4 %, Eos:0.1 %,\n Fibrinogen:546 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677\n IU/L,\n Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP, decrease by\n intervals of 2 today, check ABG per pulm recs. Goal Pa02>60 unless\n high fevers. Preferentially reduce Fi02 over PEEP this am.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT tomorrow if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning, but fever curve decreasing. Still on ATC\n tylenol and cooling blanked. Vanco level persistently low, have been\n uptitrating dose. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 7, plan for 8-day course for VAP to\n possibly complete on \n - Curbisde ID re is linezolid a better choice in terms of lung\n penetration vs consult for fevers of unclear origin\n - Check mycolytic blood cultures\n - Continue vancomycin, still not at goal trough level, however with\n increasing cr, repeat level tonight, consider continuing to titrate\n dose.\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs to eval for ? DVTs if above w/u unrevealing.\n - Consider abd imaging if persistent fevers with no clear cause, if\n doing CT tomorrow, be sure to get abd/pelvis imaging.\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours, reduce\n lasix gtt to 10mg/hour in setting of increasing cr.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 today in setting of\n continued diuresis. .\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554044, "text": ".H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554045, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure, renal failure, & aspiration PNA.\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2151-03-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554051, "text": "CCU Intern Progress Note:\n Chief Complaint:\n 24 Hour Events:\n - vanc dose increased to 1000mg q12h\n - amiodarone IV --> 400 PO TID\n - fever curve improving (100s)\n - on fentanyl gtt, lasix gtt\n - levophed gtt weaned for most day, but restarted at 4am on for\n SBP in low 80s.\n - attempted weaning PEEP, but pt not tolerating well\n - hiccup episode resulting in desat to 80s, resolved without\n intervention\n - diarrhea started --> flexiseal tube placed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:15 AM\n Piperacillin/Tazobactam (Zosyn) - 04:17 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Furosemide (Lasix) - 20 mg/hour\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:17 PM\n Fentanyl - 05:15 PM\n Other medications:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.2\nC (100.7\n HR: 96 (81 - 97) bpm\n BP: 109/69(79) {84/50(61) - 120/70(84)} mmHg\n RR: 28 (25 - 29) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 22 (21 - 22)mmHg\n Total In:\n 2,380 mL\n 477 mL\n PO:\n TF:\n 495 mL\n 306 mL\n IVF:\n 1,655 mL\n 171 mL\n Blood products:\n Total out:\n 3,560 mL\n 505 mL\n Urine:\n 3,560 mL\n 505 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,180 mL\n -28 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 18 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 30 cmH2O\n SpO2: 94%\n ABG: 7.40/43/86/27/0\n Ve: 13.3 L/min\n PaO2 / FiO2: 156\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 132 mg/dL\n 2.9 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 85 mg/dL\n 99 mEq/L\n 139 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 04:42 PM\n 04:58 PM\n 08:18 PM\n 04:12 AM\n 04:26 AM\n 02:54 PM\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n WBC\n 11.4\n 18.9\n Hct\n 36.4\n 36.1\n 37.2\n Plt\n 269\n 307\n Cr\n 2.5\n 2.3\n 2.1\n 2.9\n TCO2\n 27\n 25\n 29\n 30\n 28\n Glucose\n 141\n 130\n 147\n 132\n 132\n Other labs:\n PT / PTT / INR:18.4/31.3/1.7,\n CK / CKMB / Troponin-T:4046/9/0.30,\n ALT / AST:765/267,\n Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200,\n Differential-Neuts:86.6 %, Lymph:10.8 %, Mono:2.4 %, Eos:0.1 %,\n Fibrinogen:546 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677\n IU/L,\n Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP, decrease by\n intervals of 2 today, check ABG per pulm recs. Goal Pa02>60 unless\n high fevers. Preferentially reduce Fi02 over PEEP this am.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT tomorrow if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning, but fever curve decreasing. Still on ATC\n tylenol and cooling blanked. Vanco level persistently low, have been\n uptitrating dose. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 7, plan for 8-day course for VAP to\n possibly complete on \n - Curbisde ID re is linezolid a better choice in terms of lung\n penetration vs consult for fevers of unclear origin\n - Check mycolytic blood cultures\n - Continue vancomycin, still not at goal trough level, however with\n increasing cr, repeat level tonight, consider continuing to titrate\n dose.\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs to eval for ? DVTs if above w/u unrevealing.\n - Consider abd imaging if persistent fevers with no clear cause, if\n doing CT tomorrow, be sure to get abd/pelvis imaging.\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours, reduce\n lasix gtt to 10mg/hour in setting of increasing cr.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 today in setting of\n continued diuresis. .\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:32 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n Critical Care 60 minutes for hemodynamic instability and respiratory\n failure requiring intubation.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:33 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554335, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Oxim. Sats 90-92%. ABG sat 96% (7.45/48/84). HO aware of difference\n in sats.\n LS diminished bases. RR 14-18.\n Action:\n Peep decreased from 14-12. PS 12/FIO2 50% unchanged.\n Suctioned for small thick tan secretions.\n Response:\n Oxim. Sats 94-96%. Repeat ABG 7.37/59/82. HO aware.\n Plan:\n Contin. To wean peep . goal PO2 >60.\n Ventricular tachycardia, sustained\n Assessment:\n HR 80-90\ns SR, increasing with more wakefulness. Occas. PVC, PAC\n Action:\n Amio 400mg po as ordered. K+ repleted in eve.\n Lopressor dose increased to 25mg- for 0600 dose.\n Response:\n Stable rhythm\n Plan:\n Monitor lytes and replete prn. Contin. Po amio. Monitor effect of\n lopressor.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open spontaneously and also to voice and/or pain. Pt. appearing\n restless, uncomfortable in rotating bed- HR/BP elevated, pt. awake,\n coughing and appearing anxious.\n Action:\n Fent. Gtt was increased back to 100mcq/hr (in stages) and also given\n fent. Boluses 25-50mcq x2-3 during night.\n Also foot rest was dropped in the bari air bed so that pt. s feet could\n extend out and not be held up by the foot board.\n Pt. repositioned withpillows in the bed and continued to rotate side to\n side.\n Response:\n Good response to increase fent. Dose. Pt. still able to open eyes and\n look around. Occas. will follow command. Appearing more comfortable\n in the bed now that legs are able to extend fully.\n Plan:\n Attempt. To wean fent. Gtt as tolerated today.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.9po. CT prelim report was neg. for infectious source\n Action:\n Tylenol and ASA RTC. Vanco dose held at for supra therapeutic\n level. Cont. on zosyn\n Response:\n Vanco level to be drawn at 0600.\n Plan:\n Monoitor level. Contin. Zosyn , Tylenol and ASA.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554661, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, Nasal\n flaring; Comments: nasal flaring during sbt, otherwise nml.\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Comments: fio2 weaned per pulm request. Sbt done. Approx 40 minutes pt\n desaturated with nasal flaring, pink thin secretions. Placed back on\n peep 10.\n" }, { "category": "Nursing", "chartdate": "2151-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554389, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Oxim. Sats 90-92%. ABG sat 96% (7.45/48/84).\n LS diminished bases. RR 14-18. spontaneous Tv 600\n Action:\n Peep decreased from 14-12. PS 12/FIO2 50% unchanged.\n Suctioned for small thick tan secretions.\n Response:\n Oxim. Sats 94-96%. Repeat ABG 7.37/59/82. HO aware. AM ABG\n Plan:\n Contin. To wean peep . goal PO2 >60.\n Ventricular tachycardia, sustained\n Assessment:\n HR 80-90\ns SR, increasing with more wakefulness. Occas. PVC, PAC\n Action:\n Amio 400mg po as ordered. K+ repleted in eve.\n Lopressor dose increased to 25mg- for 0600 dose.\n Response:\n Stable rhythm\n Plan:\n Monitor lytes and replete prn. Contin. Po amio. Monitor effect of\n lopressor.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open spontaneously and also to voice and/or pain. Pt. appearing\n restless, uncomfortable in rotating bed- HR/BP elevated, pt. awake,\n coughing and appearing anxious.\n Action:\n Fent. Gtt was increased back to 100mcq/hr (in stages) and also given\n fent. Boluses 25-50mcq x2-3 during night.\n Also foot rest was dropped in the bari air bed so that pt. s feet could\n extend out and not be held up by the foot board.\n Pt. repositioned withpillows in the bed and continued to rotate side to\n side.\n Response:\n Good response to increase fent. Dose. Pt. still able to open eyes and\n look around. Occas. will follow command. Appearing more comfortable\n in the bed now that legs are able to extend fully.\n Plan:\n Attempt. To wean fent. Gtt as tolerated today.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.9po. CT prelim report was neg. for infectious source\n Action:\n Tylenol and ASA RTC. Vanco dose held at for supra therapeutic\n level. Cont. on zosyn\n Response:\n Vanco level to be drawn at 0600.\n Plan:\n Monoitor level. Contin. Zosyn , Tylenol and ASA.\n" }, { "category": "Physician ", "chartdate": "2151-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554564, "text": "CCU Intern Progress Note:\n 24 Hour Events:\n - cont weaning ventilatory support --> FIO2 down to 45%, PEEP down to\n 10%, but pt becoming more hypoxemic, so FIO2 back to 50%\n - cont to have fever - Tmax 103.6, bl cx drawn, curve downtrending this\n AM\n - will check TSH, cortisol level today (cosyntropin-stim test) as other\n causes\n - Na 154 - free water deficit ~6-7 L --> free water flushes + D5W\n - stopped lasix, antibiotics (vanc/zosyn)\n - increased metoprolol to 50 , started lisinopril 2.5mg daily\n - CT sinus - new sinusitis - ? fungal\n - ID: d/c abx given possiblity for drug-related fever\n - pulm: concur, will consider BAL if continues to be febrile or new\n spike;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.8\nC (100\n HR: 77 (73 - 103) bpm\n BP: 116/66(80) {103/57(71) - 153/86(103)} mmHg\n RR: 14 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,104 mL\n 1,239 mL\n PO:\n TF:\n 1,205 mL\n 312 mL\n IVF:\n 1,929 mL\n 557 mL\n Blood products:\n Total out:\n 4,375 mL\n 540 mL\n Urine:\n 4,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -271 mL\n 699 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 509 (509 - 700) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.40/54/74/34/6\n Ve: 7.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin\n Labs / Radiology\n 409 K/uL\n 11.4 g/dL\n 115 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 79 mg/dL\n 111 mEq/L\n 153 mEq/L\n 35.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:35 AM\n 03:27 AM\n 03:52 AM\n 09:46 AM\n 01:01 PM\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n WBC\n 13.3\n 12.3\n Hct\n 33.7\n 35.4\n Plt\n 354\n 409\n Cr\n 2.5\n 2.1\n 1.9\n TCO2\n 35\n 35\n 34\n 34\n 36\n 35\n 35\n Glucose\n 94\n 110\n 115\n Other labs:\n PT / PTT / INR:19.2/51.1/1.8,\n ALT / AST:216/99, Alk Phos / T Bili:51/0.7,\n D-dimer: ng/mL, Fibrinogen:679 mg/dL,\n Lactic Acid:1.6 mmol/L,\n Albumin:3.2 g/dL, LDH:430 IU/L,\n Ca++:8.4 mg/dL, Mg++:3.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554565, "text": "CCU Intern Progress Note:\n 24 Hour Events:\n - cont weaning ventilatory support --> FIO2 down to 45%, PEEP down to\n 10%, but pt becoming more hypoxemic, so FIO2 back to 50%\n - cont to have fever - Tmax 103.6, bl cx drawn, curve downtrending this\n AM\n - will check TSH, cortisol level today (cosyntropin-stim test) as other\n causes\n - Na 154 - free water deficit ~6-7 L --> free water flushes + D5W\n - stopped lasix, antibiotics (vanc/zosyn)\n - increased metoprolol to 50 , started lisinopril 2.5mg daily\n - CT sinus - new sinusitis - ? fungal\n - ID: d/c abx given possiblity for drug-related fever\n - pulm: concur, will consider BAL if continues to be febrile or new\n spike;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.8\nC (100\n HR: 77 (73 - 103) bpm\n BP: 116/66(80) {103/57(71) - 153/86(103)} mmHg\n RR: 14 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,104 mL\n 1,239 mL\n PO:\n TF:\n 1,205 mL\n 312 mL\n IVF:\n 1,929 mL\n 557 mL\n Blood products:\n Total out:\n 4,375 mL\n 540 mL\n Urine:\n 4,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -271 mL\n 699 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 509 (509 - 700) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.40/54/74/34/6\n Ve: 7.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin\n Labs / Radiology\n 409 K/uL\n 11.4 g/dL\n 115 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 79 mg/dL\n 111 mEq/L\n 153 mEq/L\n 35.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:35 AM\n 03:27 AM\n 03:52 AM\n 09:46 AM\n 01:01 PM\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n WBC\n 13.3\n 12.3\n Hct\n 33.7\n 35.4\n Plt\n 354\n 409\n Cr\n 2.5\n 2.1\n 1.9\n TCO2\n 35\n 35\n 34\n 34\n 36\n 35\n 35\n Glucose\n 94\n 110\n 115\n Other labs:\n PT / PTT / INR:19.2/51.1/1.8,\n ALT / AST:216/99, Alk Phos / T Bili:51/0.7,\n D-dimer: ng/mL, Fibrinogen:679 mg/dL,\n Lactic Acid:1.6 mmol/L,\n Albumin:3.2 g/dL, LDH:430 IU/L,\n Ca++:8.4 mg/dL, Mg++:3.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Nursing", "chartdate": "2151-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554317, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia which deteriorated to V.fib, s/p\n resuscitation with return to sinus tachycardia, now intubated, with\n hypoxic and hypercarbic respiratory failure, renal failure, &\n aspiration PNA.\n .H/O heart disease, congenital\n Assessment:\n HR 80-90\ns NSR with freq PVC\ns, multifocal singles, couplets and up to\n 6br non-sustained VT. One 11br SVT. Remains in positive fluid balance\n LOS. HR up to 110\ns when more awake.\n Action:\n On po amiodarone, lasix gtt continues 15mg/hr, Lopressor 12.5mg \n added to regime\n Response:\n Cont with occ to freq PVC\ns, nonsustained VT, pt is >1000cc negative\n for the day.\n Plan:\n EP to evaluate once more stablel, cont aggressive diuresis. Increase\n lopressor as tolerated, lyte repletion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Cont with temp up to 103. and ^WBC\n Action:\n Vanco and zosyn, pul toilet sx q2-4hrs for scant amt thick tan\n secretions. ATC Tylenol and ASA, fully cultured on , CT of abd\n today for possible source\n Response:\n Continues febrile\n Plan:\n Cont AB, Tylenol and ASA, check culture results, check results of CT\n scan.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains vented and sedated. On 55% FIO2, 14 PEEP, has tolerated PS\n ventilation.\n Action:\n Decreased FIo2 to 50%, Sedation 50-100mcgs/hr fentanyl, w/ coughing\n dropping sats to 88%. Bari air rotating bed in place.\n Response:\n sats 90-94% when more sedate, pt apprears uncomfortable in bari bed as\n he slides down\n Plan:\n Cont vent support, cont sedation as long as pt cont to require high\n levels of peep, reposition on bari bed as necessary.\n" }, { "category": "Physician ", "chartdate": "2151-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554836, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.7\nF - 11:00 AM\n - In afternoon, attempted wean to 40%. Was satting ok in low-mid 90s),\n then with upright SBT 0/8-> pt desatted to 80s, ABG pH 7.35/64/77, was\n increased back to FiO2 50% b/c stayed in 80s when was back on 40%,\n .\n - Overnight pt appeared to be more awake, talking and expelling air\n around ETT with coughing. Would desat to 80s during this. Fentanyl\n increased from 5->->->150. Was switched to CMV/AC, 450x14. RT to\n attempt to switch back to PSV this am. Fentanyl back down to 50mcg/hr.\n - Tap of R knee-> dry\n - TTE-> EF 50%\n - PM Na still 153, increased D5W to 150/hr\n - Continued to spike in afternoon, Tmax 102.7, re-cultured\n - Pulm: BAL likely to be low-yield; consider lines, may improve after\n extub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 38.2\nC (100.8\n HR: 91 (63 - 92) bpm\n BP: 129/76(92) {99/49(64) - 133/76(226)} mmHg\n RR: 13 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,579 mL\n 1,669 mL\n PO:\n TF:\n 1,211 mL\n 336 mL\n IVF:\n 2,538 mL\n 1,083 mL\n Blood products:\n Total out:\n 2,305 mL\n 685 mL\n Urine:\n 2,305 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,274 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 590 (458 - 692) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 42\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 93%\n ABG: 7.34/65/86./34/6\n Ve: 6.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 458 K/uL\n 11.3 g/dL\n 101 mg/dL\n 1.6 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 67 mg/dL\n 109 mEq/L\n 148 mEq/L\n 35.1 %\n 12.2 K/uL\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n WBC\n 12.3\n 12.2\n Hct\n 35.4\n 35.1\n Plt\n 409\n 458\n Cr\n 2.1\n 1.9\n 1.7\n 1.6\n TCO2\n 36\n 35\n 35\n 34\n 37\n 37\n Glucose\n 110\n 115\n 110\n 101\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:159/84, Alk Phos / T Bili:48/0.7,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:376\n IU/L, Ca++:8.2 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Mixed hypoxemia and hypercarbia. Pt continues\n to wean slowly, became hypercarbic and hypoxemic during SBT yesterday\n at 0/8, however patient was unable to stay upright and also ETT likely\n too small which is making wean more difficult. Pulm following and\n recommend extubation today with anesthesia at bedside given was\n difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:09 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Medical Decision Making\n Plan for bronchoscopy and hope for extubation later today. Have\n reviewed work-up to date for unexplained fever. Patient is acutely ill\n but does not appear toxic. Drug fever still a likely possibility given\n negative work-up. Will hold antibiotics.\n Above discussed extensively with patient.\n Total time spent on patient care: 30 minutes of critical care time.\n Additional comments:\n critical care for ventilator management/respiratory failure.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:19 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554557, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts. Strong cough.\n Freq. position changes, HOB 30-45deg.\n Contin. On IVF in addition to free water via OGT for elevated Na+.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr off lasix.\n Plan:\n Follow pulm recs. . follow Na^+\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n FUO : ? drug reaction. TM 103.7po at . HO aware.\n CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Temp down to 100.7po at 0300. cooling blanket off.\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- team to f/u on rounds.\n Cortisol stim. With Am labs.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n 0200\n pt. woke up and focusing on RN. Shaking/nodding head very\n approp. And able to focus and track. Pt was freq. oriented to place\n and time. Pt. shaking head\n to pain. Pt. trying to move arms and\n pulling on restraints. Gave dilaudid 1mg x1 for anxiety.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Good response to meds. Appearing more focused and calm.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Nursing", "chartdate": "2151-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554907, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n EVENTS: Extubated successfully this afternoon.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Inutubated w/ #7 ETT.\n Action:\n Sedation turned off. TF turned off. Extubated at 1320hrs w/ success w/\n anesthesia and respiratory present.\n Response:\n Stable sats. ABG WNL.\n Plan:\n ^Monitor sats. evening abg.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Continues febrile. Off abx. Contin to receive ASA TID and Tylenol Q6h..\n All cultures to date-neg. Last cultured .\n Action:\n Given antipyretics. Tylenol increased to 1g QID. Tmax 102.7. Cooling\n blanket placed on.\n Response:\n Temp down to 98.7 after extubation and cooling blanket. Sputum\n culture resent.\n Plan:\n Monitor temps. No abx. Unable to give evening Tylenol and ASA as OGT\n d/c\nd. plan to attempt sips this evening for evening meds. Pt very\n sleepy this afternoon.\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone & Lopressor po. IV D5W @150cc/hr for elevated NA.\n Action:\n Lytes WNL. On D5W increased to 200cc/hr continous.\n Response:\n rare. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Responsive. Appropriate @ times. Very restless @ times. Tolerated wrist\n restraints off a few times this morning. Reoriented frequently. Obeys\n commands.\n Action:\n Increased anxiety late morning, req\nd 2mg IV versed. Slept x 1hr.\n Fentanyl turned off at 12pm for extubation.\n Response:\n Extubated and pt talking\n voice impaired s/p ETT. Wife at bedside.\n Restraints off. Bed alarm on. SR up x 3.\n Plan:\n Freq reorientation. No more sedation. Fall precautions.\n Ineffective Coping\n Assessment:\n CCU team called wife this morning and updated her, as she had not\n visited yet, regarding plans to extubated early afternoon.\n Action:\n Wife in to visit after 1pm. Extubation successful. And wife at bedside\n all day. Explanations given, emotional support given.\n Response:\n Family appeared to accept explanation.\n Plan:\n Contin support pt/family asindicated.\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 554963, "text": "TITLE:\n Chief Complaint: VF arrest\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:01 AM\n INVASIVE VENTILATION - STOP 01:20 PM\n ARTERIAL LINE - STOP 04:50 AM\n FEVER - 102.8\nF - 09:47 AM\n .\n Patient was extubated yesterday with anesthesia and pulmonary present.\n Post extubation gas showed adequate oxygenation. Put patient in for\n speech and swallow evaluation given that NG tube removed and has been\n intubated for over a week. Patient interactive and responsive. Fever\n curve treding down. PM lytes showed increased Na to 149 so turned up\n D5W to 200 cc/hour. Now increasingly volume up but also persistently\n hypernatremic.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Midazolam (Versed) - 10:55 AM\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Other medications:\n No change to PMHX\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.2\nC (99\n HR: 58 (55 - 100) bpm\n BP: 99/66(70) {92/48(61) - 103/66(70)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,403 mL\n 1,455 mL\n PO:\n 120 mL\n 180 mL\n TF:\n 546 mL\n IVF:\n 3,907 mL\n 1,275 mL\n Blood products:\n Total out:\n 2,360 mL\n 675 mL\n Urine:\n 2,360 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,043 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (90 - 893) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.38/54/132/34/5\n Ve: 10.1 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.8 g/dL\n 405 K/uL\n 105 mg/dL\n 1.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 60 mg/dL\n 106 mEq/L\n 146 mEq/L\n 34.2 %\n 10.9 K/uL\n [image002.jpg]\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n WBC\n 12.2\n 10.9\n Hct\n 35.1\n 34.2\n Plt\n 458\n 405\n Cr\n 1.7\n 1.6\n 1.7\n 1.5\n TCO2\n 35\n 34\n 37\n 37\n 34\n 33\n Glucose\n 110\n 101\n 113\n 105\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:119/67, Alk Phos / T Bili:46/0.9,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.0 mg/dL, Mg++:3.1 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now extubated s/p a prolonged\n intubation for hypoxic and hypercarbic respiratory failure, persistent\n fevers now trending down and persistent hypernatremia.\n # Respiratory Failure now s/p extubation: Mixed hypoxemia and\n hypercarbia. Pt continues to wean slowly, became hypercarbic and\n hypoxemic during SBT yesterday at 0/8, however patient was unable to\n stay upright and also ETT likely too small which is making wean more\n difficult. Pulm following and recommend extubation today with\n anesthesia at bedside given was difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 554974, "text": "TITLE:\n Chief Complaint: VF arrest\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:01 AM\n INVASIVE VENTILATION - STOP 01:20 PM\n ARTERIAL LINE - STOP 04:50 AM\n FEVER - 102.8\nF - 09:47 AM\n .\n Patient was extubated yesterday with anesthesia and pulmonary present.\n Post extubation gas showed adequate oxygenation. Put patient in for\n speech and swallow evaluation given that NG tube removed and has been\n intubated for over a week. Patient interactive and responsive. Fever\n curve treding down. PM lytes showed increased Na to 149 so turned up\n D5W to 200 cc/hour. Now increasingly volume up but also persistently\n hypernatremic.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Midazolam (Versed) - 10:55 AM\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Other medications:\n No change to PMHX\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.2\nC (99\n HR: 58 (55 - 100) bpm\n BP: 99/66(70) {92/48(61) - 103/66(70)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,403 mL\n 1,455 mL\n PO:\n 120 mL\n 180 mL\n TF:\n 546 mL\n IVF:\n 3,907 mL\n 1,275 mL\n Blood products:\n Total out:\n 2,360 mL\n 675 mL\n Urine:\n 2,360 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,043 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (90 - 893) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.38/54/132/34/5\n Ve: 10.1 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.8 g/dL\n 405 K/uL\n 105 mg/dL\n 1.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 60 mg/dL\n 106 mEq/L\n 146 mEq/L\n 34.2 %\n 10.9 K/uL\n [image002.jpg]\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n WBC\n 12.2\n 10.9\n Hct\n 35.1\n 34.2\n Plt\n 458\n 405\n Cr\n 1.7\n 1.6\n 1.7\n 1.5\n TCO2\n 35\n 34\n 37\n 37\n 34\n 33\n Glucose\n 110\n 101\n 113\n 105\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:119/67, Alk Phos / T Bili:46/0.9,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.0 mg/dL, Mg++:3.1 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now extubated s/p a prolonged\n intubation for hypoxic and hypercarbic respiratory failure, persistent\n fevers now trending down and persistent hypernatremia.\n # Respiratory Failure now s/p extubation: Mixed hypoxemia and\n hypercarbia. Pt was extubated yesterday without complication. MS\n today alert and interactive. Sats stable on 4L, high flow. Likely a\n component of OSA contributing to patient\ns ongoing hypercarbia.\n - CPAP at night\n - cont. nebs\n - raise head of bed to relieve pressure from abdomen\n - Wean O2 as tolerated to maintain sats >92%\n - f/u am CXR\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - . BB to 25mg tid given bradycardia\n -Cont. Lisinopril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD. Will discuss timing with EP today\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed . Fevers now resolving after extubation.\n - ID following, appreciate their recs\n - f/u mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum pending given inc. secretions\n - Tylenol prn now given fevers resolving, d/c standing ASA\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis and insensible losses\n in setting of persistant fevers. Free water deficit initially 8L,\n improving with inc. free water flushes and D5. Na today improved to\n 146.\n -holding lasix\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair. TTE peri-arrest showed poor systolic function. Repeat on \n showed improved systolic function with EF 50%\n - holding digoxin\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n - Monitor I/O\n # ARF: due to ATN, Cr continues to improve daily.\n - d/ced lasix gtt\n - monitor UOP\n - Cont. to follow\n # Bowel motility/nutrition\n Now s/p extubation, moving bowels\n - Speech and swallow today\n - ADAT once cleared by S&S\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nutrition", "chartdate": "2151-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553377, "text": "Subjective\n Intub, sedated, paralyzed\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 140 kg\n 44.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 186\n 91.5\n Diagnosis: cardiac arrest\n PMH :\n Ebstein's Anomaly s/p TV/ASD repair\n OSA\n Pulmonary HTN\n Obesity\n HTN\n Hyperlipidemia\n Pertinent medications: amiodarone, cisatracurium, fent, levo,\n lidoncaine, versed, vasopressin, colace, hep, protocnix, abx, lasix,\n others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 03:01 AM\n BUN\n 30 mg/dL\n 03:01 AM\n Creatinine\n 2.6 mg/dL\n 03:01 AM\n Sodium\n 134 mEq/L\n 03:01 AM\n Potassium\n 5.2 mEq/L\n 07:36 AM\n Chloride\n 101 mEq/L\n 03:01 AM\n TCO2\n 22 mEq/L\n 03:01 AM\n PO2 (arterial)\n 109 mm Hg\n 09:16 AM\n PCO2 (arterial)\n 43 mm Hg\n 09:16 AM\n pH (arterial)\n 7.31 units\n 09:16 AM\n pH (urine)\n 6.5 units\n 02:56 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:16 AM\n Calcium non-ionized\n 8.5 mg/dL\n 03:01 AM\n Phosphorus\n 3.7 mg/dL\n 03:01 AM\n Ionized Calcium\n 1.09 mmol/L\n 03:25 AM\n Magnesium\n 1.7 mg/dL\n 03:01 AM\n ALT\n 400 IU/L\n 03:01 AM\n Alkaline Phosphate\n 68 IU/L\n 03:01 AM\n AST\n 448 IU/L\n 03:01 AM\n Total Bilirubin\n 1.2 mg/dL\n 03:01 AM\n WBC\n 13.4 K/uL\n 03:01 AM\n Hgb\n 14.2 g/dL\n 03:01 AM\n Hematocrit\n 42.9 %\n 03:01 AM\n Current diet order / nutrition support: NPO, TF c/s\n GI: abd firm, dist, hypo bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO, current illness\n Estimated Nutritional Needs ( per adj BW)\n Calories: 1830- (BEE x or / 20-22 cal/kg)\n Protein: 119-137 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Specifics:\n 39M presented to ED with palpitations. Pt became unresponsive and\n apneic, CPR initiated, and had witnessed aspiration during intubation.\n Pt transferred to the CCU, levophed, neosynephrine and vasopressin,\n with HR 85 and BP 125/77.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Check triglycerides\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u re poc, please page if has ?\n" }, { "category": "Nutrition", "chartdate": "2151-03-08 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553378, "text": "Subjective\n Intub, sedated, paralyzed\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 140 kg\n 44.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 186\n 91.5\n Diagnosis: cardiac arrest\n PMH :\n Ebstein's Anomaly s/p TV/ASD repair\n OSA\n Pulmonary HTN\n Obesity\n HTN\n Hyperlipidemia\n Pertinent medications: amiodarone, cisatracurium, fent, levo,\n lidoncaine, versed, vasopressin, colace, hep, protocnix, abx, lasix,\n others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 03:01 AM\n BUN\n 30 mg/dL\n 03:01 AM\n Creatinine\n 2.6 mg/dL\n 03:01 AM\n Sodium\n 134 mEq/L\n 03:01 AM\n Potassium\n 5.2 mEq/L\n 07:36 AM\n Chloride\n 101 mEq/L\n 03:01 AM\n TCO2\n 22 mEq/L\n 03:01 AM\n PO2 (arterial)\n 109 mm Hg\n 09:16 AM\n PCO2 (arterial)\n 43 mm Hg\n 09:16 AM\n pH (arterial)\n 7.31 units\n 09:16 AM\n pH (urine)\n 6.5 units\n 02:56 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 09:16 AM\n Calcium non-ionized\n 8.5 mg/dL\n 03:01 AM\n Phosphorus\n 3.7 mg/dL\n 03:01 AM\n Ionized Calcium\n 1.09 mmol/L\n 03:25 AM\n Magnesium\n 1.7 mg/dL\n 03:01 AM\n ALT\n 400 IU/L\n 03:01 AM\n Alkaline Phosphate\n 68 IU/L\n 03:01 AM\n AST\n 448 IU/L\n 03:01 AM\n Total Bilirubin\n 1.2 mg/dL\n 03:01 AM\n WBC\n 13.4 K/uL\n 03:01 AM\n Hgb\n 14.2 g/dL\n 03:01 AM\n Hematocrit\n 42.9 %\n 03:01 AM\n Current diet order / nutrition support: NPO, TF c/s\n GI: abd firm, dist, hypo bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO, current illness\n Estimated Nutritional Needs ( per adj BW)\n Calories: 1830- (BEE x or / 20-22 cal/kg)\n Protein: 119-137 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Specifics:\n 39M presented to ED with palpitations. Pt became unresponsive and\n apneic, CPR initiated, and had witnessed aspiration during intubation.\n Pt transferred to the CCU, levophed, neosynephrine and vasopressin,\n with HR 85 and BP 125/77.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Check triglycerides\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u re poc, please page if has ?\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 553383, "text": "Date of service: \n Initial consultation: CCU\n Presenting complaint: Arrhythmia\n History of present illness: 39 yo M with PMH of ebstein's anomaly s/p\n tricuspid valve reconstruction, right and left sided congestive heart\n failure, presenting with palpitations which awoke him from sleep. The\n patient presented to the ED morning of where he was found to be\n in VT 230bpm. He began to experience chest pain, given amiodarone 150mg\n IV x 1, followed by amio gtt. He became diaphoretic, given etomidate\n and shocked with 200J, followed by vifib, becoming unresponsive and\n apneic. CPR was initiated, epinephrine x 1, CPR continued, shocked at\n 360J, returning to vtach @ 240. He was intubated, returning to sinus\n rhythm, aspriating vomit; noted to have right bronchus intubation and\n ETT repositioned. Due to hypotension SBP 40's started on levophed,\n neosynephrine, and vasopressin with BP increasing to 124/77.\n Subsequently developed left pneumothroax with attempted chest tube\n placement failed, had esophageal ballon placed. Early this morning had\n two recurrent runs of a WCT for which he was treated with amiodarone\n 300mg IV then with the second run received 100mg IV lidocaine with\n initiation of lidocaine gtt. EP consultation for management of\n ventricular tachyarrythmias.\n Past medical history: 1. Ebstein anomaly s/p TV reconstruction\n -- moderate to severe TR\n --RHF, RVEF 25% in \n 2. ASD s/p primary closure \n 3. LHF with evidence of noncompaction of LV, with LVEF 28% in \n 4. Hyperlipidemia\n 5. HTN\n 6. OSA/Obesity\n 7. DVT\n 8. Superficial phlebitis\n 9. Endocarditis w/ septic emboli to brain prior to Cardiac surgery\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies: NKDA\n No Known Drug Allergies\n Current medications: Home Meds:\n Allopurinol 300mg daily\n Atorvastation 20mg daily\n Colchicine 0.6mg daily\n Digoxin 0.125mg daily\n Lasix 40mg daily\n Lisinopril 10mg daily\n Claritin 10mg prn\n CURRENT MEDICATIONS:\n Lidocaine gtt\n Amio gtt\n Norepi gtt\n Vasopressin gtt\n Zosyn IV\n Vanco IV\n Midazolam IV gtt\n Irpratropium Neb\n Albuterol Neb\n Cardiovascular ROS\n Cardiovascular ROS Details: Inubated and Sedated.\n Review of Systems\n ROS Details: Intubated and Sedated.\n Social History\n Family history: Unable to obtain.\n Social history details: Unable to obtain\n Physical Exam\n Date and time of exam: 9:00am\n General appearance: Morbidly obese gentleman. Intubated and Sedated.\n Vital signs: per R.N.\n Height: 72 Inch, 183 cm\n Weight: d kg\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible)\n Respiratory: (Effort: Intubated), (Auscultation: Decreased breath\n sounds btl, no wheeze)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: Sedated), (Muscle strength and tone: Sedated), (Edema: Right:\n 1+, Left: 1+)\n Skin: ( WNL)\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.2\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.31 / 42 / 62 / / -4 Values as of 07:36 AM\n Tests\n ECG:\n -- sinus rhythm, RBBB, LAHB\n -- WCT 240bpm\n -- WCT 140bpm, RBBB, LAHB\n Telemetry:\n Current -- sinus rhythm 88 bpm\n Holter -- average sinus rhythm 100bpm, moderate frequent apb's\n and vpb's.\n Echocardiogram: -- dilated RV with depressed RVEF, global LV\n hypokinesis EF 30-35%, RA 7.2cm, 2+ TR\n Assessment and Plan\n 39 yo with PMH of Ebstein's anomaly s/p reconstruction, ASD s/p\n repair (), LV noncompaction, biventricular heart failure, morbid\n obesity, obstructive sleep apnea\n who is in critical condition following presentation with a wide complex\n tachycardia likely originating from sites of his past intracardiac\n surgery repairs, at this time requiring vasopressor\n support and mechanical ventilation:\n 1. Ventricular Tachycardia -- at this time continue current management\n with cardiopulmonary support with continuation ofamiodarone and\n lidocaine IV gtts. Monitor K and Mg levels\n with repletion as necessary. To discuss with EP attending regarding\n possible discontinuation of amiodarone and continuation of lidocaine\n gtt at this time. Once hemodynamically improving, with\n overall improvement will at that time discuss EPS with ablation\n therapy.\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553389, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2151-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554786, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.7\nF - 11:00 AM\n - Pulm: BAL likely to be low-yield; consider lines, may improve after\n extub. In afternoon, attempted wean to 40%. Was satting ok in low-mid\n 90s), then with upright SBT 0/8-> pt desatted to 80s, ABG pH\n 7.35/64/77, was increased back to FiO2 50% b/c stayed in 80s when was\n back on 40%, .\n - Overnight pt appeared to be breathing around\n - Tap of R knee-> dry\n - TTE-> EF 50%\n - PM Na still 153, increased D5W to 150/hr\n - Continued to spike in afternoon, Tmax 102.7, re-cultured\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 38.2\nC (100.8\n HR: 91 (63 - 92) bpm\n BP: 129/76(92) {99/49(64) - 133/76(226)} mmHg\n RR: 13 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,579 mL\n 1,669 mL\n PO:\n TF:\n 1,211 mL\n 336 mL\n IVF:\n 2,538 mL\n 1,083 mL\n Blood products:\n Total out:\n 2,305 mL\n 685 mL\n Urine:\n 2,305 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,274 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 590 (458 - 692) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 42\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 93%\n ABG: 7.34/65/86./34/6\n Ve: 6.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 458 K/uL\n 11.3 g/dL\n 101 mg/dL\n 1.6 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 67 mg/dL\n 109 mEq/L\n 148 mEq/L\n 35.1 %\n 12.2 K/uL\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n WBC\n 12.3\n 12.2\n Hct\n 35.4\n 35.1\n Plt\n 409\n 458\n Cr\n 2.1\n 1.9\n 1.7\n 1.6\n TCO2\n 36\n 35\n 35\n 34\n 37\n 37\n Glucose\n 110\n 115\n 110\n 101\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:159/84, Alk Phos / T Bili:48/0.7,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:376\n IU/L, Ca++:8.2 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:09 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554809, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.7\nF - 11:00 AM\n - In afternoon, attempted wean to 40%. Was satting ok in low-mid 90s),\n then with upright SBT 0/8-> pt desatted to 80s, ABG pH 7.35/64/77, was\n increased back to FiO2 50% b/c stayed in 80s when was back on 40%,\n .\n - Overnight pt appeared to be more awake, talking and expelling air\n around ETT with coughing. Would desat to 80s during this. Fentanyl\n increased from 5->->->150. Was switched to CMV/AC, 450x14. RT to\n attempt to switch back to PSV this am. Fentanyl back down to 50mcg/hr.\n - Tap of R knee-> dry\n - TTE-> EF 50%\n - PM Na still 153, increased D5W to 150/hr\n - Continued to spike in afternoon, Tmax 102.7, re-cultured\n - Pulm: BAL likely to be low-yield; consider lines, may improve after\n extub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 38.2\nC (100.8\n HR: 91 (63 - 92) bpm\n BP: 129/76(92) {99/49(64) - 133/76(226)} mmHg\n RR: 13 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,579 mL\n 1,669 mL\n PO:\n TF:\n 1,211 mL\n 336 mL\n IVF:\n 2,538 mL\n 1,083 mL\n Blood products:\n Total out:\n 2,305 mL\n 685 mL\n Urine:\n 2,305 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,274 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 590 (458 - 692) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 42\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 93%\n ABG: 7.34/65/86./34/6\n Ve: 6.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 458 K/uL\n 11.3 g/dL\n 101 mg/dL\n 1.6 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 67 mg/dL\n 109 mEq/L\n 148 mEq/L\n 35.1 %\n 12.2 K/uL\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n WBC\n 12.3\n 12.2\n Hct\n 35.4\n 35.1\n Plt\n 409\n 458\n Cr\n 2.1\n 1.9\n 1.7\n 1.6\n TCO2\n 36\n 35\n 35\n 34\n 37\n 37\n Glucose\n 110\n 115\n 110\n 101\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:159/84, Alk Phos / T Bili:48/0.7,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:376\n IU/L, Ca++:8.2 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Mixed hypoxemia and hypercarbia. Pt continues\n to wean slowly, became hypercarbic and hypoxemic during SBT yesterday\n at 0/8, however patient was unable to stay upright and also ETT likely\n too small which is making wean more difficult. Pulm following and\n recommend extubation today with anesthesia at bedside given was\n difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:09 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553348, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n -nimbex started\n Medications\n Unchanged\n Physical Exam\n General appearance: BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1), now 2.1\n Sputum- >25PMNs, 4+ GPC in pairs and clusters\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan\n ASSESSMENT AND PLAN\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n #Respiratory Failure: Difficulty oxygenating with Fi02 100% and\n increased PEEP. Per report patient had significant aspiration during\n intubation. PE ruled out with CTA. CT initially showed left\n pneumothorax, but f/u CT showed resolution after chest tube attempt.\n Also CT and CXRs showing right sided possible aspiration PNA. Being\n ventilated according to ARDS net protocol. have reopened ASD\n repair, causing shunt.\n -echo with bubble study to evaluate for ASD\n -swan cath to check oxygen saturation in four to evaluate for\n right to left shunt\n -Giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -nimbex as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n .\n #Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressers but\n now only on levo, still requiring dopa intermittently. Will try to\n minimize PEEP to maximize venous return. may possibly be from\n decompensated heart failure. Likely has combination of cardiogenic\n shock and septic shock.\n -pressors as needed\n -fluids as neded\n -would benefit from swan ganz catheter to better understand type of\n hypotenision\n .\n # Sepsis- Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation\n -MRSA screen and precautions\n - continue vanco and zosyn, day 2\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n -hold metoprolol, lisinopril, lasix, digoxin\n -echo today\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UO\n - monitor UO\n - send urine lytes\n - consider renal consult\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF\n - monitor liver function\n - may need to stop amio\n .\n # Family dynamicis: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN:\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553358, "text": "CCU Intern Progress Note\n History of Present Illness\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n -nimbex started\n Medications\n Unchanged\n Physical Exam\n General appearance:\n BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1), now 2.1\n Sputum- >25PMNs, 4+ GPC in pairs and clusters\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan:\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, R\nL shunting, aspiration PNA,\n sepsis. Difficulty oxygenating with Fi02 100% and increased PEEP. PE\n ruled out with CTA. CT initially showed left pneumothorax, but f/u CT\n showed resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol. have reopened ASD repair, causing shunt.\n -consider TEE with bubble study to evaluate for ASD\n -consider Swan-Ganz catheter to check oxygen saturation in four\n to evaluate for right to left shunt, however, likely not\n useful at this point given mixture of cardiogenic/septic physiology\n -giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -cisatracurium (Nimbex) as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin, still requiring dopa\n intermittently. Will try to minimize PEEP to maximize venous return.\n may possibly be from decompensated heart failure. Likely has\n combination of cardiogenic shock and septic shock.\n - Pressors as needed\n - Fluids as neded, currently diuresing for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation.\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 2 on\n - Check AM trough on \n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE\n - consider diurese w lasix drip to goal -500 cc / 24 hours, with\n respiratory cautions\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UOP.\n - monitor UOP\n - check urine lytes\n - consider renal consult for ? ultrafiltration for volume overload\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF.\n Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - check AXR to eval for ileus\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - consider patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553359, "text": "CCU Intern Progress Note\n History of Present Illness\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n -nimbex started\n Medications\n Unchanged\n Physical Exam\n General appearance:\n BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1), now 2.1\n Sputum- >25PMNs, 4+ GPC in pairs and clusters\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan:\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, R\nL shunting, aspiration PNA,\n sepsis. Difficulty oxygenating with Fi02 100% and increased PEEP. PE\n ruled out with CTA. CT initially showed left pneumothorax, but f/u CT\n showed resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol. have reopened ASD repair, causing shunt.\n -consider TEE with bubble study to evaluate for ASD\n -consider Swan-Ganz catheter to check oxygen saturation in four\n to evaluate for right to left shunt, however, likely not\n useful at this point given mixture of cardiogenic/septic physiology\n -giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -cisatracurium (Nimbex) as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin, still requiring dopa\n intermittently. Will try to minimize PEEP to maximize venous return.\n may possibly be from decompensated heart failure. Likely has\n combination of cardiogenic shock and septic shock.\n - Pressors as needed\n - Fluids as neded, currently diuresing for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation.\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 2 on\n - Check AM trough on \n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE\n - consider diurese w lasix drip to goal -500 cc / 24 hours, with\n respiratory cautions\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UOP.\n - monitor UOP\n - check urine lytes\n - consider renal consult for ? ultrafiltration for volume overload\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF.\n Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - check AXR to eval for ileus\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - consider patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553365, "text": "CCU Intern Progress Note\n History of Present Illness\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n -nimbex started\n Medications\n Unchanged\n Physical Exam\n General appearance:\n BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1), now 2.1\n Sputum- >25PMNs, 4+ GPC in pairs and clusters\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan:\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, R\nL shunting, aspiration PNA,\n sepsis. Difficulty oxygenating with Fi02 100% and increased PEEP. PE\n ruled out with CTA. CT initially showed left pneumothorax, but f/u CT\n showed resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol. have reopened ASD repair, causing shunt.\n -consider TEE with bubble study to evaluate for ASD\n -consider Swan-Ganz catheter to check oxygen saturation in four\n to evaluate for right to left shunt, however, likely not\n useful at this point given mixture of cardiogenic/septic physiology\n -giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -cisatracurium (Nimbex) as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin, still requiring dopa\n intermittently. Will try to minimize PEEP to maximize venous return.\n may possibly be from decompensated heart failure. Likely has\n combination of cardiogenic shock and septic shock.\n - Pressors as needed\n - Fluids as neded, currently diuresing for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation.\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 2 on\n - Check AM trough on \n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE\n - consider diurese w lasix drip to goal -500 cc / 24 hours, with\n respiratory cautions\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UOP.\n - monitor UOP\n - check urine lytes\n - consider renal consult for ? ultrafiltration for volume overload\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF.\n Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - check AXR to eval for ileus\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - consider patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Presumed full\n DISPO: CCU for now\n ------ Protected Section ------\n Patient remains hypoxemic, hypotensive with minimal urine output.\n Requiring pressors, intubation, paralytics to effectively perfuse and\n oxygenate. His ventricular rhythms have decreased on amiodarone and\n lidocaine. Etiology of shock seems to be a mixed cardiogenic and\n vasodilatory shock complicated by his poor RV function. For now, will\n continue supportive care, work-up his distended abdomen and determine\n whether continued diuresis using Lasix gtt is necessary. He may\n require PA catheter guided therapy given complex intracardiac\n hemodynamics and ultrafiltration, possibly. Will look whether there is\n a right to left shunt using echocardiography. TEE if TTE has\n suboptimal images. Communicated plan and gravity of condition to wife\n and mother. Critical care time spent 60 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:07 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553390, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553391, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553392, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553393, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. Remains intubated with Aspiration PNA & ?Failure-requiring\n fio2-100% & PEEP up 16.. Pressors weaned to Levophed & Vasopressin.\n Chest Tube insertion for right pneumothorac-unsuccessful-resolved on\n own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Sat\ns low 88-91% with PO2 70-80. CXR-Aspiration PNA,\n resolved pneumothorac, & ?failure. Renal Failure with elevated Creat &\n decreased urinary output.\n Action:\n Adjusted vent settings with goal maintaining sat >90. Pulm toilet.\n Lasix sm doses to gently diurese. Paralized with cisatricurium.\n Response:\n Sats <90% despite Peep-16. Fio2 remain @ 100%. Po2 mid 70\ns Without\n response to Lasix 10mg then 20mg ivp. Awaitng results of paralytic.\n Plan:\n ?Pulm Consult. Contin adjust vent to optimized resp status. ?PA Line\n placement to determine volume status. ?Continue diuresis attempt with\n Lasix.\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT. Episodes of Sustained Slow VT-130\ns with\n stable BP.\n Action:\n EKG with rhythm strip. Rebolus with Amiodarone X2-1^st 300mg with\n repat 150mg with resolution of rhythm.Amiodarone gtt increased to\n 1.0mg/min. with episode received 500ml NS. Lido bolus & gtt for\n recurrent slow vt.\n Response:\n Post second bolus & gtt increase without further episodes of Slow VT.\n Convert to sr with lido-required vasopressin due to decrease in maps.\n Plan:\n EP consult. Contin Amiodarone & Lido gtts.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. T Max-101.8 po. Cultured previous shift. BCx2 sent\n with Am labs.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n Ineffective Coping\n Assessment:\n Difficult situation. Wife understanding-dealing with events. Mom very\n angry-thinks that son is not receiving appropriate care. Wanting to\n move son to . Focused on EW events-CPR resulting in broken ribs.\n When in pt room only communication with mom results in explosive\n outbursts.\n Action:\n Resident attempted to talk with Mom.\n Response:\n success. Mom wants Experts to care for son.\n :\n Contin to support as indicated & tolerated. SS consult.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554646, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 102. Remains off antibiotics.\n Action:\n Conts on ATC Tylenol. PRN cooling blanket. Pt recultured this pm.\n Response:\n Cultures negative to date. Fever felt to be drug related.\n Plan:\n Stool sent for C dif. Cont to check cultures. Follow ID\n recommendations.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 50% 12 PS 10 peep. Pt conts to desat with activity.\n Action:\n Able to wean down Fio2 to 40% To attempt spontaneous breathing trial\n this pm.\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt much lighter this am. Able to follow commands. MAE.\n Action:\n Fentanyl weaned off.\n Response:\n Pt awake in NAD\n Plan:\n Sedate overnite for rest. ? extubation in am.\n" }, { "category": "Physician ", "chartdate": "2151-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554791, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.7\nF - 11:00 AM\n - In afternoon, attempted wean to 40%. Was satting ok in low-mid 90s),\n then with upright SBT 0/8-> pt desatted to 80s, ABG pH 7.35/64/77, was\n increased back to FiO2 50% b/c stayed in 80s when was back on 40%,\n .\n - Overnight pt appeared to be more awake, talking and expelling air\n around ETT with coughing. Would desat to 80s during this. Fentanyl\n increased from 5->->->150. Was switched to CMV/AC, 450x14. RT to\n attempt to switch back to PSV this am. Fentanyl back down to 50mcg/hr.\n - Tap of R knee-> dry\n - TTE-> EF 50%\n - PM Na still 153, increased D5W to 150/hr\n - Continued to spike in afternoon, Tmax 102.7, re-cultured\n - Pulm: BAL likely to be low-yield; consider lines, may improve after\n extub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 38.2\nC (100.8\n HR: 91 (63 - 92) bpm\n BP: 129/76(92) {99/49(64) - 133/76(226)} mmHg\n RR: 13 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,579 mL\n 1,669 mL\n PO:\n TF:\n 1,211 mL\n 336 mL\n IVF:\n 2,538 mL\n 1,083 mL\n Blood products:\n Total out:\n 2,305 mL\n 685 mL\n Urine:\n 2,305 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,274 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 590 (458 - 692) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 42\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 93%\n ABG: 7.34/65/86./34/6\n Ve: 6.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 458 K/uL\n 11.3 g/dL\n 101 mg/dL\n 1.6 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 67 mg/dL\n 109 mEq/L\n 148 mEq/L\n 35.1 %\n 12.2 K/uL\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n WBC\n 12.3\n 12.2\n Hct\n 35.4\n 35.1\n Plt\n 409\n 458\n Cr\n 2.1\n 1.9\n 1.7\n 1.6\n TCO2\n 36\n 35\n 35\n 34\n 37\n 37\n Glucose\n 110\n 115\n 110\n 101\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:159/84, Alk Phos / T Bili:48/0.7,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:376\n IU/L, Ca++:8.2 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:09 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554793, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.7\nF - 11:00 AM\n - In afternoon, attempted wean to 40%. Was satting ok in low-mid 90s),\n then with upright SBT 0/8-> pt desatted to 80s, ABG pH 7.35/64/77, was\n increased back to FiO2 50% b/c stayed in 80s when was back on 40%,\n .\n - Overnight pt appeared to be more awake, talking and expelling air\n around ETT with coughing. Would desat to 80s during this. Fentanyl\n increased from 5->->->150. Was switched to CMV/AC, 450x14. RT to\n attempt to switch back to PSV this am. Fentanyl back down to 50mcg/hr.\n - Tap of R knee-> dry\n - TTE-> EF 50%\n - PM Na still 153, increased D5W to 150/hr\n - Continued to spike in afternoon, Tmax 102.7, re-cultured\n - Pulm: BAL likely to be low-yield; consider lines, may improve after\n extub.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 03:14 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.7\n Tcurrent: 38.2\nC (100.8\n HR: 91 (63 - 92) bpm\n BP: 129/76(92) {99/49(64) - 133/76(226)} mmHg\n RR: 13 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,579 mL\n 1,669 mL\n PO:\n TF:\n 1,211 mL\n 336 mL\n IVF:\n 2,538 mL\n 1,083 mL\n Blood products:\n Total out:\n 2,305 mL\n 685 mL\n Urine:\n 2,305 mL\n 685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,274 mL\n 984 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 590 (458 - 692) mL\n PS : 8 cmH2O\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI: 42\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 93%\n ABG: 7.34/65/86./34/6\n Ve: 6.7 L/min\n PaO2 / FiO2: 174\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 458 K/uL\n 11.3 g/dL\n 101 mg/dL\n 1.6 mg/dL\n 34 mEq/L\n 4.4 mEq/L\n 67 mg/dL\n 109 mEq/L\n 148 mEq/L\n 35.1 %\n 12.2 K/uL\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n WBC\n 12.3\n 12.2\n Hct\n 35.4\n 35.1\n Plt\n 409\n 458\n Cr\n 2.1\n 1.9\n 1.7\n 1.6\n TCO2\n 36\n 35\n 35\n 34\n 37\n 37\n Glucose\n 110\n 115\n 110\n 101\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:159/84, Alk Phos / T Bili:48/0.7,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:376\n IU/L, Ca++:8.2 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving. Attempted\n to wean FiO2 down to 45% from 50% but still hypoxemic so back to 50%.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c\nd diuresis for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodarone PO 400mg tid\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abz with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenan insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS.\n Continued to spike fevers, but fever curve seems to be decreasing.\n Still on ATC tylenol, aspirin and cooling blanket. Fem line removed\n and sent for culture with no growth. Possible drug fever given\n persistent fever with no pos. cx data. C. diff negative. CT with PO\n contrast did not show clear source of fevers. CT sinus did have partial\n opacifications of bilaterally mastoids. CVL placed .\n - d/c abx yesterday per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test today\n - check LFTs, CK, TSH\n - Call rheum for repeat knee tap\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n last night 8L.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat today to assess any regain of systolic funtion.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen in place given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee as above.\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:09 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 554955, "text": "TITLE:\n Chief Complaint: VF arrest\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:01 AM\n INVASIVE VENTILATION - STOP 01:20 PM\n ARTERIAL LINE - STOP 04:50 AM\n FEVER - 102.8\nF - 09:47 AM\n .\n Patient was extubated yesterday with anesthesia and pulmonary present.\n Post extubation gas showed adequate oxygenation. Put patient in for\n speech and swallow evaluation given that NG tube removed and has been\n intubated for over a week. Patient interactive and responsive. Fever\n curve treding down. PM lytes showed increased Na to 149 so turned up\n D5W to 200 cc/hour. Now increasingly volume up but also persistently\n hypernatremic.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Midazolam (Versed) - 10:55 AM\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Other medications:\n No change to PMHX\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.2\nC (99\n HR: 58 (55 - 100) bpm\n BP: 99/66(70) {92/48(61) - 103/66(70)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,403 mL\n 1,455 mL\n PO:\n 120 mL\n 180 mL\n TF:\n 546 mL\n IVF:\n 3,907 mL\n 1,275 mL\n Blood products:\n Total out:\n 2,360 mL\n 675 mL\n Urine:\n 2,360 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,043 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (90 - 893) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.38/54/132/34/5\n Ve: 10.1 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.8 g/dL\n 405 K/uL\n 105 mg/dL\n 1.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 60 mg/dL\n 106 mEq/L\n 146 mEq/L\n 34.2 %\n 10.9 K/uL\n [image002.jpg]\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n WBC\n 12.2\n 10.9\n Hct\n 35.1\n 34.2\n Plt\n 458\n 405\n Cr\n 1.7\n 1.6\n 1.7\n 1.5\n TCO2\n 35\n 34\n 37\n 37\n 34\n 33\n Glucose\n 110\n 101\n 113\n 105\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:119/67, Alk Phos / T Bili:46/0.9,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.0 mg/dL, Mg++:3.1 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now extubated s/p a prolonged\n intubation for hypoxic and hypercarbic respiratory failure, persistent\n fevers now trending down and persistent hypernatremia.\n # Respiratory Failure now s/p extubation: Mixed hypoxemia and\n hypercarbia. Pt continues to wean slowly, became hypercarbic and\n hypoxemic during SBT yesterday at 0/8, however patient was unable to\n stay upright and also ETT likely too small which is making wean more\n difficult. Pulm following and recommend extubation today with\n anesthesia at bedside given was difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2151-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553261, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished > L- sat\ns low- hypoxic by ABG\ns- CXR\n consolidation R\n Action:\n Chest CT done- pneumothorax noted- in- CT attempted L but\n unsuccessful- esophageal balloon placed- PEEP increased 20\n Response:\n Hypotensive w/ high PEEP-> decreased to 12\n Plan:\n CT guided chest tube placement @ IR\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT\n Action:\n Amiodarone gtt @ .5mg/min- trending enzymes.\n Response:\n No sustained runs of VT.\n Plan:\n EP consult.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 PO @ 1400- hypotensive requiring pressors.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553329, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received intubated on full support. With Peep of 16.\n serial abg\ns continues to reveal moderate to severe hypoxemia. Peep\n temporarily decreased to alleviate hypotension and shortly increased to\n 20 d/t unacceptable spo2. Recruitment maneuver X\ns 2 with Physician @\n bedside. Plan to continue with current vent settings and efforts to\n maintain oxygenation.\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553330, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n -nimbex started\n Medications\n Unchanged\n Physical Exam\n General appearance: BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1)\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan\n ASSESSMENT AND PLAN\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs).\n -consider lidocaine gtt if returns to VT\n -continue amiodarone gtt for now, but consider changing medication \n LFTs\n -electrophysiology consult\n .\n #Respiratory Failure: Difficulty oxygenating with Fi02 100% and\n increased PEEP. Per report patient had significant aspiration during\n intubation. PE ruled out with CTA. CT initially showed left\n pneumothorax, but f/u CT showed resolution after chest tube attempt.\n Also CT and CXRs showing right sided possible aspiration PNA. Being\n ventilated according to ARDS net protocol.\n -Giving lasix this AM at increased dose to improve saturation.\n -ARDS net protocol\n -starting nimbex as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitro\n -pulm following- appreciate recs\n .\n #Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressers but\n now only on levo, still requiring dopa intermittently. Will try to\n minimize PEEP to maximize venous return. may possibly be from\n decompensated heart failure. Likely has combination of cardiogenic\n shock and septic shock.\n -pressors as needed\n -fluids as neded\n -would benefit from swan ganz catheter to better understand type of\n hypotenision\n .\n # Leukocytosis/fever/right lobe infiltrate- likely aspiration PNA\n - continue vanco and zosyn, day 2\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n -hold metoprolol, lisinopril, lasix, digoxin\n -echo today\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UO\n - monitor UO\n - send urine lytes\n - consider renal consult\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF\n - monitor liver function\n - may need to stop amio\n .\n # Family dynamicis: family concerned about care of pt in the hosptial\n - social work consult\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN:\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553342, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. Remains intubated with Aspiration PNA & ?Failure-requiring\n fio2-100% & PEEP up 16.. Pressors weaned to Levophed & Vasopressin.\n Chest Tube insertion for right pneumothorac-unsuccessful-resolved on\n own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Sat\ns low 88-91% with PO2 70-80. CXR-Aspiration PNA,\n resolved pneumothorac, & ?failure. Renal Failure with elevated Creat &\n decreased urinary output.\n Action:\n Adjusted vent settings with goal maintaining sat >90. Pulm toilet.\n Lasix sm doses to gently diurese. Paralized with cisatricurium.\n Response:\n Sats <90% despite Peep-16. Fio2 remain @ 100%. Po2 mid 70\ns Without\n response to Lasix 10mg then 20mg ivp. Awaitng results of paralytic.\n Plan:\n ?Pulm Consult. Contin adjust vent to optimized resp status. ?PA Line\n placement to determine volume status. ?Continue diuresis attempt with\n Lasix.\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT. Episodes of Sustained Slow VT-130\ns with\n stable BP.\n Action:\n EKG with rhythm strip. Rebolus with Amiodarone X2-1^st 300mg with\n repat 150mg with resolution of rhythm.Amiodarone gtt increased to\n 1.0mg/min. with episode received 500ml NS. Lido bolus & gtt for\n recurrent slow vt.\n Response:\n Post second bolus & gtt increase without further episodes of Slow VT.\n Convert to sr with lido-required vasopressin due to decrease in maps.\n Plan:\n EP consult. Contin Amiodarone & Lido gtts.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. T Max-101.8 po. Cultured previous shift. BCx2 sent\n with Am labs.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n Ineffective Coping\n Assessment:\n Difficult situation. Wife understanding-dealing with events. Mom very\n angry-thinks that son is not receiving appropriate care. Wanting to\n move son to . Focused on EW events-CPR resulting in broken ribs.\n When in pt room only communication with mom results in explosive\n outbursts.\n Action:\n Resident attempted to talk with Mom.\n Response:\n success. Mom wants Experts to care for son.\n :\n Contin to support as indicated & tolerated. SS consult.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553443, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments: paralyzed/sedated\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: wean nitric oxide as tolerates\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Pleural pressure measurement\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: 40 ppm\n Indication: ARDS\n Effect of therapy: >=15% increase in PaO2[]\n Nitric Oxide trial: Continued\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2151-03-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554546, "text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Pt remained on psv all night. No vent changes required. RSBI held due\n to peep level.\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 554949, "text": "TITLE:\n Chief Complaint: VF arrest\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 10:01 AM\n INVASIVE VENTILATION - STOP 01:20 PM\n ARTERIAL LINE - STOP 04:50 AM\n FEVER - 102.8\nF - 09:47 AM\n .\n Patient was extubated yesterday with anesthesia and pulmonary present.\n Post extubation gas showed adequate oxygenation. Put patient in for\n speech and swallow evaluation given that NG tube removed and has been\n intubated for over a week. Patient interactive and responsive. Fever\n curve treding down. PM lytes showed increased Na to 149 so turned up\n D5W to 200 cc/hour.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:20 AM\n Midazolam (Versed) - 10:55 AM\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Other medications:\n No change to PMHX\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 37.2\nC (99\n HR: 58 (55 - 100) bpm\n BP: 99/66(70) {92/48(61) - 103/66(70)} mmHg\n RR: 18 (13 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 70 Inch\n Total In:\n 5,403 mL\n 1,455 mL\n PO:\n 120 mL\n 180 mL\n TF:\n 546 mL\n IVF:\n 3,907 mL\n 1,275 mL\n Blood products:\n Total out:\n 2,360 mL\n 675 mL\n Urine:\n 2,360 mL\n 675 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,043 mL\n 780 mL\n Respiratory support\n O2 Delivery Device: High flow neb, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 352 (90 - 893) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 55\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.38/54/132/34/5\n Ve: 10.1 L/min\n PaO2 / FiO2: 132\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 10.8 g/dL\n 405 K/uL\n 105 mg/dL\n 1.5 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 60 mg/dL\n 106 mEq/L\n 146 mEq/L\n 34.2 %\n 10.9 K/uL\n [image002.jpg]\n 04:33 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n WBC\n 12.2\n 10.9\n Hct\n 35.1\n 34.2\n Plt\n 458\n 405\n Cr\n 1.7\n 1.6\n 1.7\n 1.5\n TCO2\n 35\n 34\n 37\n 37\n 34\n 33\n Glucose\n 110\n 101\n 113\n 105\n Other labs: PT / PTT / INR:17.9/34.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:119/67, Alk Phos / T Bili:46/0.9,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.0 mg/dL, Mg++:3.1 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure now s/p extubation: Mixed hypoxemia and\n hypercarbia. Pt continues to wean slowly, became hypercarbic and\n hypoxemic during SBT yesterday at 0/8, however patient was unable to\n stay upright and also ETT likely too small which is making wean more\n difficult. Pulm following and recommend extubation today with\n anesthesia at bedside given was difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2151-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555042, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers.\n D5W @ 200cc/hr continous for elevated NA levels\n evening lytes to be\n drawn.\n Ventricular tachycardia, sustained\n Assessment:\n SB/SR 50-70s. rare PVCs.\n Action:\n Betablocker held this am due to SB 50s. Lopressor decreased to 25mg po\n BID. Amiodarone 200mg po TID continued.\n Response:\n HR remains SR 60s today. SBP 90-100s.\n Plan:\n Give Lopressor this evening at decreased dose if HR remains above 60.\n SBP>100. Continue amio at current dose per EP. Con\nt betablockade. If\n pt continues to be afebrile overnite, EPS study planned for am for\n ablation. Possible ICD placement due to likely high ventricular scar\n burden, instability of VT, and VF requiring shock/resucitation\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains extubated. No respiratory distress. Sats >95%.\n Action:\n Weaned off high flow O2. O2 4L n/c w/ sats 94-98%. LS clear, dim. Pt\n doing DB+C and Incentive spirometry.\n Response:\n Improving IS. Weaned off high flow, remains on NC 4L . wife brought in\n pt\ns own bipap from home to wear this evening.\n Plan:\n Pt to wear own bipap this evening for OSA.\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553321, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- Trop-T: <0.01 CK: 267 MB: 6 to CK: 262 MB: 7 Trop-T:\n 0.36, to CK 740, MB 9, trop 0.30\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1, returned to slower rhythm\n -did not respond to lasix, gave 40IV x 1\n Medications\n Unchanged\n Physical Exam\n General appearance: BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1)\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan\n ASSESSMENT AND PLAN\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs).\n -consider lidocaine gtt if returns to VT\n -continue amiodarone gtt for now, but consider changing medication \n LFTs\n -electrophysiology consult\n .\n #Respiratory Failure: Difficulty oxygenating with Fi02 100% and\n increased PEEP. Per report patient had significant aspiration during\n intubation. PE ruled out with CTA. CT initially showed left\n pneumothorax, but f/u CT showed resolution after chest tube attempt.\n Also CT and CXRs showing right sided possible aspiration PNA. Being\n ventilated according to ARDS net protocol. Giving lasix this AM at\n increased dose to improve saturation.\n -ARDS net protocol\n -\n -albuterol, ipratropium, racemic epinephrine nebs, with careful\n moinitoring of HR\n .\n #Hypotension:Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n weaned off for a short period, still requiring intermittently. Will\n try to minimize PEEP to maximize venous return. may possibly be from\n decompensated heart failure.\n -pressors as needed\n -fluids as neded\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n -hold metoprolol, lisinopril, lasix, digoxin\n -echo\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN:\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553323, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. Remains intubated with Aspiration PNA & ?Failure-requiring\n fio2-100% & PEEP up 16.. Pressors weaned to Levophed & Vasopressin.\n Chest Tube insertion for right pneumothorac-unsuccessful-resolved on\n own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Sat\ns low 88-91% with PO2 70-80. CXR-Aspiration PNA,\n resolved pneumothorac, & ?failure. Renal Failure with elevated Creat &\n decreased urinary output.\n Action:\n Adjusted vent settings with goal maintaining sat >90. Pulm toilet.\n Lasix sm doses to gently diurese.\n Response:\n Sats <90% despite Peep-16. Fio2 remain @ 100%. Po2 mid 70\ns Without\n response to Lasix 10mg then 20mg ivp.\n Plan:\n ?Pulm Consult. Contin adjust vent to optimized resp status. ?PA Line\n placement to determine volume status. ?Continue diuresis attempt with\n Lasix.\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT. Episodes of Sustained Slow VT-130\ns with\n stable BP.\n Action:\n EKG with rhythm strip. Rebolus with Amiodarone X2-1^st 300mg with\n repat 150mg with resolution of rhythm.Amiodarone gtt increased to\n 1.0mg/min. with episode received 500ml NS.\n Response:\n Post second bolus & gtt increase without further episodes of Slow VT.\n Plan:\n EP consult. Contin Amiodarone gtt.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. T Max-101.8 po. Cultured previous shift. BCx2 sent\n with Am labs.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n" }, { "category": "Social Work", "chartdate": "2151-03-08 00:00:00.000", "description": "Social Work Progress Note", "row_id": 553430, "text": "SOCIAL WORK: Pt/family referred to SW to support family coping. Pt is\n a 39yo married father, with lifelong hx of cardiac disease, admitted\n s/p cardiac arrest, and currently intubated and sedated on CCU. Case\n discussed with RN and medical record reviewed. Pt\ns wife, , and\n mother have been present since admission. Team reports family have had\n complaints about pt\ns care and communication, but less distressed after\n discussion with pt\ns attending today. SW met with wife and mother in\n family waiting area. Pt\ns mother vented her worries about pt\ns care,\n partially based on her own experience as a pt here at . Mother\n worried that pt is not at MA General, where he has had most of his\n treatment, including surgeries, throughout his life. Mother and wife\n vented their fears about the gravity of pt\ns illness, and feeling like\n they almost lost him last night. SW normalized their anxiety/distress,\n and supported them in processing their concerns. Provided orientation\n re: roles and availability of medical staff to provide pt updates.\n Answered questions to help orient family to the hospital, such as where\n to go to eat when cafeteria closes, etc. Wife asked about children\n visiting, (they have 3children ages 13, 12 and 2). SW provided\n psycho-ed about how to talk to children about pt\ns illness, and how to\n prepare the older children, if they ask to visit pt. Mother and wife\n express understanding pt is very ill, and expressed hope that if he\n gets through the next day without more complications, that they may\n begin to feel less over whelmed. They asked appropriate questions\n about usual course of treatment. Wife expressed concern that pt may\n try to get back to work prematurely. SW provided information about ST\n and LT disability and HR contact as pt is a hospital employee.\n ASSESSMENT: Family overwhelmed with the uncertainty of pt\ns illness.\n Wife and mother seemed somewhat relieved with opportunity to express\n their feelings. Per family description, pt may have difficult\n adjustment to illness, and per medical record he has hx of poor\n adherence to treatment.\n PLAN:\n -SW will follow with team to support family and pt coping.\n -Will assess pt\ns mood and adjustment when he is able, provide\n counseling and assist with referrals prn.\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553431, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16.. Pressors weaned to Levophed\n & Vasopressin. Chest Tube insertion for right\n pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Vent settings 100%/450/32/20 peep. Sat\ns 85%, not\n correlating w/ abg sat. CXR-Aspiration PNA, resolved pneumothorac, &\n ?failure.\n Renal Failure with elevated Creat & decreased urinary output.\n Cisastricorium\n Action:\n Nitric Oxide initiated at 40. During day, adjusted Fio2 down to 70%.\n Pulm toilet. Lasix gtt started\n Response:\n Able to slowly Fio2. u/.o up to 100cc/hr, but remains +\n Plan:\n Cont adjust vent and Nitric Oxide. Continue diuresis attempt with\n Lasix.\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT. Episodes of Sustained Slow VT-130\ns with\n stable BP.\n Action:\n EKG with rhythm strip. Rebolus with Amiodarone X2-1^st 300mg with\n repat 150mg with resolution of rhythm.Amiodarone gtt increased to\n 1.0mg/min. with episode received 500ml NS. Lido bolus & gtt for\n recurrent slow vt.\n Response:\n Post second bolus & gtt increase without further episodes of Slow VT.\n Convert to sr with lido-required vasopressin due to decrease in maps.\n Plan:\n EP consult. Contin Amiodarone & Lido gtts.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. T Max-101.8 po. Cultured previous shift. BCx2 sent\n with Am labs.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n Ineffective Coping\n Assessment:\n Difficult situation. Wife understanding-dealing with events. Mom very\n angry-thinks that son is not receiving appropriate care. Wanting to\n move son to . Focused on EW events-CPR resulting in broken ribs.\n When in pt room only communication with mom results in explosive\n outbursts.\n Action:\n Resident attempted to talk with Mom.\n Response:\n success. Mom wants Experts to care for son.\n :\n Contin to support as indicated & tolerated. SS consult.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Comprehensive Physician Note/BACH consu", "row_id": 553432, "text": "TITLE: BACH consult\n Date of service: \n Initial consultation: CCU\n History of present illness: 39 y/o male with history of Ebstein anomaly\n of the tricuspid valve and ASD s/p TV reconstruction and primary ASD\n closure , right and left sided congestive heart failure, known poor\n medical compliance (has missed various f/u appointments at CHB with Dr\n , and at with Dr , who presented to the ED\n with palpitations which awoke him from sleep the morning of . He\n was found to be in VT 230bpm. He began to experience chest pain, given\n amiodarone 150mg IV x 1, followed by amio gtt. He became diaphoretic,\n given etomidate and shocked with 200J, followed by vifib, becoming\n unresponsive and apneic. CPR was initiated, epinephrine x 1, CPR\n continued, shocked at 360J, returning to vtach @ 240. He was intubated,\n returning to sinus rhythm, aspriating vomit; noted to have right\n bronchus intubation and ETT repositioned. Due to hypotension SBP 40's\n started on levophed, neosynephrine, and vasopressin with BP increasing\n to 124/77. Subsequently developed left pneumothroax with attempted\n chest tube placement failed, had esophageal ballon placed. Early this\n morning had two recurrent runs of a WCT for which he was treated with\n amiodarone 300mg IV then with the second run received 100mg IV\n lidocaine with initiation of lidocaine gtt.\n Currently on vasopressin and norepinephrine with SBP 100s, on broad\n spectrum antibiotics for aspiration PNA (temp 104 F), on iNO\n to optimize V/Q mismatch. Initially found to have pneumothorax post rib\n fractures from chest compressions, resolved on repeat chest CT.\n EP consulted: etiology of VT uncertain, likely secondary to CMP, since\n ASD repair and TV ring would not be expected to give RVOT type VT. Also\n ? junctional tachycardia secondary to medications vs SVT due to bypass\n tract. EP recommended 1) EPS when stable 2) Stop lidocaine 3) Adenosine\n to treat ongoing SVT (unsuccesful).\n BACH team consulted for assistance in management.\n Past medical history: 1) Ebstein anomaly of the tricuspid valve and\n atrial septal defect\n a) Attempted device closure of ASD complicated by foreign\n body movement into thoracic circulation which was removed (,\n CHB, Dr . Lock).\n b) Tricuspid valve reconstruction ( technique) with\n a 34 mm tricuspid valve ring, serial number , model 4500, and\n primary closure of ASD (, ; Dr\n ).\n c) MRI at : left ventricular end diastolic\n volume of 169.29 cc, LVEF 29.76%, and a right ventricular end diastolic\n volume of 391.15 cc and a right ejection fraction of 36.6%. ? LV\n non-compaction. Mod-severe tricuspid regurgitation.\n d) Exercise test performed at CHB (bicycle): able\n to exercise for 8.72 minutes. Peak VO2 12.6 ml/Kg. Peak RER 1.09. Able\n to increase his heart rate appropriately with exercise and there was\n evidence of mild restrictive obstructive lung disease on his baseline\n spirometry. Peak heart rate was 140 bpm.\n 2) Temporal brain abscess diagnosed age 8 after dental\n procedure treated with antibiotics at CHB.\n 3) OSA, does not wear CPAP machine on a regular basis.\n 4) Recurrent lower extremity cellulitis requiring many\n hospital admissions for IV antibiotics.\n 5) Hyperlipidemia.\n 6) Obesity.\n 7) Gout.\n 8) S/p MVA in in which he had a right lung collapse,\n broken vertebrae, right hip fracture, clavicle fracture, and a\n contusion.\n 9) Hypertension.\n 10) Seasonal allergies.\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: No), (Quit: Yes), (Cigarettes: 1 packs / day x 15 yrs),\n (Discontinue tobacco: more than 10 years ago)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies: NKDA\n No Known Drug Allergies\n Current medications: Lidocaine gtt, Amio gtt, Norepi gtt, Vasopressin\n gtt, Zosyn IV, Vanco IV, Midazolam IV, Ipratropium, Albuterol neb\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Murmur, Chest pain, DOE, Edema, Palpitations, TIA / CVA\n Cardiovascular ROS Signs and Symptoms Absent\n Rheumatic fever, SOB, PND, Orthopnea, Syncope, Presyncope,\n Lightheadedness, Pulmonary embolism, DVT, Claudication, Exertional\n buttock pain, Exertional calf pain\n Review of Systems\n Organ system ROS abnormal\n Respiratory, Musculoskeletal\n Organ system ROS normal\n Constitutional, Eyes, ENT, Gastrointestinal, Endocrine, Hematology /\n Lymphatic, Genitourinary, Integumentary, Neurological, Psychiatric,\n Allergy / Immune\n Signs and symptoms absent\n Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,\n Bleeding during surgery, Joint pains, Myalgias\n Social History\n Marital status: married\n Occupation: IT technician\n Children: 3\n (Alcohol: Yes), (Recreational drug use: No)\n Family history: Non-contributory\n Social history details: Married with three children (two stepchildren).\n He works as an IT service technician at . He consumes two-three\n alcoholic drinks daily (beer). No current tobacco (quit smoking more\n than 10 years ago: 1ppd for 15 years). No illicit drug use.\n Physical Exam\n Date and time of exam: \n General appearance: Vented, sedated\n Vital signs: per R.N.\n Height: 70 Inch, 178 cm\n BP right arm:\n 100 / 65 mmHg\n supine\n T current: 104.8 C\n HR: 90 bpm\n RR: 32 insp/min\n O2 sat: 116 % 70% FiO2\n Vital sign details: 3.1 L positive\n Eyes: (Conjunctiva and lids: Abnormal)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Jugular veins: Not visible),\n (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: Abnormal), (Auscultation: Abnormal)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: Abnormal), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL)\n Skin: (Abnormal)\n Labs\n 270\n 14.1\n 129\n 3.2\n 23\n 5.3\n 41\n 99\n 132\n 41.0\n 14.1\n [image002.jpg]\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n WBC\n 13.9\n 17.7\n 13.4\n 14.1\n Hgb\n 14.4\n 15.0\n 14.2\n 14.1\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n 41.0\n Plt\n 326\n 326\n 338\n 270\n INR\n 1.9\n 2.5\n PTT\n 37.5\n Na+\n 134\n 134\n 132\n K + (Serum)\n 6.0\n 6.2\n 5.6\n 5.3\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 98\n 101\n 99\n HCO3\n 21\n 22\n 23\n BUN\n 26\n 30\n 41\n Creatinine\n 2.3\n 2.6\n 3.2\n Glucose\n 112\n 126\n 129\n CK\n 740\n CK-MB\n 9\n Troponin T\n 0.30\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n ABG: 7.32 / 45 / 96 / / -3 Values as of 03:17 PM\n Tests\n ECG: (Date: ), EKG : WCT 140 bpm, RBBB, LAHB\n Echocardiogram: (Date: ), TEE: No atrial septal defect by 2D or\n color Doppler. Well seated tricuspid annular ring with mild-moderate\n tricuspid regurgitation. Severe right ventricular cavity enlargement\n with depressed biventricular systolic function.\n TTE: The left atrium is mildly dilated. Left ventricular wall\n thicknesses and cavity size are normal. Systolic performance could not\n be assessed. The right ventricular cavity is markedly dilated The free\n wall is hypokinetic. The aortic and tricuspid valves are not well seen.\n The mitral valve is grossly normal. No definite mitral regurgitation is\n seen.\n TTE : dilated RV with depressed RVEF, global LV hypokinesis EF\n 30%, 2+ TR\n Assessment and Plan\n 39 yo male with history of Ebstein's anomaly and ASD s/p TV\n reconstruction and primary ASD closure , LV noncompaction,\n biventricular heart failure, moderate-severe tricuspid regurgitation,\n morbid obesity, OSA, who presented on with unstable ventricular\n tachycardia s/p resuscitation, who is now critically ill, intubated, on\n pressors, on broad spectrum antibiotics for aspiration PNA, and in\n ARDS with difficulty oxygenating, increased PEEP requiring iNO.\n 1) Biventricular heart failure with tricuspid regurgitation.\n - His fluid status is difficult to assess given his body habitus, he is\n grossly positive by I/O. Nevertheless, would not aggressively diurese\n given his ongoing infection.\n - PA line monitoring would be ideal, although insertion of a neck line\n may be problem in this morbidly obese patient.\n - He has not been considered a surgical candidate for a re-do TV\n reconstruction in the past given his comorbidities and non-compliance.\n - Wean pressors as tolerated.\n 2) Ventricular tachycardia, possibly related to his cardiomyopathy and\n less likely to his prior surgery. There is also a question of SVT due\n to a bypass tract (common in Ebstein's anomaly).\n - Continue amiodarone drip. Stop lidocaine per EP recs.\n - EPS when clinically stable\n - Monitor K and magnesium\n 3) ARDS. Pulmonary following and assisting in ventilator management.\n Difficult oxygenation is secondary to PNA with V/Q mismatch and not\n related to a residual intracardiac shunt, as demostrated by today's\n TEE.\n 4) Sepsis.\n - continue broad spectrum antibiotics\n - await culture results\n Will follow with you\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553446, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16.. Pressors weaned to Levophed\n & Vasopressin. Chest Tube insertion for right\n pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Vent settings 100%/450/32/20 peep. Sat\ns 85%, not\n correlating w/ abg sat. CXR-Aspiration PNA, resolved pneumothorac, &\n ?failure.\n Renal Failure with elevated Creat & decreased urinary output.\n Cisatricurium at 0.18mg/kg/hr.\n Action:\n Nitric Oxide initiated at 40. During day, adjusted Fio2 down to 70%.\n Pulm toilet. Lasix gtt started. TOF on 0.18 cisatricurium is 4\n twitches. Slowly increased up to 0.26mg/kg/hr.\n Response:\n Able to slowly Fio2. u/.o up to 100cc/hr, but remains + for the\n day. Adequate paralyzation w/ tof at 2.\n Plan:\n Cont adjust vent and Nitric Oxide. Continue diuresis attempt with\n Lasix. Cont check tof for 2 twitches.\n .H/O heart disease, congenital\n Assessment:\n Rec\nd pt in junctional rhythm in 80\ns. BP 80-110/ on Vasopressin\n 2.4units/hr and Levophed 0.4mcg/kg/min, amiodarone 1mg/min and\n Lidocaine 2mg/hmin.\n Action:\n Per EP lidocaine dc\nd. Adenosine 6mg f/b 12mg ivp at 1400 without\n change in rhythm. Able to slowly decrease levophed to 0.35mcg/kg.\n Defib w/ hands off pads maintained at bedside. BACH\n staff consulted. Records obtained from .\n Response:\n Maintaining sbp >100/ HR continues junctional.\n Plan:\n Monitor for arrythmias, decrease pressors as tolerated,\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. 104.8-104.4. Cultured previous shift. BCx2 sent with\n Am labs.\n Action:\n Levophed gtt and Vasopressin cont as above. MRSA screening done.\n Tylenol 1000mg x1. Cooling blanket initiated. Zocyn and Vancomycin\n continue.\n Response:\n MAPs > 60, but continues febrile.\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly, monitor pnd cultures,\n consider Tylenol/motrin despite increased lfts.\n Ineffective Coping\n Assessment:\n Pt\ns wife and mother throughout day. Understandingly overwhelmed\n by current situation.\n Action:\n Family meeting w/ Dr. , Meeting w/ Children\ns Hospital BACH staff,\n meeting w/ social service. Patient relations notifed\n Response:\n Family feeling less overwhelmed today, as pt is more stable. They do\n realize the severity of pt\ns situation and are asking appropriate\n questions.\n Plan:\n Cont support w/ social service and md updates as needed.\n" }, { "category": "Physician ", "chartdate": "2151-03-09 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553503, "text": "CCU Intern Progress Note:\n History of Present Illness\n \n - continues to be febrile 102-103, received tylenol 2gm max/day, no\n motrin ARF/CRF, on vanc/zosyn\n - UOP improved, urine lytes showed FeBUN 16.7% (<35) --> prerenal\n - vanc trough = 6.6 (LOW) --> gave 500mg IV x 1 and increased daily\n dose to 1250mg IV q24h\n - TEE - No atrial septal defect by 2D or color Doppler. Well seated\n tricuspid annular ring with mild-moderate tricuspid regurgitation.\n Severe right ventricular cavity enlargement with depressed\n biventricular systolic function.\n - AXR, CXR - stable (though difficult to see anything); CXR -\n Unchanged cardiomegaly with bilateral retrocardiac atelectasis,\n unchanged mediastinal widening.\n - evaluated by BACH service ( congenital cards) -\n continue management (nothing revolutionary)\n - pulm - continue iNO, consider Swan-Ganz for pressures\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 40.4 C\n Tmax F last 24 hours: 104.8 F\n T current C: 39 C\n T current F: 102.2 F\n Previous day:\n Intake: 5,273 mL\n Output: 2,123 mL\n Fluid balance: 3,150 mL\n Today:\n Intake: 1,050 mL\n Output: 940 mL\n Fluid balance: 110 mL\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 239\n 13.0\n 170\n 3.2\n 23\n 4.4\n 48\n 96\n 129\n 38.2\n 13.2\n [image002.jpg]\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n 04:53 PM\n 03:33 AM\n WBC\n 13.4\n 14.1\n 13.2\n Hgb\n 14.2\n 14.1\n 13.0\n Hct (Serum)\n 42.9\n 41.0\n 38.2\n Plt\n 338\n 270\n 239\n INR\n 1.9\n 2.5\n 2.2\n PTT\n 37.5\n 39.6\n 42.7\n Na+\n 134\n 132\n 129\n K + (Serum)\n 6.2\n 5.6\n 5.3\n 4.4\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 101\n 99\n 96\n HCO3\n 22\n 23\n 23\n BUN\n 30\n 41\n 48\n Creatinine\n 2.6\n 3.2\n 3.2\n Glucose\n 126\n 129\n 170\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n 92\n ABG: 7.40 / 36 / 83 / / -1 Values as of 03:44 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, R\nL shunting, aspiration PNA,\n sepsis. Difficulty oxygenating with Fi02 100% and increased PEEP. PE\n ruled out with CTA. CT initially showed left pneumothorax, but f/u CT\n showed resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol. have reopened ASD repair, causing shunt.\n -consider TEE with bubble study to evaluate for ASD\n -consider Swan-Ganz catheter to check oxygen saturation in four\n to evaluate for right to left shunt, however, likely not\n useful at this point given mixture of cardiogenic/septic physiology\n -giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -cisatracurium (Nimbex) as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin, still requiring dopa\n intermittently. Will try to minimize PEEP to maximize venous return.\n may possibly be from decompensated heart failure. Likely has\n combination of cardiogenic shock and septic shock.\n - Pressors as needed\n - Fluids as neded, currently diuresing for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation.\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 2 on\n - Check AM trough on \n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE\n - consider diurese w lasix drip to goal -500 cc / 24 hours, with\n respiratory cautions\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UOP.\n - monitor UOP\n - check urine lytes\n - consider renal consult for ? ultrafiltration for volume overload\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF.\n Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - check AXR to eval for ileus\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - consider patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Respiratory ", "chartdate": "2151-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553504, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: No Breathing efforts\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: 20 ppm\n Indication: Acute right heart failure\n Effect of therapy: >=15% increase in PaO2[]\n Nitric Oxide trial: Continued\n Comments:\n Pulse oximetry appears improved but ABG Po2 do not reflect this, not\n correlating closely. ABG indicating some improvement in ventilatory\n dynamics, Pco2 decreasing. Plan is for Course of vent support subject\n of review by attending on rounds today.\n" }, { "category": "Physician ", "chartdate": "2151-03-09 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553522, "text": "CCU Intern Progress Note:\n History of Present Illness\n \n - continues to be febrile 102-103, received tylenol 2gm max/day, no\n motrin ARF/CRF, on vanc/zosyn\n - UOP improved, urine lytes showed FeBUN 16.7% (<35) --> prerenal\n - vanc trough = 6.6 (LOW) --> gave 500mg IV x 1 and increased daily\n dose to 1250mg IV q24h\n - TEE - No atrial septal defect by 2D or color Doppler. Well seated\n tricuspid annular ring with mild-moderate tricuspid regurgitation.\n Severe right ventricular cavity enlargement with depressed\n biventricular systolic function.\n - AXR, CXR - stable (though difficult to see anything); CXR -\n Unchanged cardiomegaly with bilateral retrocardiac atelectasis,\n unchanged mediastinal widening.\n - evaluated by BACH service ( congenital cards) -\n continue management (nothing revolutionary)\n - pulm - continue iNO, consider Swan-Ganz for pressures\n -still on nitric oxide, vasopressin and levo\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 40.4 C\n Tmax F last 24 hours: 104.8 F\n T current C: 39 C\n T current F: 102.2 F\n Previous day:\n Intake: 5,273 mL\n Output: 2,123 mL\n Fluid balance: 3,150 mL\n Today:\n Intake: 1,050 mL\n Output: 940 mL\n Fluid balance: 110 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 32, FiO2 70%, SpO2 99%, nitric oxide\n at 20\n VS: HR 81, 91-93; BP 98-61; 96-110/61-79\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm except for cool toes\n Labs\n 239\n 13.0\n 170\n 3.2\n 23\n 4.4\n 48\n 96\n 129\n 38.2\n 13.2\n [image002.jpg]\n ABG 7.4/36/83/23\n ALT 1211\n AST 1132\n AP 53\n T Bili 1.8\n Alb 3.3\n Ca 8.2, mag 1.7, phos 5.0\n FDP 80-160, Fibrinogen 546\n Urine lytes- UreaN 199, Cr 93, Na 38, Osml 346\n Sputum cx\n oral flora prelim\n Urine cx- 8000 GP bacteria\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n 04:53 PM\n 03:33 AM\n WBC\n 13.4\n 14.1\n 13.2\n Hgb\n 14.2\n 14.1\n 13.0\n Hct (Serum)\n 42.9\n 41.0\n 38.2\n Plt\n 338\n 270\n 239\n INR\n 1.9\n 2.5\n 2.2\n PTT\n 37.5\n 39.6\n 42.7\n Na+\n 134\n 132\n 129\n K + (Serum)\n 6.2\n 5.6\n 5.3\n 4.4\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 101\n 99\n 96\n HCO3\n 22\n 23\n 23\n BUN\n 30\n 41\n 48\n Creatinine\n 2.6\n 3.2\n 3.2\n Glucose\n 126\n 129\n 170\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n 92\n ABG: 7.40 / 36 / 83 / / -1 Values as of 03:44 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. This AM had sevarel episodes of what\n may have been VT with rate in 120s to 130s, improved with amio bolus\n and increased gtt (however, now also increased LFTs). Required addition\n of lidocaine gtt.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, R\nL shunting, aspiration PNA,\n sepsis. Difficulty oxygenating with Fi02 100% and increased PEEP. PE\n ruled out with CTA. CT initially showed left pneumothorax, but f/u CT\n showed resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol. have reopened ASD repair, causing shunt.\n -consider TEE with bubble study to evaluate for ASD\n -consider Swan-Ganz catheter to check oxygen saturation in four\n to evaluate for right to left shunt, however, likely not\n useful at this point given mixture of cardiogenic/septic physiology\n -giving lasix this AM at increased dose, so far little improvement\n -ARDS net protocol\n -cisatracurium (Nimbex) as paralytic \n -nebs\n -if still poor saturation, will consider inhaled nitrous oxide\n -pulm following- appreciate recs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin, still requiring dopa\n intermittently. Will try to minimize PEEP to maximize venous return.\n may possibly be from decompensated heart failure. Likely has\n combination of cardiogenic shock and septic shock.\n - Pressors as needed\n - Fluids as neded, currently diuresing for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation.\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 2 on\n - Check AM trough on \n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE\n - consider diurese w lasix drip to goal -500 cc / 24 hours, with\n respiratory cautions\n .\n # ARF: Cr increased to 2.6. Likely hypotension. Possible ATN. Low\n UOP.\n - monitor UOP\n - check urine lytes\n - consider renal consult for ? ultrafiltration for volume overload\n .\n # Transaminitis: LFTs increased, may be from shock liver, and/or CHF.\n Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - check AXR to eval for ileus\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to \n - social work consult\n - consider patient relations/advocate consults\n - likely benefit from family meeting today\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-09 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553529, "text": "CCU Intern Progress Note:\n History of Present Illness\n \n - continues to be febrile 102-103, received tylenol 2gm max/day, no\n motrin ARF/CRF, on vanc/zosyn\n - UOP improved, urine lytes showed FeBUN 16.7% (<35) --> prerenal\n - vanc trough = 6.6 (LOW) --> gave 500mg IV x 1 and increased daily\n dose to 1250mg IV q24h\n - TEE - No atrial septal defect by 2D or color Doppler. Well seated\n tricuspid annular ring with mild-moderate tricuspid regurgitation.\n Severe right ventricular cavity enlargement with depressed\n biventricular systolic function.\n - AXR, CXR - stable (though difficult to see anything); CXR -\n Unchanged cardiomegaly with bilateral retrocardiac atelectasis,\n unchanged mediastinal widening.\n - evaluated by BACH service ( congenital cards) -\n continue management (nothing revolutionary)\n - pulm - continue iNO, consider Swan-Ganz for pressures\n -still on nitric oxide, vasopressin and levo\n -tele- frequent 3-4 beat runs of NSVT\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 40.4 C\n Tmax F last 24 hours: 104.8 F\n T current C: 39 C\n T current F: 102.2 F\n Previous day:\n Intake: 5,273 mL\n Output: 2,123 mL\n Fluid balance: 3,150 mL\n Today:\n Intake: 1,050 mL\n Output: 940 mL\n Fluid balance: 110 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 32, FiO2 70%, SpO2 99%, nitric oxide\n at 20\n VS: HR 81, 91-93; BP 98-61; 96-110/61-79\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 239\n 13.0\n 170\n 3.2\n 23\n 4.4\n 48\n 96\n 129\n 38.2\n 13.2\n [image002.jpg]\n ABG 7.4/36/83/23\n ALT 1211, AST 1132\n AP 53\n T Bili 1.8\n Alb 3.3\n Ca 8.2, mag 1.7, phos 5.0\n FDP 80-160, Fibrinogen 546\n Urine lytes- UreaN 199, Cr 93, Na 38, Osml 346\n Sputum cx\n oral flora prelim\n Urine cx- 8000 GP bacteria\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n 04:53 PM\n 03:33 AM\n WBC\n 13.4\n 14.1\n 13.2\n Hgb\n 14.2\n 14.1\n 13.0\n Hct (Serum)\n 42.9\n 41.0\n 38.2\n Plt\n 338\n 270\n 239\n INR\n 1.9\n 2.5\n 2.2\n PTT\n 37.5\n 39.6\n 42.7\n Na+\n 134\n 132\n 129\n K + (Serum)\n 6.2\n 5.6\n 5.3\n 4.4\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 101\n 99\n 96\n HCO3\n 22\n 23\n 23\n BUN\n 30\n 41\n 48\n Creatinine\n 2.6\n 3.2\n 3.2\n Glucose\n 126\n 129\n 170\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n 92\n ABG: 7.40 / 36 / 83 / / -1 Values as of 03:44 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Cardiac enzymes mildly elevated, likely\n related to CPR and cardioversion. AM 1/26 episodes of SVT with rate in\n 120s to 130s, improved with amio bolus x 2 and lido gtt, now off lido.\n -likely need VT albation\n -continue amiodarone gtt for now, but careful monitoring of LFTs\n -electrophysiology consult\n .\n # Respiratory Failure: Likely multifactorial origin possibling include\n low cardiac output, volume overload, aspiration PNA, sepsis. No shunt\n seen on TEE bubble study. Difficulty oxygenating until addition of\n nitric oxide on , now on Fi02 70% and PEEP of 20. PE ruled out with\n CTA. CT initially showed left pneumothorax, but f/u CT showed\n resolution after chest tube attempt. Also CT and CXRs showing\n right-sided possible aspiration PNA, which is consistent w/ reported\n aspiration during intubation. Being ventilated according to ARDS net\n protocol.\n -pulm recs to stop paralytic- Nimbex, decrease FIO2 to 60%, and start\n weaning nitric oxide\n -continuing lasix gtt, improved UO\n -ARDS net protocol\n -nebs\n - CXR to eval for PTX\n .\n # Hypotension: Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n now only on levophed and vasopressin. Will try to minimize PEEP to\n maximize venous return. Likely due to both cardiogenic and septic\n shock.\n - Pressors as needed\n - Fluids as neded, but currently on lasix gtt for volume overload\n - consider Swan-Ganz placement to evaluate pressures/volumes\n .\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 3 on\n - Following vanco levels\n - follow sputum, urine, and blood cxs\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - consider diurese w lasix drip to goal -500 cc / 24 hours\n .\n # ARF: Cr increased to 3.2. Likely hypotension. Prerenal by urine\n lytes. UO now improved\n - monitor UOP\n - renally dose meds\n .\n # Transaminitis: LFTs increased to 1000s, likely from shock liver, and\n CHF. Also has abdominal extension.\n - monitor liver function\n - may need to stop amio\n - AXR done on - no free air, no obstruction seen (wet read)\n .\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - patient relations/advocate consults\n - Children\ns congenital specialist contact- no other recs\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553611, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16... Chest Tube insertion for\n right pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished/clear throughout. Sx for thick tan plugs.\n Cisatricurium at 0.24, Fentanyl 250 and Versed 6mg/hr. On vent support\n Action:\n Paralytics dc\nd at 0900. Sedation dc\nd at 1100. Attempting Fio2 and\n Nitric Oxide wean. Pt w/ +cough w/ ETT sx. During day, adjusted Fio2\n down to 60%. Nitric Oxide decreased to 10. Aggressive Pulm toilet.\n Lasix gtt increased to 20mg/hr\n Response:\n + withdrawal to painful stimuli off sedation, Able to slowly Fio2.\n U/O increased, so 800cc negative over last 10hrs.\n Plan:\n Cont adjust vent and Nitric Oxide. Cont aggressive pulmonary\n toileting. Continue diuresis with Lasix.\n .H/O heart disease, congenital\n Assessment:\n Rec\nd pt in junctional rhythm in 80\ns w/ one 5br vt at 0800. BP\n 80-110/ on Vasopressin 2.4units/hr and Levophed 0.4mcg/kg/min,\n amiodarone 1mg/min. Mg 1.7\n Action:\n With sedation off and when pt is stimulated, HR is 80\ns nsr w/ rare\n single pvc. Able to stop Vasopressin maintaining SBP 100-100.\n Amiodarone dc\nd. Magnesium repleted.\n Response:\n Maintaining sbp >100/ HR continues junctional alt w/ nsr. No vea.\n Plan:\n Monitor for arrythmias, decrease pressors as tolerated, lyte\n repletion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102..\n Action:\n Levophed gtt and Vasopressin cont as above. MRSA screening done.\n Tylenol 1000mg x1. Cooling blanket initiated. Zocyn and Vancomycin\n continue.\n Response:\n MAPs > 60, but continues febrile.\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly, monitor pnd cultures,\n consider Tylenol/motrin despite increased lfts.\n Ineffective Coping\n Assessment:\n Pt\ns wife and mother throughout day.\n Action:\n Updates by Dr. , BACH team, pulmonary team,\n Response:\n Family is more comfortable w/ care as pt is more stable. They do\n realize the severity of pt\ns situation and are asking appropriate\n questions.\n Plan:\n Cont support w/ social service and md updates as needed.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553612, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16... Chest Tube insertion for\n right pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished/clear throughout. Sx for thick tan plugs.\n Cisatricurium at 0.24, Fentanyl 250 and Versed 6mg/hr. On vent support\n Action:\n Paralytics dc\nd at 0900. Sedation dc\nd at 1100. Attempting Fio2 and\n Nitric Oxide wean. Pt w/ +cough w/ ETT sx. During day, adjusted Fio2\n down to 60%. Nitric Oxide decreased to 10. Aggressive Pulm toilet.\n Lasix gtt increased to 20mg/hr\n Response:\n + withdrawal to painful stimuli off sedation, Able to slowly Fio2.\n U/O increased, so 800cc negative over last 10hrs.\n Plan:\n Cont adjust vent and Nitric Oxide. Cont aggressive pulmonary\n toileting. Continue diuresis with Lasix.\n .H/O heart disease, congenital\n Assessment:\n Rec\nd pt in junctional rhythm in 80\ns w/ one 5br vt at 0800. BP\n 80-110/ on Vasopressin 2.4units/hr and Levophed 0.4mcg/kg/min,\n amiodarone 1mg/min. Mg 1.7\n Action:\n With sedation off and when pt is stimulated, HR is 80\ns nsr w/ rare\n single pvc. Able to stop Vasopressin maintaining SBP 100-100.\n Amiodarone dc\nd. Magnesium repleted.\n Response:\n Maintaining sbp >100/ HR continues junctional alt w/ nsr. No vea.\n Plan:\n Monitor for arrythmias, decrease pressors as tolerated, lyte\n repletion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7. Continues on vanc and zocyn,\n Action:\n Levophed gtt and Vasopressin cont as above. MRSA screening done.\n Tylenol 1000mg x1. Cooling blanket initiated. Zocyn and Vancomycin\n continue.\n Response:\n MAPs > 60, but continues febrile.\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly, monitor pnd cultures,\n consider Tylenol/motrin despite increased lfts.\n Ineffective Coping\n Assessment:\n Pt\ns wife and mother throughout day.\n Action:\n Updates by Dr. , BACH team, pulmonary team,\n Response:\n Family is more comfortable w/ care as pt is more stable. They do\n realize the severity of pt\ns situation and are asking appropriate\n questions.\n Plan:\n Cont support w/ social service and md updates as needed.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553613, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16... Chest Tube insertion for\n right pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished/clear throughout. Sx for thick tan plugs.\n Cisatricurium at 0.24, Fentanyl 250 and Versed 6mg/hr. On vent support\n Action:\n Paralytics dc\nd at 0900. Sedation dc\nd at 1100. Attempting Fio2 and\n Nitric Oxide wean. Pt w/ +cough w/ ETT sx. During day, adjusted Fio2\n down to 60%. Nitric Oxide decreased to 10. Aggressive Pulm toilet.\n Lasix gtt increased to 20mg/hr\n Response:\n + withdrawal to painful stimuli off sedation, Able to slowly Fio2.\n U/O increased, so 800cc negative over last 10hrs.\n Plan:\n Cont adjust vent and Nitric Oxide. Cont aggressive pulmonary\n toileting. Continue diuresis with Lasix.\n .H/O heart disease, congenital\n Assessment:\n Rec\nd pt in junctional rhythm in 80\ns w/ one 5br vt at 0800. BP\n 80-110/ on Vasopressin 2.4units/hr and Levophed 0.4mcg/kg/min,\n amiodarone 1mg/min. Mg 1.7\n Action:\n With sedation off and when pt is stimulated, HR is 80\ns nsr w/ rare\n single pvc. Able to stop Vasopressin maintaining SBP 100-100.\n Amiodarone dc\nd. Magnesium repleted.\n Response:\n Maintaining sbp >100/ HR continues junctional alt w/ nsr. No vea.\n Plan:\n Monitor for arrythmias, decrease pressors as tolerated, lyte\n repletion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 now down to 101.\n Action:\n Levophed gtt. Cooling blanket continued. Zocyn and Vancomycin\n continue.\n Response:\n MSRA +\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly, monitor pnd cultures,\n consider Tylenol/motrin despite increased lfts.\n Ineffective Coping\n Assessment:\n Pt\ns wife and mother throughout day.\n Action:\n Updates by Dr. , BACH team, pulmonary team,\n Response:\n Family is more comfortable w/ care as pt is more stable. They do\n realize the severity of pt\ns situation and are asking appropriate\n questions.\n Plan:\n Cont support w/ social service and md updates as needed.\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553436, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. - Remains intubated with Aspiration PNA &\n ?Failure-requiring fio2-100% & PEEP up 16.. Pressors weaned to Levophed\n & Vasopressin. Chest Tube insertion for right\n pneumothorac-unsuccessful-resolved on own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Vent settings 100%/450/32/20 peep. Sat\ns 85%, not\n correlating w/ abg sat. CXR-Aspiration PNA, resolved pneumothorac, &\n ?failure.\n Renal Failure with elevated Creat & decreased urinary output.\n Cisatricurium at 0.18mg/kg/hr.\n Action:\n Nitric Oxide initiated at 40. During day, adjusted Fio2 down to 70%.\n Pulm toilet. Lasix gtt started. TOF on 0.18 cisatricurium is 4\n twitches. Slowly increased up to 0.26mg/kg/hr.\n Response:\n Able to slowly Fio2. u/.o up to 100cc/hr, but remains + for the\n day. Adequate paralyzation w/ tof at 2.\n Plan:\n Cont adjust vent and Nitric Oxide. Continue diuresis attempt with\n Lasix. Cont check tof for 2 twitches.\n .H/O heart disease, congenital\n Assessment:\n Rec\nd pt in junctional rhythm in 80\ns. BP 80-110/ on Vasopressin\n 2.4units/hr and Levophed 0.4mcg/kg/min, amiodarone 1mg/min and\n Lidocaine 2mg/hmin.\n Action:\n Per EP lidocaine dc\nd. Adenosine 6mg f/b 12mg ivp at 1400 without\n change in rhythm. Able to slowly decrease levophed to 0.35mcg/kg.\n Defib w/ hands off pads maintained at bedside. BACH\n staff consulted. Records obtained from .\n Response:\n Maintaining sbp >100/ HR continues junctional.\n Plan:\n Monitor for arrythmias, decrease pressors as tolerated,\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. 104.8-104.4. Cultured previous shift. BCx2 sent with\n Am labs.\n Action:\n Levophed gtt and Vasopressin cont as above. MRSA screening done.\n Tylenol 1000mg x1. Cooling blanket initiated. Zocyn and Vancomycin\n continue.\n Response:\n MAPs > 60, but continues febrile.\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly, monitor pnd cultures,\n consider Tylenol/motrin despite increased lfts.\n Ineffective Coping\n Assessment:\n Pt\ns wife and mother throughout day. Understandingly overwhelmed\n by current situation.\n Action:\n Family meeting w/ Dr. , Meeting w/ Children\ns Hospital BACH staff,\n meeting w/ social service. Patient relations notifed\n Response:\n Family feeling less overwhelmed today, as pt is more stable. They do\n realize the severity of pt\ns situation and are asking appropriate\n questions.\n Plan:\n Cont support w/ social service and md updates as needed.\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555204, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Mixed hypoxemia and hypercarbia. Pt continues\n to wean slowly, became hypercarbic and hypoxemic during SBT yesterday\n at 0/8, however patient was unable to stay upright and also ETT likely\n too small which is making wean more difficult. Pulm following and\n recommend extubation today with anesthesia at bedside given was\n difficult intubation.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - Extubation this afternoon with pulm and anesthesia at bedside\n - Consider bronch prior to extubation.\n - cont. nebs\n - If fails extubation will discuss trach. F/u pulm recs.\n - raise head of bed\n - f/u am CXR for tube position.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - amiodarone decreased to 200mg tid given received 10gm loading\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abx with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenal insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS. All culture data negative thus far. Now with increasing\n secretions.\n Continued to spike fevers. Still on ATC tylenol, aspirin and cooling\n blanket. Fem line removed and sent for culture with no growth.\n Possible drug fever given persistent fever with no pos. cx data. C.\n diff negative. CT with PO contrast did not show clear source of fevers.\n CT sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Repeat sputum given inc. secretions\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test normal\n - follow LFTs, CK, TSH normal\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n initially 8L, improving with inc. free water flushes and D5.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n - lytes\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat yesterday showed improved systolic function with EF 50%\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr improving, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - Had been on D5 drip for free water. D/Ced overnight on as Na\n WNL\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee yesterday without fluid.\n - Cont. to monitor.\n FEN: agressively replete lytes, treat hypernatremia with free water\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553767, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n EVENTS: increasing runs of beats VT this morning, then pt started\n becoming hypotensive during brief episodes\n given Amio bolus 300mg IVP\n then started back on amiodarone gtt. Levophed con\nt at 0.12mcg/kg/min.\n Pt decompensated after turn this morning (hypotensive and increased O2\n needs), nitrox was off since 9am, then pt turned at 930am\n after\n 1030am pt improving. RIJ TLC placed w/ assist of ultrasound by Dr \n difficult placement. Confirmed by CXR per CCU team. Rt groin line\n needs to be D/C\nd this evening and tip sent for culture.\n ACCESS: RIJ TLC, R femoral TLC (to be d/c\nd), R radial Aline. 1 PIV.\n Ventricular tachycardia, sustained\n Assessment:\n Pt having runs of beats VT this morning. After 12pm\n pt starting\n to have hypotension w/ runs, and frequency increasing. Defib pads on\n (new since 4am today). Heparin s/q TID. Compression boots.\n Action:\n Amio 300mg IVP given at noon. Followed by amio gtt 1mg/min x 6hrs.\n Response:\n Decreased ectopy. Now when pt having pairs of PVCs, having no decrease\n in BP. No runs noted tonite. Decreased rate to 0.5mg/min this evening.\n Plan:\n Con\nt amio gtt.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lasix gtt @ 20mg/hr. LS diminished throughout. Nitrox via vent.\n Action:\n Good urine output. Nitrox d/c\nd at 9am.\n Response:\n Good abg this afternoon , weaned Fio2 to 50%, then Fio2 to 100% for\n line placement, weaned Fio2 back to 60%. Evening abg ok\n repeat again\n this evening.\n Plan:\n Cont diuresis. Repeat abg. Attempt to decrease peep from 20 to 18\n tonite.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Febrile all day today. Tmax 103 even after Tylenol at 6am.\n Action:\n Cooling blanket turned back on. Extra dose Tylenol given this morning.\n Tylenol ordered q6h ATC. Also added ASA 325mg TID ATC for fever.\n Ibuprofin d/c\nd (contraindicated per labs). Temps 102.3-102.5. Zosyn\n q8. vanco q24h due this evening. Scant secretions. Sputum cx sent this\n afternoon. BC off aline and BC off femoral line sent this morning. VAP\n oral care q4h.\n Response:\n Evening Temp finally down to 101.5.\n Plan:\n Con\nt cooling blanket. Con\nt to monitor temps. Con\nt abx. Pt due for\n vanco trough w/ evening dose tonite. d/c Rt femoral TLC this evening\n and sent tip for culture. New lines for drips and infuse via new RIJ\n TLC.\n" }, { "category": "Nursing", "chartdate": "2151-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554888, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n EVENTS: Extubated successfully this afternoon.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Inutubated w/ #7 ETT.\n Action:\n Sedation turned off. TF turned off. Extubated at 1320hrs w/ success w/\n anesthesia and respiratory present.\n Response:\n Stable sats. ABG WNL.\n Plan:\n ^Monitor sats. evening abg.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Continues febrile. Off abx. Contin to receive ASA TID and Tylenol Q6h..\n All cultures to date-neg. Last cultured .\n Action:\n Given antipyretics. Tylenol increased to 1g QID. Tmax 102.7. Cooling\n blanket placed on.\n Response:\n Temp down to 98.7 after extubation and cooling blanket. Sputum\n culture resent.\n Plan:\n Monitor temps. No abx. Unable to give evening Tylenol and ASA as OGT\n d/c\nd. plan to attempt sips this evening for evening meds. Pt very\n sleepy this afternoon.\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone & Lopressor po. IV D5W @150cc/hr for elevated NA.\n Action:\n Lytes WNL. On D5W increased to 200cc/hr continous.\n Response:\n rare. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Responsive. Appropriate @ times. Very restless @ times. Tolerated wrist\n restraints off a few times this morning. Reoriented frequently. Obeys\n commands.\n Action:\n Increased anxiety late morning, req\nd 2mg IV versed. Slept x 1hr.\n Fentanyl turned off at 12pm for extubation.\n Response:\n Extubated and pt talking\n voice impaired s/p ETT. Wife at bedside.\n Restraints off. Bed alarm on. SR up x 3.\n Plan:\n Freq reorientation. No more sedation. Fall precautions.\n Ineffective Coping\n Assessment:\n CCU team called wife this morning and updated her, as she had not\n visited yet, regarding plans to extubated early afternoon.\n Action:\n Wife in to visit after 1pm. Extubation successful. And wife at bedside\n all day. Explanations given, emotional support given.\n Response:\n Family appeared to accept explanation.\n Plan:\n Contin support pt/family asindicated.\n" }, { "category": "Physician ", "chartdate": "2151-03-10 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553647, "text": "TITLE:\n History of Present Illness\n - off amio elevated LFTs. NSR but increasing ectopy overnight.\n - lasix increased to 20 in the morning (then ~800cc negative during the\n day)\n - NO at 10 all day and stopped in the evening, FiO2 weaned to 60%,\n midazolam weaned off, vasopressin stopped\n - no bowel sounds, no bowel movement\n - started TF, nutrition consult\n - vitamin K repleted\n - still febrile to 101.7\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 39.2 C\n Tmax F last 24 hours: 102.6 F (0800 )\n T current C: 38.6 C\n T current F: 101.4 F\n Previous day:\n Intake: 2,631 mL\n Output: 3,820 mL\n Fluid balance: -1,189 mL\n Today:\n Intake: 321 mL\n Output: 680 mL\n Fluid balance: -359 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 28, FiO2 60%, SpO2 95%, nitric oxide\n at 10\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 249\n 12.9\n 137\n 3.1\n 23\n 4.6\n 55\n 96\n 132\n 38.0\n 14.4\n [image002.jpg]\n 04:53 PM\n 03:33 AM\n 08:43 AM\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n WBC\n 13.2\n 14.4\n Hgb\n 13.0\n 12.9\n Hct (Serum)\n 38.2\n 38.0\n Plt\n 239\n 249\n INR\n 2.2\n PTT\n 42.7\n Na+\n 129\n 132\n K + (Serum)\n 4.4\n 4.6\n Cl\n 96\n 96\n HCO3\n 23\n 23\n BUN\n 48\n 55\n Creatinine\n 3.2\n 3.1\n Glucose\n 170\n 137\n CK\n 4046\n O2 sat (arterial)\n 92\n 98\n 94\n 89\n 94\n 97\n 98\n ABG: 7.44 / 38 / 97 / / 1 Values as of 05:14 AM\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Intrapulmonary shunt\n through consolidations still possibility. However, patient also seems\n to have improved FiO2 requirement after starting furosemide gtt\n yesterday.\n - Wean FiO2, nitric and PEEP as tolerated.\n - Discontinue paralytics as tolerated by ability to ventilate.\n - continuing lasix gtt, aim net negative I/O, start by increasing lasix\n gtt and IV metolazone\n - ARDS net protocol\n - nebs\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs.\n - Appreciate electrophysiology\n - Discontinue amiodarone today\n - may need EP study and possible ablation\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Discontinue vasopressin today as tolerated, and titrate levophed if\n able.\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 4, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low\n - follow sputum, urine, and blood cxs\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - consider diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen\n - Consider Tube feeds if good bowel function\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone\n - Discontinue amiodarone\n - monitor liver function\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - patient relations/advocate consults\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-10 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553663, "text": "TITLE:\n History of Present Illness\n - off amio elevated LFTs. Junctional rhythm changed to NSR, but\n increasing ectopy overnight.\n - lasix increased to 20 in the morning and continued all day\nnegative 1\n L+\n - NO at 10 all day and stopped in the evening, FiO2 weaned to 60%\n - midazolam gtt off (bolus 1-2 mg q2-4h), also getting fentanyl 50 mcg\n ~q2h\n - vasopressin stopped, levophed decreased to .1 mcg/kg/min\n - no bowel sounds, no bowel movement\nincreased bowel regimen\n - started TF, nutrition consult\n - vitamin K repleted\n - still febrile to 101.7\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 39.2 C\n Tmax F last 24 hours: 102.6 F (0800 )\n T current C: 38.6 C\n T current F: 101.4 F\n Previous day:\n Intake: 2,631 mL\n Output: 3,820 mL\n Fluid balance: -1,189 mL\n Today:\n Intake: 321 mL\n Output: 680 mL\n Fluid balance: -359 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 28, FiO2 60%, SpO2 95%, nitric oxide\n at 10\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 249\n 12.9\n 137\n 3.1\n 23\n 4.6\n 55\n 96\n 132\n 38.0\n 14.4\n [image002.jpg]\n 04:53 PM\n 03:33 AM\n 08:43 AM\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n WBC\n 13.2\n 14.4\n Hgb\n 13.0\n 12.9\n Hct (Serum)\n 38.2\n 38.0\n Plt\n 239\n 249\n INR\n 2.2\n PTT\n 42.7\n Na+\n 129\n 132\n K + (Serum)\n 4.4\n 4.6\n Cl\n 96\n 96\n HCO3\n 23\n 23\n BUN\n 48\n 55\n Creatinine\n 3.2\n 3.1\n Glucose\n 170\n 137\n CK\n 4046\n O2 sat (arterial)\n 92\n 98\n 94\n 89\n 94\n 97\n 98\n ABG: 7.44 / 38 / 97 / / 1 Values as of 05:14 AM\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Intrapulmonary shunt\n through consolidations still possibility. However, patient also seems\n to have improved FiO2 requirement after starting furosemide gtt\n yesterday.\n - Wean FiO2, nitric and PEEP as tolerated.\n - Discontinue paralytics as tolerated by ability to ventilate.\n - continuing lasix gtt, aim net negative I/O, start by increasing lasix\n gtt and IV metolazone\n - ARDS net protocol\n - nebs\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs.\n - Appreciate electrophysiology\n - Discontinue amiodarone today\n - may need EP study and possible ablation\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Discontinue vasopressin today as tolerated, and titrate levophed if\n able.\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 4, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low\n - follow sputum, urine, and blood cxs\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - consider diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen\n - Consider Tube feeds if good bowel function\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone\n - Discontinue amiodarone\n - monitor liver function\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - patient relations/advocate consults\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553770, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n EVENTS: increasing runs of beats VT this morning, then pt started\n becoming hypotensive during brief episodes\n given Amio bolus 300mg IVP\n then started back on amiodarone gtt. Levophed con\nt at 0.12mcg/kg/min.\n Pt decompensated after turn this morning (hypotensive and increased O2\n needs), nitrox was off since 9am, then pt turned at 930am\n after\n 1030am pt improving. RIJ TLC placed w/ assist of ultrasound by Dr \n difficult placement. Confirmed by CXR per CCU team. Rt groin line\n needs to be D/C\nd this evening and tip sent for culture. BC x 2 this\n morning. Sputum Cx sent.\n ACCESS: RIJ TLC, R femoral TLC (to be d/c\nd), R radial Aline. 1 PIV.\n Ventricular tachycardia, sustained\n Assessment:\n Pt having runs of beats VT this morning. After 12pm\n pt starting\n to have hypotension w/ runs, and frequency increasing. Defib pads on\n (new since 4am today). Heparin s/q TID. Compression boots.\n Action:\n Amio 300mg IVP given at noon. Followed by amio gtt 1mg/min x 6hrs.\n Response:\n Decreased ectopy. Now when pt having pairs of PVCs, having no decrease\n in BP. No runs noted tonite. Decreased rate to 0.5mg/min this evening.\n Plan:\n Con\nt amio gtt. Evening lytes wnl.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lasix gtt @ 20mg/hr. LS diminished throughout. Nitrox via vent.\n Action:\n Lasix gtt. Nitrox d/c\nd at 9am.\n Response:\n Good diuresis. -750cc since midnite. Goal negative 500-1L. Good abg\n this afternoon , weaned Fio2 to 50%, then Fio2 to 100% for line\n placement, weaned Fio2 back to 60%. Evening abg ok\n repeat again this\n evening.\n Plan:\n Cont diuresis. Repeat abg. Attempt to decrease peep from 20 to 18\n tonite.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Febrile all day today. Tmax 103 even after Tylenol at 6am.\n Action:\n Cooling blanket turned back on. Extra dose Tylenol given this morning.\n Tylenol ordered q6h ATC. Also added ASA 325mg TID ATC for fever.\n Ibuprofin d/c\nd (contraindicated per labs). Temps 102.3-102.5. Zosyn\n q8. vanco q24h due this evening. Scant secretions. Sputum cx sent this\n afternoon. BC off aline and BC off femoral line sent this morning. VAP\n oral care q4h.\n Response:\n Evening Temp finally down to 101.5.\n Plan:\n Con\nt cooling blanket. Con\nt to monitor temps. Con\nt abx. Pt due for\n vanco trough w/ evening dose tonite. d/c Rt femoral TLC this evening\n and sent tip for culture. New lines for drips and infuse via new RIJ\n TLC.\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554668, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 102. Remains off antibiotics.\n Action:\n Conts on ATC Tylenol. PRN cooling blanket. Pt recultured this pm.\n Response:\n Cultures negative to date. Fever felt to be drug related.\n Plan:\n Stool sent for C dif. Cont to check cultures. Follow ID\n recommendations.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 50% 12 PS 10 peep. Pt conts to desat with activity.\n Action:\n Able to wean down Fio2 to 40%. spontaneous breathing trial this pm\n 8/0.\n Response:\n Able to tolerate for short period pt very restless O2 sats 86-94%\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt much lighter this am. Able to follow commands. MAE.\n Action:\n Fentanyl weaned off.\n Response:\n Pt awake in NAD\n Plan:\n Sedate overnite for rest. ? extubation in am.\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Cardiology Physician Note EP", "row_id": 555021, "text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: -Successfully extubated on \n -Feels well, c/o fatigue, arm and leg weakness\n -Denies CP, palpitations, SOB. cough, chills, fever\n Medications\n Unchanged (see daily progess note)\n Physical Exam\n General appearance: Appears well, NAD\n BP: 99 / 54 mmHg\n HR: 66 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 38.1 C\n Tmax F last 24 hours: 100.6 F\n T current C: 37.2 C\n T current F: 99 F\n Previous day:\n Intake: 5,399 mL\n Output: 2,360 mL\n Fluid balance: 3,039 mL\n Today:\n Intake: 2,639 mL\n Output: 675 mL\n Fluid balance: 1,964 mL\n Cardiovascular: (Auscultation: Distant S1 and S2, no murmurs)\n Respiratory: (Auscultation: CTA anteriorly with coarse sounds)\n Abdomen: (Palpation: Soft, NTND, +BS)\n Labs\n 405\n 10.8\n 105\n 1.5\n 34\n 4.1\n 60\n 106\n 146\n 34.2\n 10.9\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 02:35 PM\n 04:30 AM\n WBC\n 12.3\n 12.2\n 10.9\n Hgb\n 11.4\n 11.3\n 10.8\n Hct (Serum)\n 35.4\n 35.1\n 34.2\n Plt\n \n INR\n 1.8\n 1.6\n 1.6\n PTT\n 51.1\n 34.2\n 35.2\n Na+\n 154\n 153\n 153\n 148\n 149\n 146\n K + (Serum)\n 3.6\n 3.5\n 3.8\n 4.4\n 4.1\n 4.1\n Cl\n 113\n 111\n 111\n 109\n 108\n 106\n HCO3\n 33\n 34\n 34\n 34\n 33\n 34\n BUN\n 77\n 79\n 75\n 67\n 69\n 60\n Creatinine\n 2.1\n 1.9\n 1.7\n 1.6\n 1.7\n 1.5\n Glucose\n 110\n 115\n 110\n 101\n 113\n 105\n O2 sat (arterial)\n 91\n 93\n 93\n 92\n ABG: / / / 34 / Values as of 04:30 AM\n Tests\n Telemetry: -Short rare NSVT (2-3 beats)\n Assessment and Plan\n 39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers.\n 1. Ventricular tachycardia-\n -Continue oral amiodarone at current dose\n -Continue beta blockade\n -Once afebrile x 24 hrs (likely by am), will likely obtain EPS with an\n attempt to induce clinical VT and possible ablation\n -Will consider ICD regardless, due to likely high ventricular scar\n burden, instability of VT, and VF requiring shock/resucitation\n ------ Protected Section ------\n Pt seen examined w/drMorello. Agree w/assessment and plan. Will review\n w/drs and for ep procedures.\n ------ Protected Section Addendum Entered By: \n on: 14:35 ------\n" }, { "category": "General", "chartdate": "2151-03-19 00:00:00.000", "description": "Generic Note", "row_id": 555406, "text": "RESPIRATORY CARE NOTE: Patient assisted with CPAP set-up. Has his own\n autoset unit with nasal pillows and 2 lpm O2 titrated in. Tolerates\n well.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554401, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments:\n Plan\n Next 24-48 hours: wean peep as tol\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2151-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554579, "text": "CCU Intern Progress Note:\n 24 Hour Events:\n - cont weaning ventilatory support --> FIO2 down to 45%, PEEP down to\n 10%, but pt becoming more hypoxemic, so FIO2 back to 50%\n - cont to have fever - Tmax 103.6, bl cx drawn, curve downtrending this\n AM\n - will check TSH, cortisol level today (cosyntropin-stim test) as other\n causes\n - Na 154 - free water deficit ~6-7 L --> free water flushes + D5W\n - stopped lasix, antibiotics (vanc/zosyn)\n - increased metoprolol to 50 , started lisinopril 2.5mg daily\n - CT sinus - new sinusitis - ? fungal\n - ID: d/c abx given possiblity for drug-related fever\n - pulm: concur, will consider BAL if continues to be febrile or new\n spike;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.8\nC (100\n HR: 77 (73 - 103) bpm\n BP: 116/66(80) {103/57(71) - 153/86(103)} mmHg\n RR: 14 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,104 mL\n 1,239 mL\n PO:\n TF:\n 1,205 mL\n 312 mL\n IVF:\n 1,929 mL\n 557 mL\n Blood products:\n Total out:\n 4,375 mL\n 540 mL\n Urine:\n 4,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -271 mL\n 699 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 509 (509 - 700) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.40/54/74/34/6\n Ve: 7.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Gen: Obese, less sedated, intubated, moving limbs, nodding/shaking head\n in response to questions\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin\n Labs / Radiology\n 409 K/uL\n 11.4 g/dL\n 115 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 79 mg/dL\n 111 mEq/L\n 153 mEq/L\n 35.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:35 AM\n 03:27 AM\n 03:52 AM\n 09:46 AM\n 01:01 PM\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n WBC\n 13.3\n 12.3\n Hct\n 33.7\n 35.4\n Plt\n 354\n 409\n Cr\n 2.5\n 2.1\n 1.9\n TCO2\n 35\n 35\n 34\n 34\n 36\n 35\n 35\n Glucose\n 94\n 110\n 115\n Other labs:\n PT / PTT / INR:19.2/51.1/1.8,\n ALT / AST:216/99, Alk Phos / T Bili:51/0.7,\n D-dimer: ng/mL, Fibrinogen:679 mg/dL,\n Lactic Acid:1.6 mmol/L,\n Albumin:3.2 g/dL, LDH:430 IU/L,\n Ca++:8.4 mg/dL, Mg++:3.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving. Attempted\n to wean FiO2 down to 45% from 50% but still hypoxemic so back to 50%.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis yesterday for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodarone PO 400mg tid\n - titrate up BB for HR control, increased to 50mg yesterday\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx yesterday per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -D5W + free water flushes for repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen in place given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2151-03-17 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554994, "text": "TITLE:\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: -Successfully extubated on \n -Feels well, c/o fatigue, arm and leg weakness\n -Denies CP, palpitations, SOB. cough, chills, fever\n Medications\n Unchanged (see daily progess note)\n Physical Exam\n General appearance: Appears well, NAD\n BP: 99 / 54 mmHg\n HR: 66 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 38.1 C\n Tmax F last 24 hours: 100.6 F\n T current C: 37.2 C\n T current F: 99 F\n Previous day:\n Intake: 5,399 mL\n Output: 2,360 mL\n Fluid balance: 3,039 mL\n Today:\n Intake: 2,639 mL\n Output: 675 mL\n Fluid balance: 1,964 mL\n Cardiovascular: (Auscultation: Distant S1 and S2, no murmurs)\n Respiratory: (Auscultation: CTA anteriorly with coarse sounds)\n Abdomen: (Palpation: Soft, NTND, +BS)\n Labs\n 405\n 10.8\n 105\n 1.5\n 34\n 4.1\n 60\n 106\n 146\n 34.2\n 10.9\n [image002.jpg]\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 02:35 PM\n 04:30 AM\n WBC\n 12.3\n 12.2\n 10.9\n Hgb\n 11.4\n 11.3\n 10.8\n Hct (Serum)\n 35.4\n 35.1\n 34.2\n Plt\n \n INR\n 1.8\n 1.6\n 1.6\n PTT\n 51.1\n 34.2\n 35.2\n Na+\n 154\n 153\n 153\n 148\n 149\n 146\n K + (Serum)\n 3.6\n 3.5\n 3.8\n 4.4\n 4.1\n 4.1\n Cl\n 113\n 111\n 111\n 109\n 108\n 106\n HCO3\n 33\n 34\n 34\n 34\n 33\n 34\n BUN\n 77\n 79\n 75\n 67\n 69\n 60\n Creatinine\n 2.1\n 1.9\n 1.7\n 1.6\n 1.7\n 1.5\n Glucose\n 110\n 115\n 110\n 101\n 113\n 105\n O2 sat (arterial)\n 91\n 93\n 93\n 92\n ABG: / / / 34 / Values as of 04:30 AM\n Tests\n Telemetry: -Short rare NSVT (2-3 beats)\n Assessment and Plan\n 39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers.\n 1. Ventricular tachycardia-\n -Continue oral amiodarone at current dose\n -Continue beta blockade\n -Once afebrile x 24 hrs (likely by am), will likely obtain EPS with an\n attempt to induce clinical VT and possible ablation\n -Will consider ICD regardless, due to likely high ventricular scar\n burden, instability of VT, and VF requiring shock/resucitation\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555314, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: CCU for now, PT and OT consult\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n have seen and examined the patient. I have reviewed the above note\n and plans.\n I would add the following remarks:\n Medical Decision Making\n Cardiac status stable 1 day post extubation. Will need EP study at some\n point but he is reluctant for now. Continue current therapy. Reevaluate\n for EP study in next day or so.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:42 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 555376, "text": "Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Respiration / Gas Exchange, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2151-03-17 00:00:00.000", "description": "Generic Note", "row_id": 554992, "text": "TITLE: Bedside Evaluation\n Pt seen for a bedside evaluation and was without overt signs of\n aspiration. Pt can be advanced to a regular diet with thin liquids but\n will require assistance for feeding. Please see Web OMR or the paper\n chart for additional details.\n , MS, CCC-SLP\n Pager#\n 10:15\n" }, { "category": "Nursing", "chartdate": "2151-03-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 555516, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, shocked into VF, requiring intubation\n and pressors.\n WIFE is HCP.\n CV - Pt has been without vea x 7 days, stable on Amiodarone and\n lopressor. Plan for EPS and ICD placement.\n Resp -Extubation , able to tolerate nasal canula\n now weaned to\n room air.\n Gi\n Abd obese w/ +bs. Tolerating NAS low chol diet. OB\n stool.\n Large BM this morning ()\n GU\n foley cath patent to amber urine.\n ID\n afebrile. Last temp spike . off antibiotics. Positive nasal\n swab for MRSA- on contact precautions.\n Access\n new Lt medial #20G PIV. RIJ d/c\nd this morning.\n Activity\n OOB to chair/commode w/ 2 assist. Working w/ physical\n therapy daily.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT/shock on admit to EW. Now stable on po amio and lopressor.\n Action:\n Discussing need for pacer/AICD with family. Dr. and EP in\n discussion.\n Response:\n pt. and wife have discussed need for EP study and possible AICD. EP\n planning on doing EPS and ICD placement early next week\n not sure of\n date\n CCU team to contact EP this afternoon and let wife know which\n day they might plan to do procedure\n as wife is planning on going back\n to work next week.\n Plan:\n Contin. to follow plan and discussions with family. Keep wife updated.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Intubated x10days\n now deconditioned and working with PT.\n Action:\n OOB x2 times . using chair back and 2 assist to stand up and\n shuffle to bed or chair.\n Response:\n c/o pain in back of calves when standing or walking. Appearing winded\n with activity. Resolves with rest.\n Plan:\n Work with PT. if pt in hospital over weekend for EPS early next\n week, pt should be able to go home with rehab visiting. Encourage pt to\n do leg lifts and foot pumping to increase tolerance.\n Respiration / Gas Exchange, Impaired\n Assessment:\n s/p aspiration PNA/acute hypoxia\n.7 days of antibiotics. Now afeb. On\n 2L NC. LS clear, diminished. Using incentive spirometry.\n Action:\n Encourage to cough/deep breath. prn nebs have not been needed.\n Uses home CPAP set up. With assist from RT. On room air today\n sats\n stable 94-96%, no SOB.\n Response:\n No c/o SOB. Non productive strong cough.\n Took off CPAP ~ 0500- awake\n Plan:\n Monitor sats. Prn nebs. Monitor sats with activity. CPAP at night.\n Incentive spirometry.\n Knowledge, Impaired\n Assessment:\n Decrease knowledge base r/t EP/AICD and nutrition\n Action:\n Wife states that she is bringing in laptop today () so pt. can\n research more about Pacemakers/AICD\ns. has been in discussions with\n MD\n -family brought in food from home (salad, humous, pita) for pt. pt.\n also states that he drinks regular soda and a large amt. of o.j. at\n home and at work. We talked about need to watch calories and sugar\n intake.\n Talked about setting up consult with a nutritionist.\n Response:\n Pt. is agreeable to having nutrition consult.\n Plan:\n Continue with teaching.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CARDIAC ARREST\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 140 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: Ebstein anomaly, s/p tricuspid valve\n reconstruction- mod to severe tricuspid regurg & R heart failulre w/\n RVEF 25% in - ASD S/P primary closure - Lt heart failure w/\n evidence of noncompaction of LV w/ LVEF 28% in - hyperlididemia-\n obstructive sleep apnea- obesity- DVT- superficial phlebitis-\n endocarditis w/ septic emboli to brain prior to cardiac surgery.\n DIFFICULT INTUBATION.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:53\n Temperature:\n 98.2\n Arterial BP:\n S:124\n D:71\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 30% %\n 24h total in:\n 995 mL\n 24h total out:\n 1,350 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 05:29 AM\n Potassium:\n 3.9 mEq/L\n 05:29 AM\n Chloride:\n 102 mEq/L\n 05:29 AM\n CO2:\n 33 mEq/L\n 05:29 AM\n BUN:\n 39 mg/dL\n 05:29 AM\n Creatinine:\n 1.1 mg/dL\n 05:29 AM\n Glucose:\n 84 mg/dL\n 05:29 AM\n Hematocrit:\n 32.9 %\n 05:29 AM\n Finger Stick Glucose:\n 113\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley, #20 Lt arm PIV. (difficult stick, IV placed peripheral this\n morning, RIJ d/c'd and tip cultured).\n Valuables / Signature\n Patient valuables: glasses, phone at bedside, mp3 player at bedside\n (sent w/ patient and wife to ).\n Other valuables:\n Clothes: sent w/ patient.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: wife\n Jewelry:\n Transferred from: CCU \n Transferred to: \n Date & time of Transfer: 1430hrs.\n" }, { "category": "Physician ", "chartdate": "2151-03-13 00:00:00.000", "description": "Cardiology Resident Progress Note", "row_id": 554164, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:11 PM\n ARTERIAL LINE - START 05:11 PM\n MULTI LUMEN - STOP 05:14 PM\n ARTERIAL LINE - STOP 05:14 PM\n INVASIVE VENTILATION - STOP 05:14 PM\n FEVER - 102.0\nF - 12:00 PM\n - weaned to pressure support, decreasing PEEP, decreasing levophed\n - LENIs to w/u fever--negative for clot\n - R knee tap to w/u fever--no crystals, inflammatory\n - pulm: wean PEEP, CT in AM if can't\n - creatinine improving, net in-->increased lasix gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.2\nC (100.7\n HR: 94 (86 - 100) bpm\n BP: 112/62(76) {95/52(63) - 145/77(93)} mmHg\n RR: 15 (14 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 3,316 mL\n 491 mL\n PO:\n TF:\n 1,289 mL\n 272 mL\n IVF:\n 1,517 mL\n 220 mL\n Blood products:\n Total out:\n 3,060 mL\n 890 mL\n Urine:\n 3,060 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 256 mL\n -399 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 650 (540 - 650) mL\n PS : 12 cmH2O\n RR (Set): 28\n RR (Spontaneous): 16\n PEEP: 14 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 30 cmH2O\n SpO2: 93%\n ABG: 7.42/48/77/30/5\n Ve: 12 L/min\n PaO2 / FiO2: 140\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 151 mg/dL\n 2.5 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 91 mg/dL\n 102 mEq/L\n 143 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n 08:00 AM\n 11:09 AM\n 12:00 PM\n 03:09 PM\n 05:35 PM\n 11:48 PM\n WBC\n 18.9\n Hct\n 37.2\n Plt\n 307\n Cr\n 2.1\n 2.9\n 2.5\n TCO2\n 28\n 28\n 32\n 32\n Glucose\n 147\n 132\n 132\n 128\n 144\n 151\n Other labs: PT / PTT / INR:18.4/31.3/1.7, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:765/267, Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200, Differential-Neuts:83.0 %, Band:3.0 %,\n Lymph:11.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:546 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP, decrease by\n intervals of 2 today, check ABG per pulm recs. Goal Pa02>60 unless\n high fevers. Preferentially reduce Fi02 over PEEP this am.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT tomorrow if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning, but fever curve decreasing. Still on ATC\n tylenol and cooling blanked. Vanco level persistently low, have been\n uptitrating dose. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 7, plan for 8-day course for VAP to\n possibly complete on \n - Curbisde ID re is linezolid a better choice in terms of lung\n penetration vs consult for fevers of unclear origin\n - Check mycolytic blood cultures\n - Continue vancomycin, still not at goal trough level, however with\n increasing cr, repeat level tonight, consider continuing to titrate\n dose.\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs to eval for ? DVTs if above w/u unrevealing.\n - Consider abd imaging if persistent fevers with no clear cause, if\n doing CT tomorrow, be sure to get abd/pelvis imaging.\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours, reduce\n lasix gtt to 10mg/hour in setting of increasing cr.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 today in setting of\n continued diuresis. .\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K yesterday\n - check amylase and lipase\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:06 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:11 PM\n Multi Lumen - 05:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554165, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia which deteriorated to V.fib, s/p\n resuscitation with return to sinus tachycardia, now intubated, with\n hypoxic and hypercarbic respiratory failure, renal failure, &\n aspiration PNA.\n .H/O heart disease, congenital\n Assessment:\n HR 80-90\ns NSR with freq PVC\ns, runs nonsustained VT up to 6 bts.\n Remains in positive fluid balance.\n Action:\n On po amiodarone, lasix gtt increased from 10mg to 15mg/hr. K+\n repleated.\n Response:\n Cont with occ to freq PVC\ns, nonsustained VT.\n Plan:\n EP to evaluate once more stable.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Cont with low grade T and ^WBC\n Action:\n Vanco and zosyn, pul toilet, ATC Tylenol and ASA, fully cultured on\n \n Response:\n T max 100.7 po tonight off cooling blanket\n Plan:\n Cont AB, Tylenol and ASA, check culture results.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains vented and sedated. Cont to require 55% FIO2, 14 PEEP, has\n tolerated PS ventilation.\n Action:\n Decreased peep from 16-14, sedation decreased yesterday, increased\n again last night for sl agitation, coughing, dropping sats to 88%. Had\n to remove pt from Bari Air bed as bed was broken, rep to return with\n new bed today.\n Response:\n sats 90-94% when more sedate, also higher with R side down, ABG:\n 77/48/7.44\n Plan:\n Cont vent support, cont sedation as long as pt cont to require high\n levels of peep, defer RISBI. Rotate on Bari air when available.\n Altered mental status (not Delirium)\n Assessment:\n Pt arouses to voice and spontaneously awakens, does not follow commands\n consistently, but does calm with verbal reassurances. Pt desats to high\n 80\ns when sedation lightened.\n Action:\n Fent increased to 100mcg/hr, gave midaz 1 mg bolus for increased\n restlessness, coughing and desating.\n Response:\n Maintaining better oxygenation with increased sedation.\n Plan:\n Wean sedation once O2 requirement/peep level has decreased. Freq\n reorientation as pt wakes from sedation.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554722, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Frequent desaturation episodes\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Periodic SBT's for conditioning, Reduce PEEP as\n tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Respiratory Care:\n Pt remains intubated and on vent. Had periods where he appeared to be\n anxious, and had forceful coughing and exhalations, even with sedation.\n Eventually placed onto CMV mode on vent with additional sedation to\n rest for night. Will place pt back to PSV in am as tolerates.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554843, "text": "Resp. Care Note: 1325\n Patient\ns RSBI 55, Suctioned for minimal secretions.\n Positive cuff leak, extubated smoothly to 80% cool mist\n Via face tent, with 4Liters nasal O2.\n Patient appears comfortable RR around 20 bpm..\n" }, { "category": "Nursing", "chartdate": "2151-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555052, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers.\n : A+Ox3 today. Wife in visiting this afternoon. D5W @ 200cc/hr\n continous for elevated NA levels\n evening lytes to be drawn. PT on\n consult\nbut did not get to see pt today to get him out of bed. Pt\n doing leg and arm lifts in bed. Assisting with turns.\n PLAN: for EPS in am if afebrile overnite. Wear bipap overnite.\n Ventricular tachycardia, sustained\n Assessment:\n SB/SR 50-70s. rare PVCs.\n Action:\n Betablocker held this am due to SB 50s. Lopressor decreased to 25mg po\n BID. Amiodarone 200mg po TID continued.\n Response:\n HR remains SR 60s today. SBP 90-100s.\n Plan:\n Give Lopressor this evening at decreased dose if HR remains above 60.\n SBP>100. Continue amio at current dose per EP. Con\nt betablockade. If\n pt continues to be afebrile overnite, EPS study planned for am for\n ablation. Possible ICD placement due to likely high ventricular scar\n burden, instability of VT, and VF requiring shock/resucitation\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains extubated. No respiratory distress. Sats >95%.\n Action:\n Weaned off high flow O2. O2 4L n/c w/ sats 94-98%. LS clear, dim. Pt\n doing DB+C and Incentive spirometry.\n Response:\n Improving IS. Weaned off high flow, remains on NC 4L . wife brought in\n pt\ns own bipap from home to wear this evening.\n Plan:\n Pt to wear own bipap this evening for OSA.\n" }, { "category": "Physician ", "chartdate": "2151-03-13 00:00:00.000", "description": "Cardiology Resident Progress Note", "row_id": 554246, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:11 PM\n ARTERIAL LINE - START 05:11 PM\n MULTI LUMEN - STOP 05:14 PM\n ARTERIAL LINE - STOP 05:14 PM\n INVASIVE VENTILATION - STOP 05:14 PM\n FEVER - 102.0\nF - 12:00 PM\n - weaned to pressure support, decreasing PEEP, decreasing levophed\n - LENIs to w/u fever--negative for clot\n - R knee tap to w/u fever--no crystals, inflammatory\n - pulm: wean PEEP, CT in AM if can't\n - creatinine improving, net in-->increased lasix gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.2\nC (100.7\n HR: 94 (86 - 100) bpm\n BP: 112/62(76) {95/52(63) - 145/77(93)} mmHg\n RR: 15 (14 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 3,316 mL\n 491 mL\n PO:\n TF:\n 1,289 mL\n 272 mL\n IVF:\n 1,517 mL\n 220 mL\n Blood products:\n Total out:\n 3,060 mL\n 890 mL\n Urine:\n 3,060 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 256 mL\n -399 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 650 (540 - 650) mL\n PS : 12 cmH2O\n RR (Set): 28\n RR (Spontaneous): 16\n PEEP: 14 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 30 cmH2O\n SpO2: 93%\n ABG: 7.42/48/77/30/5\n Ve: 12 L/min\n PaO2 / FiO2: 140\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 151 mg/dL\n 2.5 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 91 mg/dL\n 102 mEq/L\n 143 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n 08:00 AM\n 11:09 AM\n 12:00 PM\n 03:09 PM\n 05:35 PM\n 11:48 PM\n WBC\n 18.9\n Hct\n 37.2\n Plt\n 307\n Cr\n 2.1\n 2.9\n 2.5\n TCO2\n 28\n 28\n 32\n 32\n Glucose\n 147\n 132\n 132\n 128\n 144\n 151\n Other labs: PT / PTT / INR:18.4/31.3/1.7, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:765/267, Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200, Differential-Neuts:83.0 %, Band:3.0 %,\n Lymph:11.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:546 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. High A-a gradient. Pt\n continues to improve, with decreasing Fi02 and NO now off. Compliance\n improving. Methemaglobin negative.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP 12 pre pulm,\n decrease by intervals of 2 today, Goal Pa02>60\n - Cont. pressure support\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT today if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed, currently off\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Vanco\n level was persistently low, have been uptitrating dose, now\n supratherapeutic. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 8, plan for 8-day course for VAP to\n possibly complete on \n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - Discuss stopping abx today given completed 8 days and no pos. blood\n cultures\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs negative.\n - Consider CT sinus, chest, abdomen today.\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 yesterday in setting\n of continued diuresis, Cr improved to 2.4 today with good UOP.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen on hold given now with diarrhea (holding off\n reglan/erythromycin for concern for ectopy/ QT prolongation), if needed\n can try low dose reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:06 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:11 PM\n Multi Lumen - 05:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-13 00:00:00.000", "description": "Cardiology Resident Progress Note", "row_id": 554248, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:11 PM\n ARTERIAL LINE - START 05:11 PM\n MULTI LUMEN - STOP 05:14 PM\n ARTERIAL LINE - STOP 05:14 PM\n INVASIVE VENTILATION - STOP 05:14 PM\n FEVER - 102.0\nF - 12:00 PM\n - weaned to pressure support, decreasing PEEP, decreasing levophed\n - LENIs to w/u fever--negative for clot\n - R knee tap to w/u fever--no crystals, inflammatory\n - pulm: wean PEEP, CT in AM if can't\n - creatinine improving, net in-->increased lasix gtt\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Furosemide (Lasix) - 15 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.2\nC (100.7\n HR: 94 (86 - 100) bpm\n BP: 112/62(76) {95/52(63) - 145/77(93)} mmHg\n RR: 15 (14 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 3,316 mL\n 491 mL\n PO:\n TF:\n 1,289 mL\n 272 mL\n IVF:\n 1,517 mL\n 220 mL\n Blood products:\n Total out:\n 3,060 mL\n 890 mL\n Urine:\n 3,060 mL\n 890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 256 mL\n -399 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 650 (540 - 650) mL\n PS : 12 cmH2O\n RR (Set): 28\n RR (Spontaneous): 16\n PEEP: 14 cmH2O\n FiO2: 55%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 30 cmH2O\n SpO2: 93%\n ABG: 7.42/48/77/30/5\n Ve: 12 L/min\n PaO2 / FiO2: 140\n Physical Examination\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs / Radiology\n 307 K/uL\n 12.6 g/dL\n 151 mg/dL\n 2.5 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 91 mg/dL\n 102 mEq/L\n 143 mEq/L\n 37.2 %\n 18.9 K/uL\n [image002.jpg]\n 06:26 PM\n 11:00 PM\n 04:36 AM\n 04:51 AM\n 08:00 AM\n 11:09 AM\n 12:00 PM\n 03:09 PM\n 05:35 PM\n 11:48 PM\n WBC\n 18.9\n Hct\n 37.2\n Plt\n 307\n Cr\n 2.1\n 2.9\n 2.5\n TCO2\n 28\n 28\n 32\n 32\n Glucose\n 147\n 132\n 132\n 128\n 144\n 151\n Other labs: PT / PTT / INR:18.4/31.3/1.7, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:765/267, Alk Phos / T Bili:58/1.5,\n Amylase / Lipase:103/200, Differential-Neuts:83.0 %, Band:3.0 %,\n Lymph:11.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:546 mg/dL, Lactic\n Acid:1.6 mmol/L, Albumin:3.2 g/dL, LDH:677 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.7 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. High A-a gradient. Pt\n continues to improve, with decreasing Fi02 and NO now off. Compliance\n improving. Methemaglobin negative.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP 12 pre pulm,\n decrease by intervals of 2 today, Goal Pa02>60\n - Cont. pressure support\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT today if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed, currently off\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Vanco\n level was persistently low, have been uptitrating dose, now\n supratherapeutic. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 8, plan for 8-day course for VAP to\n possibly complete on \n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - Discuss stopping abx today given completed 8 days and no pos. blood\n cultures\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs negative.\n - Consider CT sinus, chest, abdomen today.\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 yesterday in setting\n of continued diuresis, Cr improved to 2.4 today with good UOP.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen on hold given now with diarrhea (holding off\n reglan/erythromycin for concern for ectopy/ QT prolongation), if needed\n can try low dose reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:06 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:11 PM\n Multi Lumen - 05:11 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff\n Physical Examination\n per \n Medical Decision Making\n per housestaff\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n respiratory status is improving with better cxr - weaning fio2\n no further arrhythmias on amiodarone\n lfts improving\n new rash - ask id to comment - exclude vancomycin\n ultimately will require EPS and ICD\n ------ Protected Section Addendum Entered By: \n on: 10:26 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554269, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia which deteriorated to V.fib, s/p\n resuscitation with return to sinus tachycardia, now intubated, with\n hypoxic and hypercarbic respiratory failure, renal failure, &\n aspiration PNA.\n .H/O heart disease, congenital\n Assessment:\n HR 80-90\ns NSR with freq PVC\ns, multifocal singles, couplest and up to\n 6br non-sustained VT. One 11br SVT. Remains in positive fluid balance\n LOS.\n Action:\n On po amiodarone, lasix gtt continues 15mg/hr.\n Response:\n Cont with occ to freq PVC\ns, nonsustained VT.\n Plan:\n EP to evaluate once more stable.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Cont with temp up to 103. and ^WBC\n Action:\n Vanco and zosyn, pul toilet sx q2-4hrs for scant amt thick tan\n secretions. ATC Tylenol and ASA, fully cultured on , CT\n Response:\n Continues febrile\n Plan:\n Cont AB, Tylenol and ASA, check culture results, check results of CT\n scatn.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains vented and sedated. On 55% FIO2, 14 PEEP, has tolerated PS\n ventilation.\n Action:\n Decreased FIo2 to 50%,\n sedation decreased yesterday, increased again last night for sl\n agitation, coughing, dropping sats to 88%. Had to remove pt from Bari\n Air bed as bed was broken, rep to return with new bed today.\n Response:\n sats 90-94% when more sedate, also higher with R side down, ABG\n Plan:\n Cont vent support, cont sedation as long as pt cont to require high\n levels of peep, defer RISBI. Rotate on Bari air when available.\n Altered mental status (not Delirium)\n Assessment:\n Pt arouses to voice and spontaneously awakens, does not follow commands\n consistently, but does calm with verbal reassurances. Pt desats to high\n 80\ns when sedation lightened.\n Action:\n Fent increased to 100mcg/hr, gave midaz 1 mg bolus for increased\n restlessness, coughing and desating.\n Response:\n Maintaining better oxygenation with increased sedation.\n Plan:\n Wean sedation once O2 requirement/peep level has decreased. Freq\n reorientation as pt wakes from sedation.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555459, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely PMP next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: CCU for now, PT and OT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2151-03-18 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 555257, "text": "Subjective\n Haven\nt eat anything yet!\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 95 mg/dL\n 05:14 AM\n Glucose Finger Stick\n 111\n 08:00 AM\n BUN\n 41 mg/dL\n 05:14 AM\n Creatinine\n 1.1 mg/dL\n 05:14 AM\n Sodium\n 140 mEq/L\n 05:14 AM\n Potassium\n 3.8 mEq/L\n 05:14 AM\n Chloride\n 100 mEq/L\n 05:14 AM\n TCO2\n 33 mEq/L\n 05:14 AM\n PO2 (arterial)\n 132 mm Hg\n 02:43 PM\n PCO2 (arterial)\n 54 mm Hg\n 02:43 PM\n pH (arterial)\n 7.38 units\n 02:43 PM\n pH (urine)\n 5.0 units\n 03:47 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 02:43 PM\n Albumin\n 3.0 g/dL\n 04:30 AM\n Calcium non-ionized\n 8.1 mg/dL\n 05:14 AM\n Phosphorus\n 3.5 mg/dL\n 05:14 AM\n Ionized Calcium\n 1.08 mmol/L\n 04:26 AM\n Magnesium\n 2.9 mg/dL\n 05:14 AM\n ALT\n 101 IU/L\n 05:14 AM\n Alkaline Phosphate\n 56 IU/L\n 05:14 AM\n AST\n 58 IU/L\n 05:14 AM\n Amylase\n 103 IU/L\n 04:12 AM\n Total Bilirubin\n 0.8 mg/dL\n 05:14 AM\n WBC\n 11.8 K/uL\n 05:14 AM\n Hgb\n 10.7 g/dL\n 05:14 AM\n Hematocrit\n 32.6 %\n 05:14 AM\n Current diet order / nutrition support: Regluar, heart healthy, NPO for\n Procedure except Meds, Start: After 12:01AM on date , may take\n ice chips, Resume diet after procedure.\n GI: obese, +BS\n Assessment of Nutritional Status\n39 y/o male with Ebstein's anomaly s/p tricuspid valve reconstruction and conges\ntive heart failure initially intub d/t hypoxia, pt started on TF, TF off prior t\no extubation. Pt extubated , s/p S & S eval, ok to diet adv to a PO diet of\nthin liquids and\nregular consistency solids. Pt reported wanting to eat, but has been NPO for ?\n procedure, will f/u re intakes once diet resumes.\n Medical Nutrition Therapy Plan - Recommend the Following\n Cont current diet order, diet consistency per SLP\ns recommendation\n Multivitamin / Mineral supplement: daily\n Check chemistry 10 panel daily, replete prn\n Cont BG mgt\n Other: f/u re intakes, please page if has ?\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "EP Follow Up", "row_id": 555259, "text": "TITLE: EP Follow-up Note\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness:\n -No events overnight\n -Feels well, still weak\n -No atrial or ventricular arrhythmias overnight\n Medications\n Unchanged\n See CCU Progress note\n Physical Exam\n BP: 106 / 57 mmHg\n HR: 64 bpm\n RR: 16 insp/min\n Tmax C last 24 hours: 36.1 C\n Tmax F last 24 hours: F\n T current C: 36.1 C\n T current F: 97 F\n Previous day:\n Intake: 5,759 mL\n Output: 2,150 mL\n Fluid balance: 3,609 mL\n Today:\n Output: 1,180 mL\n Fluid balance: -1,180 mL\n Cardiovascular: (Auscultation: Distant S1 and S2)\n Respiratory: (Auscultation: Coarse BS B/L)\n Abdomen: (Palpation: Soft, NTND), (Auscultation: +BS)\n Neurological: (Orientation: alert)\n Extremities:\n Right: (Edema: Chronic changes)\n Left: (Edema: Chronic changes)\n Labs\n 420\n 10.7\n 95\n 1.1\n 33\n 3.8\n 41\n 100\n 140\n 32.6\n 11.8\n [image002.jpg]\n 08:05 PM\n 04:16 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 02:35 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.3\n 12.2\n 10.9\n 11.8\n Hgb\n 11.4\n 11.3\n 10.8\n 10.7\n Hct (Serum)\n 35.4\n 35.1\n 34.2\n 32.6\n Plt\n 20\n INR\n 1.8\n 1.6\n 1.6\n PTT\n 51.1\n 34.2\n 35.2\n Na+\n 153\n 153\n 148\n 149\n 146\n 140\n 140\n K + (Serum)\n 3.5\n 3.8\n 4.4\n 4.1\n 4.1\n 4.2\n 3.8\n Cl\n 111\n 111\n 109\n 108\n 106\n 101\n 100\n HCO3\n 34\n 34\n 34\n 33\n 34\n 33\n 33\n BUN\n 79\n 75\n 67\n 69\n 60\n 43\n 41\n Creatinine\n 1.9\n 1.7\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n Glucose\n 115\n 110\n 101\n 113\n 105\n 113\n 95\n O2 sat (arterial)\n 93\n 93\n 92\n ABG: / / / 33 / Values as of 05:14 AM\n Tests\n Telemetry: No events, SR\n Assessment and Plan\n 39 year old male with h/o Ebstein's anomaly s/p TV reconstruction,\n biventricular systolic dysfunction p/w monomorphic VT shocked into VF,\n resucitated, now improving on amiodarone and beta-blockade.\n 1. Ventricular Tachycardia:\n -Plan for EPS, likely next week\n -At this point, continue amiodarone at 200 mg tid and beta blocker as\n tolerated, but may need to discontinue BB for EPS in future\n -Pending findings at EPS, +/- ICD; may consider d/c amiodraone in\n future, as this is likely a poor medicine for him to be on for extended\n period due t o young age and multiple side effects.\n ------ Protected Section ------\n Pt seen/examined w/ dr . Today\ns note reviewed. Agree\n w/assessment plan\n ------ Protected Section Addendum Entered By: \n on: 11:34 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554161, "text": ".H/O heart disease, congenital\n Assessment:\n HR 80-90\ns NSR with freq PVC\ns, runs nonsustained VT up to 6 bts.\n Remains in positive fluid balance.\n Action:\n On po amiodarone, lasix gtt increased from 10mg to 15mg/hr. K+\n repleated.\n Response:\n Cont with occ to freq PVC\ns, nonsustained VT.\n Plan:\n EP to evaluate once more stable.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Cont with low grade T and ^WBC\n Action:\n Vanco and zosyn, pul toilet, ATC Tylenol and ASA, fully cultured on\n \n Response:\n T max 100.7 po tonight off cooling blanket\n Plan:\n Cont AB, Tylenol and ASA, check culture results.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains vented and sedated.\n Action:\n Decreased peep from 16-14, sedation decreased yesterday.\n Response:\n sats 90-94%, ABG: 77/48/7.44\n Plan:\n Cont vent support, cont sedation as long as pt cont to require high\n levels of peep, defer RISBI\n Altered mental status (not Delirium)\n Assessment:\n Pt arouses to voice and spontaneously awakens, does not follow commands\n consistently, but does calm with verbal reassurances. Pt desats to high\n 80\ns when sedation lightened.\n Action:\n Fent increased to 100mcg/hr, gave midaz 1 mg bolus for increased\n restlessness, coughing and desating.\n Response:\n Maintaining better oxygenation with increased sedation.\n Plan:\n Wean sedation once O2 requirement/peep level has decreased.\n" }, { "category": "General", "chartdate": "2151-03-18 00:00:00.000", "description": "Generic Note", "row_id": 555170, "text": "RESPIRATORY CARE NOTE: Patient set-up on home Autoset CPAP machine\n that wife brought in. Tolerating nasal pillows well. Titrated 4 l/m\n O2 into mask.\n , RRT\n" }, { "category": "Rehab Services", "chartdate": "2151-03-18 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 555231, "text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 39 yo w/Ebstein's\n anomaly, s/p ASD/TV repair, w/heart failure, PAH, admitted on \n after presenting with malaise and found with VTach in ER, given amio,\n shocked. Patient then had VFib arrest, resuscitated w/CPR, epi, shock,\n intubated, c/b aspiration & R PTX, subseq hypotensive requiring\n pressors. Pt was extubated \n Past Medical / Surgical History: ASD s/p primary closure ,\n hyperlipidemia, OSA,\n obesity, DVT, superficial phlebitis, and endocarditis with septic\n emboli to brain prior to cardiac surgery\n Medications: Amiodarone, Lisinopril, Metoprolol,\n Radiology: cxr : There is no consolidation. The lungs are clear\n Labs:\n 32.6\n 10.7\n 420\n 11.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: Married, works at in clinical\n engineering\n Living Environment: Private 2 level home\n Prior Functional Status / Activity Level: I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: A and O x 3, able to\n recall 3 items after 5 minutes. Answers questions appropriately.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 63\n 99/51\n 95% 2L\n Sit\n /\n Activity\n 66\n 89/73\n 96% 2L\n Stand\n /\n Recovery\n 65\n 105/52\n 95% RA\n Total distance walked:\n Minutes:\n Pulmonary Status: Strong cough productive of thin white sputum. LS\n diminished t/o\n Integumentary / Vascular: R IJ, foley\n Sensory Integrity: Intact to LT t/o\n Pain / Limiting Symptoms: No reports of pain t/o evaluation\n Posture:\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n B shldr flexion 3-/5\n B elb flexion \n B knee ext > 3+/5\n R hip flexion \n L hip flexion \n Motor Function: Decreased velocity and accuracy with , FTN limited\n by decreased shldr strength\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n T\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required Mod A x 2 to stand and take 3 small steps to\n chair. Rapid fatigue. Able to achieve full upright with semiflexed\n knees\n Education / Communication: Pt educated on role of PT, importance of\n increase activity and time OOB. Pt status discussed with RN\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Balance, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Muscle Performance, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 39 yo m admitted with V-tach\n converted to V-fib arrest requiring resuscitation, intubation, pressor\n support. Pt has had prolonged ICU stay and intubation, his above\n impairments are c/w deconditioning. Pt is functioning well below\n baseline, given his age and PLOF feel he has good potential to progress\n with all activity. Pending patients inpatient LOS he maybe able to\n achieve safe level of I for d/c home, however rehab maybe needed.\n Goals\n Time frame: 1 wk\n 1.\n I bed mobility\n 2.\n I transfers\n 3.\n I sit to stand\n 4.\n I amb > 300'\n 5.\n Increase decrease FOS\n 6.\n Maintain SaO2 > 95% on RA\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: 3-5x/wk\n f/u balance, strength, mobility training. Progress ambulation. Cont pt\n education and d/c planning.\n Rec 2 person A for transfers.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555233, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: CCU for now, PT and OT consult\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "EP Follow Up", "row_id": 555234, "text": "TITLE: EP Follow-up Note\n History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness:\n -No events overnight\n -Feels well, still weak\n -No atrial or ventricular arrhythmias overnight\n Medications\n Unchanged\n See CCU Progress note\n Physical Exam\n BP: 106 / 57 mmHg\n HR: 64 bpm\n RR: 16 insp/min\n Tmax C last 24 hours: 36.1 C\n Tmax F last 24 hours: F\n T current C: 36.1 C\n T current F: 97 F\n Previous day:\n Intake: 5,759 mL\n Output: 2,150 mL\n Fluid balance: 3,609 mL\n Today:\n Output: 1,180 mL\n Fluid balance: -1,180 mL\n Cardiovascular: (Auscultation: Distant S1 and S2)\n Respiratory: (Auscultation: Coarse BS B/L)\n Abdomen: (Palpation: Soft, NTND), (Auscultation: +BS)\n Neurological: (Orientation: alert)\n Extremities:\n Right: (Edema: Chronic changes)\n Left: (Edema: Chronic changes)\n Labs\n 420\n 10.7\n 95\n 1.1\n 33\n 3.8\n 41\n 100\n 140\n 32.6\n 11.8\n [image002.jpg]\n 08:05 PM\n 04:16 AM\n 03:21 PM\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 02:35 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.3\n 12.2\n 10.9\n 11.8\n Hgb\n 11.4\n 11.3\n 10.8\n 10.7\n Hct (Serum)\n 35.4\n 35.1\n 34.2\n 32.6\n Plt\n 20\n INR\n 1.8\n 1.6\n 1.6\n PTT\n 51.1\n 34.2\n 35.2\n Na+\n 153\n 153\n 148\n 149\n 146\n 140\n 140\n K + (Serum)\n 3.5\n 3.8\n 4.4\n 4.1\n 4.1\n 4.2\n 3.8\n Cl\n 111\n 111\n 109\n 108\n 106\n 101\n 100\n HCO3\n 34\n 34\n 34\n 33\n 34\n 33\n 33\n BUN\n 79\n 75\n 67\n 69\n 60\n 43\n 41\n Creatinine\n 1.9\n 1.7\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n Glucose\n 115\n 110\n 101\n 113\n 105\n 113\n 95\n O2 sat (arterial)\n 93\n 93\n 92\n ABG: / / / 33 / Values as of 05:14 AM\n Tests\n Telemetry: No events, SR\n Assessment and Plan\n 39 year old male with h/o Ebstein's anomaly s/p TV reconstruction,\n biventricular systolic dysfunction p/w monomorphic VT shocked into VF,\n resucitated, now improving on amiodarone and beta-blockade.\n 1. Ventricular Tachycardia:\n -Plan for EPS, likely next week\n -At this point, continue amiodarone at 200 mg tid and beta blocker as\n tolerated, but may need to discontinue BB for EPS in future\n -Pending findings at EPS, +/- ICD; may consider d/c amiodraone in\n future, as this is likely a poor medicine for him to be on for extended\n period due t o young age and multiple side effects.\n" }, { "category": "Nursing", "chartdate": "2151-03-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554152, "text": ".H/O heart disease, congenital\n Assessment:\n HR 80-90\ns NSR with freq PVC\ns, runs nonsustained VT up to 6 bts.\n Remains in positive fluid balance.\n Action:\n On po amiodarone, lasix gtt increased from 10mg to 15mg/hr. K+\n repleated.\n Response:\n Cont with occ to freq PVC\ns, nonsustained VT.\n Plan:\n EP to evaluate once more stable.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554528, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts.\n Freq. position changes, HOB 30-45deg.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr.\n Plan:\n Follow pulm recs. .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 103.7po at . HO aware. CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- follow up with possible coverage.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554529, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts.\n Freq. position changes, HOB 30-45deg.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr.\n Plan:\n Follow pulm recs. .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 103.7po at . HO aware. CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- follow up with possible coverage.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n 0200\n pt. woke up and focusing on RN. Shaking/nodding head very\n approp. And able to focus and track. Orinted to place and time. Pt.\n shaking head\n to pain. Pt. trying to move arms and pulling on\n restraints. Gave dilaudid 1mg x1 for anxiety.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Good response to meds. Appearing more focused.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Respiratory ", "chartdate": "2151-03-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554476, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 7\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason: Emergent (1st time); Comments: cardiac arrest\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Active exhalations; Comments:\n periods of agitation/restlessness. RN aware.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: heater block malfunctioning on ventilator (needing freq flow\n sensor changes. Vent changed out thia AM w/o incident).\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated; Comments: plan MD: wean fio2\n to .40, then reduce PEEP as tol. However, PaO2=66 on fio2 .45.\n SpO2=90-92%. Will cont to monitor.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n 14:19\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554539, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts. Strong cough.\n Freq. position changes, HOB 30-45deg.\n Contin. On IVF in addition to free water via OGT for elevated Na+.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr off lasix.\n Plan:\n Follow pulm recs. . follow Na^+\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n FUO : ? drug reaction. TM 103.7po at . HO aware.\n CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Temp down to 100.7po at 0300. cooling blanket off.\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- team to f/u on rounds.\n Cortisol stim. With Am labs.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n 0200\n pt. woke up and focusing on RN. Shaking/nodding head very\n approp. And able to focus and track. Pt was freq. oriented to place\n and time. Pt. shaking head\n to pain. Pt. trying to move arms and\n pulling on restraints. Gave dilaudid 1mg x1 for anxiety.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Good response to meds. Appearing more focused and calm.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554533, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts.\n Freq. position changes, HOB 30-45deg.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr.\n Plan:\n Follow pulm recs. .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 103.7po at . HO aware. CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- follow up with possible coverage.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n 0200\n pt. woke up and focusing on RN. Shaking/nodding head very\n approp. And able to focus and track. Orinted to place and time. Pt.\n shaking head\n to pain. Pt. trying to move arms and pulling on\n restraints. Gave dilaudid 1mg x1 for anxiety.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Good response to meds. Appearing more focused.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554438, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolipoma, also small bilateral pleural\n effusions and consolidations, sm pulmonary nodule; no pelvic or\n abdominal fluid; thoracic compression fracture\n - off pressors all day\n - PEEP to 10, FIO2 to 50%\n - ID recs given scan are to d/c abx.\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP 110-130s/60-80s\n HR 80-100\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin, unchanged from\n \n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -repeat PM Na\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n gradually improving though no source of fever\n stop antibiotics\n hold lasix\n continue amiodarone\n will consider eps plus likely ICD next week\n ------ Protected Section Addendum Entered By: \n on: 09:45 ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n improving mental status though not back to baseline\n will plan on diagnostic cath prior to ICD - will only intervene on\n coronaries if there is severe cad\n ------ Protected Section Addendum Entered By: \n on: 09:56 ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes. Greater than 50% time\n counseling / coordinating care.\n Additional comments:\n extensive discussion with son about prior episodes\n describes eyes deviating to the left with blank stare and\n unresponsiveness\n bradycardia has all been vagal\n eeg on\n plan on pacemaker next week\n ------ Protected Section Addendum Entered By: \n on: 10:22 ------\n" }, { "category": "Social Work", "chartdate": "2151-03-15 00:00:00.000", "description": "Social Work Progress Note", "row_id": 554640, "text": "SOCIAL WORK: Case discussed with RN, pt has remained stable with\n gradual improvement over the weekend; still intubated. SW met with\n pt\ns wife in his room; pt awake, able to nod understanding, but\n somewhat distressed as he cannot communicate. Wife has been going home\n at night, and at pt\ns side most of the day. She reports feeling\n relief, as pt is progressing. Children have not visited again, but\n wife hopes pt will be extubated and have fewer tubes in later in the\n week, creating a better environment for children. Wife has no\n complaints, reports being very pleased with pt\ns care on CCU, and\n attention to her needs. SW will continue to follow to support family\n coping. Will assess pt\ns adjustment and provide intervention as needed\n when he is able to communicate.\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555217, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia s/p intubation and extubation, plan\n for EP procedure with ventricular fibrillation ablation as well as ICD\n placement.\n .\n # Respiratory Failure\n now resolved: Initially mixed hypoxemia and\n hypercarbia. Patient currently\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Initially Amiodarone loaded and continued outpatient\n metoprolol. Decreased Amiodarone dose to 200 mg PO TID as has received\n 10 g loading dose. Beta blocker had to be titrated down in the setting\n of bradycardia. Plan is for EP study today with ICD placement.\n - NPO for EP study today\n # BP: Patient without history of hypertension. On beta blocker as an\n outpatient as well as Lisinopril. Yesterday patient with low blood\n pressures.\n - lower beta blocker dose\n - keep ACEi at current dose, would like to uptitrate as\n tolerated when able\n # Fever- now resolved : Patient initially with Fevers to 103-104,\n initially considered to be due to aspiration PNA. Patient completed\n course of abx with no sputum production and improving pulmonary\n function. Chest CT did not show evidence for ongoing infection. Ddx\n for previous fever included occult infection (abscess, acalculous\n cholecystitis, sinusitis), gout, thermoregulatory dysfunciton after\n cardiac arrest/non-exposure heat stroke, drug fever, thyroid storm,\n adrenal insufficiency (although less likely now that not hypotensive).\n Not exposed to any culprit meds for NMS. All culture data negative\n thus far.\n Fem line removed and sent for culture with no growth. Possible drug\n fever given persistent fever with no pos. cx data. C. diff negative. CT\n with PO contrast did not show clear source of fevers. CT sinus did have\n partial opacifications of bilaterally mastoids. CVL placed .\n Antibioitcs were discontinued as per ID reccomendations. Blood cultures\n NGTD, stim test normal, TSH normal. Fungal blood cultures no\n growth to date.\n .\n # Hypernatremia now resolved - Patient treated with free water flushes\n through NG tube as well as d5W now with normal sodium discontinued free\n water.\n - cont to monitor Na\n # Chronic Systolic heart failure - Congestive Heart Failure: Echo s/p\n arrest demonstrated right and left sided heart failure, s/p tricuspid\n reconstruction and ASD repair. Repeat echocardiogram on \n demonstrates marked right ventricular cavity enlargement with free wall\n hypokinesis. Normal left ventricular cavity size with low normal\n systolic function. Well seated tricuspid annuloplasty ring with\n increased gradient. Patient is seen at Children\ns congenital heart\n center.\n - hold digoxin\n - hold diuresis for now , would restart on discharge\n - continue low dose ACEi\n .\n # Acute renal failure: likely ATN, Creatinine max to 3.2 during this\n admission, creatinine improved now to 1.1. Likely ATN in the setting\n of VF arrest.\n - monitor UOP\n - renally dose medications\n - avoid nephrotoxins\n # Nutrition\n patient passed speech and swallow evaluation yesterday.\n Taking good PO.\n .\n # Transaminitis: Multifactorial from shock liver, heart failure (acute\n after arrest) and Amiodarone continuing to improve daily.\n - continue to trend LFTs\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Attempted to tap knee again however tap was dry.\n Not currently getting treated with any agents, fever has broken and\n swelling improved.\n - continue to monitor\n FEN: replete lytes PRN\n ACCESS: IJ placed \n PROPHYLAXIS:\n -DVT ppx with sub q heparin, colace, senna, PPi\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555218, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia s/p intubation and extubation, plan\n for EP procedure with ventricular fibrillation ablation as well as ICD\n placement.\n .\n # Respiratory Failure\n now resolved: Initially mixed hypoxemia and\n hypercarbia. Patient with OSA on CPAP at home at night.\n - continue nighttime CPAP\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Initially Amiodarone loaded and continued outpatient\n metoprolol. Decreased Amiodarone dose to 200 mg PO TID as has received\n 10 g loading dose. Beta blocker had to be titrated down in the setting\n of bradycardia. Plan is for EP study today with ICD placement.\n - NPO for EP study today\n # BP: Patient without history of hypertension. On beta blocker as an\n outpatient as well as Lisinopril. Yesterday patient with low blood\n pressures.\n - lower beta blocker dose\n - keep ACEi at current dose, would like to uptitrate as\n tolerated when able\n # Fever- now resolved : Patient initially with Fevers to 103-104,\n initially considered to be due to aspiration PNA. Patient completed\n course of abx with no sputum production and improving pulmonary\n function. Chest CT did not show evidence for ongoing infection. Ddx\n for previous fever included occult infection (abscess, acalculous\n cholecystitis, sinusitis), gout, thermoregulatory dysfunciton after\n cardiac arrest/non-exposure heat stroke, drug fever, thyroid storm,\n adrenal insufficiency (although less likely now that not hypotensive).\n Not exposed to any culprit meds for NMS. All culture data negative\n thus far.\n Fem line removed and sent for culture with no growth. Possible drug\n fever given persistent fever with no pos. cx data. C. diff negative. CT\n with PO contrast did not show clear source of fevers. CT sinus did have\n partial opacifications of bilaterally mastoids. CVL placed .\n Antibioitcs were discontinued as per ID reccomendations. Blood cultures\n NGTD, stim test normal, TSH normal. Fungal blood cultures no\n growth to date.\n .\n # Hypernatremia now resolved - Patient treated with free water flushes\n through NG tube as well as d5W now with normal sodium discontinued free\n water.\n - cont to monitor Na\n # Chronic Systolic heart failure - Congestive Heart Failure: Echo s/p\n arrest demonstrated right and left sided heart failure, s/p tricuspid\n reconstruction and ASD repair. Repeat echocardiogram on \n demonstrates marked right ventricular cavity enlargement with free wall\n hypokinesis. Normal left ventricular cavity size with low normal\n systolic function. Well seated tricuspid annuloplasty ring with\n increased gradient. Patient is seen at Children\ns congenital heart\n center.\n - hold digoxin\n - hold diuresis for now , would restart on discharge\n - continue low dose ACEi\n .\n # Acute renal failure: likely ATN, Creatinine max to 3.2 during this\n admission, creatinine improved now to 1.1. Likely ATN in the setting\n of VF arrest.\n - monitor UOP\n - renally dose medications\n - avoid nephrotoxins\n # Nutrition\n patient passed speech and swallow evaluation yesterday.\n Taking good PO.\n .\n # Transaminitis: Multifactorial from shock liver, heart failure (acute\n after arrest) and Amiodarone continuing to improve daily.\n - continue to trend LFTs\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Attempted to tap knee again however tap was dry.\n Not currently getting treated with any agents, fever has broken and\n swelling improved.\n - continue to monitor\n FEN: replete lytes PRN\n ACCESS: IJ placed \n PROPHYLAXIS:\n -DVT ppx with sub q heparin, colace, senna, PPi\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555219, "text": "TITLE: CCU Progress Note\n - EP eval'ed for PMP. Will go today\n - S&S eval with no aspiration\n - Afebrile so far\n - Decreased Bblocker as bradycardic\n - Tylenol PRN now as afebrile\n - PM Na 140 so DCed D5\n - Family expressing concerns about PMP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:42 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.9\nC (96.7\n HR: 63 (58 - 65) bpm\n BP: 93/57(66) {78/32(45) - 103/65(70)} mmHg\n RR: 16 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 5,759 mL\n PO:\n 1,540 mL\n TF:\n IVF:\n 4,219 mL\n Blood products:\n Total out:\n 2,150 mL\n 900 mL\n Urine:\n 2,150 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,609 mL\n -900 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia s/p intubation and extubation, plan\n for EP procedure with ventricular fibrillation ablation as well as ICD\n placement.\n .\n # Respiratory Failure\n now resolved: Initially mixed hypoxemia and\n hypercarbia. Patient with OSA on CPAP at home at night.\n - continue nighttime CPAP\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Initially Amiodarone loaded and continued outpatient\n metoprolol. Decreased Amiodarone dose to 200 mg PO TID as has received\n 10 g loading dose. Beta blocker had to be titrated down in the setting\n of bradycardia. Plan is for EP study with ICD placement at some point,\n however given that recently had fever and that patient has not been out\n of bed, may need repeat intubation will hold on procedure for a few\n days. Spoke with Dr. concerning this\n - f/u daily EP recs\n - .\n # BP: Patient without history of hypertension. On beta blocker as an\n outpatient as well as Lisinopril. Yesterday patient with low blood\n pressures.\n - lower beta blocker dose\n - keep ACEi at current dose, would like to uptitrate as\n tolerated when able\n # Fever- now resolved : Patient initially with Fevers to 103-104,\n initially considered to be due to aspiration PNA. Patient completed\n course of abx with no sputum production and improving pulmonary\n function. Chest CT did not show evidence for ongoing infection. Ddx\n for previous fever included occult infection (abscess, acalculous\n cholecystitis, sinusitis), gout, thermoregulatory dysfunciton after\n cardiac arrest/non-exposure heat stroke, drug fever, thyroid storm,\n adrenal insufficiency (although less likely now that not hypotensive).\n Not exposed to any culprit meds for NMS. All culture data negative\n thus far.\n Fem line removed and sent for culture with no growth. Possible drug\n fever given persistent fever with no pos. cx data. C. diff negative. CT\n with PO contrast did not show clear source of fevers. CT sinus did have\n partial opacifications of bilaterally mastoids. CVL placed .\n Antibioitcs were discontinued as per ID reccomendations. Blood cultures\n NGTD, stim test normal, TSH normal. Fungal blood cultures no\n growth to date.\n .\n # Hypernatremia now resolved - Patient treated with free water flushes\n through NG tube as well as d5W now with normal sodium discontinued free\n water.\n - cont to monitor Na\n # Chronic Systolic heart failure - Congestive Heart Failure: Echo s/p\n arrest demonstrated right and left sided heart failure, s/p tricuspid\n reconstruction and ASD repair. Repeat echocardiogram on \n demonstrates marked right ventricular cavity enlargement with free wall\n hypokinesis. Normal left ventricular cavity size with low normal\n systolic function. Well seated tricuspid annuloplasty ring with\n increased gradient. Patient is seen at Children\ns congenital heart\n center.\n - hold digoxin\n - hold diuresis for now , would restart on discharge\n - continue low dose ACEi\n .\n # Acute renal failure: likely ATN, Creatinine max to 3.2 during this\n admission, creatinine improved now to 1.1. Likely ATN in the setting\n of VF arrest.\n - monitor UOP\n - renally dose medications\n - avoid nephrotoxins\n # Nutrition\n patient passed speech and swallow evaluation yesterday.\n Taking good PO.\n .\n # Transaminitis: Multifactorial from shock liver, heart failure (acute\n after arrest) and Amiodarone continuing to improve daily.\n - continue to trend LFTs\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Attempted to tap knee again however tap was dry.\n Not currently getting treated with any agents, fever has broken and\n swelling improved.\n - continue to monitor\n FEN: replete lytes PRN\n ACCESS: IJ placed \n PROPHYLAXIS:\n -DVT ppx with sub q heparin, colace, senna, PPi\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554430, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolipoma, also small bilateral pleural\n effusions and consolidations, sm pulmonary nodule; no pelvic or\n abdominal fluid; thoracic compression fracture\n - off pressors all day\n - PEEP to 10, FIO2 to 50%\n - ID recs given scan are to d/c abx.\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP 110-130s/60-80s\n HR 80-100\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin, unchanged from\n \n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -repeat PM Na\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554432, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolipoma, also small bilateral pleural\n effusions and consolidations, sm pulmonary nodule; no pelvic or\n abdominal fluid; thoracic compression fracture\n - off pressors all day\n - PEEP to 10, FIO2 to 50%\n - ID recs given scan are to d/c abx.\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP 110-130s/60-80s\n HR 80-100\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin, unchanged from\n \n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -repeat PM Na\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n gradually improving though no source of fever\n stop antibiotics\n hold lasix\n continue amiodarone\n will consider eps plus likely ICD next week\n ------ Protected Section Addendum Entered By: \n on: 09:45 ------\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554435, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolipoma, also small bilateral pleural\n effusions and consolidations, sm pulmonary nodule; no pelvic or\n abdominal fluid; thoracic compression fracture\n - off pressors all day\n - PEEP to 10, FIO2 to 50%\n - ID recs given scan are to d/c abx.\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP 110-130s/60-80s\n HR 80-100\n Gen: Obese, less sedated, intubated, moving limbs\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin, unchanged from\n \n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c diuresis today for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Off pressors, now elevated BP while weaning sedation.\n Added back on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - add on low dose ACEI\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff toxin negative. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - d/c abx today per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n # Hypernatremia - likely in setting of diuresis.\n -hold lasix gtt\n -repeat PM Na\n -D5W free water repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - d/c lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n gradually improving though no source of fever\n stop antibiotics\n hold lasix\n continue amiodarone\n will consider eps plus likely ICD next week\n ------ Protected Section Addendum Entered By: \n on: 09:45 ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes.\n Additional comments:\n improving mental status though not back to baseline\n will plan on diagnostic cath prior to ICD - will only intervene on\n coronaries if there is severe cad\n ------ Protected Section Addendum Entered By: \n on: 09:56 ------\n" }, { "category": "General", "chartdate": "2151-03-14 00:00:00.000", "description": "Temperature curve", "row_id": 554520, "text": "TITLE: Temperature curve\n [image002.jpg]\n" }, { "category": "General", "chartdate": "2151-03-14 00:00:00.000", "description": "Temperature curve", "row_id": 554521, "text": "TITLE: Temperature curve\n [image002.jpg]\n ------ Protected Section ------\n [image004.jpg]\n ------ Protected Section Addendum Entered By: , MD\n on: 20:44 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554622, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554524, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 103.7po at . HO aware. CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554743, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n lasix gtt off since (elevated Na+). LS diminished. Sats 93-97% on\n 50% FIO2. Tv 500-600\ns. RR 14-16.\n CT () showing small bilat. Pleural effus. And consolidations.\n Action:\n No vent changes. Suctioned for thick tan, small amts. Strong cough.\n Freq. position changes, HOB 30-45deg.\n Contin. On IVF in addition to free water via OGT for elevated Na+.\n Response:\n Stable sats tolerating turning and position changes.\n u/o contin. 60-100cc/hr off lasix.\n Plan:\n Follow pulm recs. . follow Na^+ ^\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n FUO : ? drug reaction. TM 103.7po at . HO aware.\n CT showing diffuse sinus congestion.\n All culures NGTD (sputum oral flora, urine GPC, BC neg). ID following\n and recommended d/c antibiotics. Last dose of vanco 0800. zosyn\n 0800.\n Action:\n Placed on cooling blanket. Tylenol 2gm/day contin. And ASA contin.\n Response:\n Temp down to 100.7po at 0300. cooling blanket off.\n Plan:\n Follow with ID recs.\n CT showing sinus congestion- team to f/u on rounds.\n Cortisol stim. With Am labs.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT arrest\n was on amio gtt- changed to po last week. Lopressor po\n started over the weekend and titrated up to 50mg . HR 70-80\ns SR\n with occas. PVC, PAC\n lisinopril started .\n Action:\n Getting K+ repletion QD with diuresis- now off.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Wife visiting in eve and actively talking to pt.\n pt. opening eyes\n and sometimes smiling in responsse to something she said. Does not\n appear to focus and does not follow finger. Will nod head occas. to\n command or question and somttimes he appears to be trying to talk.\n Will not squeeze hand or move extrem. To command. Does move all\n extreme. Spontaneously on bed.\n 0200\n pt. woke up and focusing on RN. Shaking/nodding head very\n approp. And able to focus and track. Pt was freq. oriented to place\n and time. Pt. shaking head\n to pain. Pt. trying to move arms and\n pulling on restraints. Gave dilaudid 1mg x1 for anxiety.\n Action:\n Fent. Gtt decreased to 80mcq/hr. ROM to extrem.\n Response:\n Tolerating lower dose of fent. , wakes but does not become agitated.\n No elevtated HR/BP.\n Required 2 doses of fent. 25mcq bolus with turning.\n Good response to meds. Appearing more focused and calm.\n Plan:\n Wean fent. Gtt again today to let pt. become for wakeful. Got tired\n toward the eve and placed on higher dose for the night.\n Ineffective Coping\n Assessment:\n Wife and mother left ~ . spoke with resident before leaving.\n Biggest concern is the fever. MD went over all the results of CT and\n cultures. Family expressing concern about pt. being off antibiotics.\n Explanation given.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation and thanked staff before\n leaving.\n Plan:\n Wife is coming back ~ 7am today and wants to speak with all MD\n" }, { "category": "Nursing", "chartdate": "2151-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554758, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains intubated & vented. Thick tannish secretions. Able to expel air\n & talk around inflated ETT cuff @ times. Sats decreasing when above\n occurring.\n Action:\n Sx as indicated. ETT cuff pressure cked-35mmhg. Vent settings chged to\n CMV/AC. Sedation increased & bloused w Versed 2mg iv x2. Freq. position\n changes, HOB 30-45deg. On IVF in addition to free water via OGT for\n elevated Na+.\n Response:\n Stable sats w increased sedation. Without recurrence of leak with\n increased sedation. Adeq U/O-remains overall positive approx 4l.\n Plan:\n Place back on CPAP/PS as tolerated. Contin vent wean as tolerated.\n Maint adeq sedation.^\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Continues febrile. Off abx. Contin to receive ASA & Tylenol tid. All\n cultures to date-neg. Last cultured .\n Action:\n Tylenol 2gm/day and ASA contin.\n Response:\n Remains febrile. Off cooling blanket.\n Plan:\n Follow with ID recs. Contin present rx.\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone & Lopressor po.\n Action:\n Maint Potassium >4.0.\n Response:\n Occas. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Responsive. Appropriate @ times. Very restless @ times. Will attempt to\n reach for ETT if able.\n Action:\n Fent. Gtt increased due to forceful coughing (freq) resulting in\n leakage around ETT cuff & decreased sats.\n Response:\n Improved sats w increased fentanyl gtt. Remains easily\n arousable-following simple commands.\n Plan:\n Decrease sedation as tolerated. Adeq safety measures. Reorient freq.\n Ineffective Coping\n Assessment:\n Patients wife & mother encouraged with patients progress. Becomes\n easily concerned when vent/monitor alarms.\n Action:\n Explanation and support given to all concerns.\n Response:\n Family appeared to accept explanation.\n Plan:\n Contin support pt/family asindicated.\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555220, "text": "39 yo M with h/o Ebstein's anomaly, s/p TV annuloplasty\n ring/reconstruction with biventricular HF p/w unstable monomprphic VT,\n on amiodarone. Pt is now improving from complicating issues of\n respiratory failure, fevers. Wife stayed over noc. D5W maintenance\n for elevated NA levels d/c\nd (Na+ 140) PT on consult but did not get to\n see pt yet. Pt conts doing leg and arm lifts & assisting with turns.\n NPO p mn for EP study in AM, remained afebrile. Wore own bipap\n overnite.\n Ventricular tachycardia, sustained\n Assessment:\n In SB/SR 60s-70s. rare PVCs.\n Action:\n On Lopressor 25mg po BID. Amiodarone 200mg po TID.\n Response:\n HR remains SR 60s today. SBP 90-100s.\n Plan:\n Continue amio at current dose per EP. Con\nt betablockade as tol. EP\n study planned today for ablation & possible ICD placement.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Remains extubated. No respiratory distress. Sats >95%.\n Action:\n Cont\nd on O2 @ 4L n/c w/ sats 94-98%. LS clear, dim in bases. BIPAP on\n for sleeping.\n Response:\n Slept well on BIPAP, maintained sats >94%.\n Plan:\n Cont weaning 02 support as tol.\n" }, { "category": "Nursing", "chartdate": "2151-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554517, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n On 50%/12peep/12/ps. TV 400-600, sats 90-97%. bs bases.\n Lasix gtt @5mg/hr. On 100cc D5w x 1000cc for NA 155.\n Action:\n Peep decreased from . Once tolerated, Fio2 to 45%.\n Lasix gtt stopped as pt diuresing 150-200cc/hr. Suctioned for small\n thick tan secretions.\n Fentanyl gtt to 25mcg/hr so as to lighten through day.\n Response:\n Oxim. Sats 90-96% ABG late in afternoon 7.53-42-58. Continues to\n diurese off lasix HO aware ABG 7.44/50/81. Afternoon Na 154\n Plan:\n Placed back on 50%, Sedation restarted at 100mcg/hr fentanyl, will\n start D5W in IV as well as via OGT.\n Ventricular tachycardia, sustained\n Assessment:\n HR 80-90\ns SR, multifocal PVC\ns, ventricular trigemeny noted. Stable\n BP throughout day\n Action:\n Amio 400mg po as ordered.\n Response:\n Stable rhythm. BP stable on lopressor. K+3.7 late in day\n Plan:\n K+ replete, increase Lopressor, monitor arrythmias.\n Altered mental status (not Delirium)\n Assessment:\n Pt lightened to 25mcg/hr fentanyl. Pt will open eyes, and appear to\n briefly focus when name is called. Nod and shake head no\n appropriately. Does not follow commands. RR increased to 30 w/ some\n agitation through day. ABG as above.\n Action:\n Fentanyl gtt increased back to 100mcg/hr at 1800.\n Response:\n Pt more restful on increased dose of fentanyl.\n Plan:\n Attempt to wean fentanyl gtt again in am.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 103.4 (12 noon) . ASA and Tylenol cont rtc.\n Action:\n Pt rec\nd am dose of zocyn then all abx dc\nd today.\n Response:\n Cont febrile through day but down to 102.9 at 4pm\n Plan:\n Cont monitor temps and cont asa and Tylenol\n Ineffective Coping\n Assessment:\n Pt restless on kinair rotating bed and in sedation. Mother asking\n for pt to be sedated as he\nlooks uncomfortable\n Action:\n Much time spent w/ mother and wife, explaining and need for lighter\n sedation, and need for turning and positioning in regards to pulmonary\n status.\n Response:\n Mother and wife understand and are appreciative of care.\n Plan:\n Cont keep mom and wife informed of . Social service as necessary.\n Bari air bed placed on pt at 1700. Pt able to tolerated bed\n throughout night. However, when pt\ns sedation lightened, his\n spontaneous movement in bed increased. HOB is raised per vap\n protocol, but he continually slides down in bed, to the point of having\n legs swinging out from bottom/side of bed.\n For pt safety, pt placed back on regular CCU atmos air bed. Turned and\n positioned q2-3hrs.\n" }, { "category": "Nursing", "chartdate": "2151-03-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 555415, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, shocked into VF, requiring intubation\n and pressors. Pt\n CV - Pt has been without vea x 7 days, stable on Amiodarone and\n lopressor.\n Resp -Extubation , able to tolerate NP.\n Gi\n Abd obese w/ +bs. Tolerating NAS low chol diet. OB\n stool .\n GU\n foley cath patent to amber urine.\n ID\n afebrile. Last temp spike . off antibiotics. Positive nasal\n swab for MRSA- on contact precautions.\n Access\n RIJ TLC.\n Activity\n OOB to chair/commode w/ 2 assist.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT/shock on admit to EW. Now stable on po amio and lopressor.\n Action:\n Discussing need for pacer/AICD with family. Dr. and EP in\n discussion.\n Response:\n pt. and wife have discussed need for EP study and possible AICD. Now\n the question is whether he stays in hospital prior to study or goes\n home first.\n Plan:\n Contin. to follow plan and discussions with family.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Intubated x10days\n now deconditioned and working with PT.\n Action:\n OOB x2 times . using chair back and 2 assist to stand up and\n shuffle to bed or chair.\n Response:\n c/o pain in back of calves when standing or walking. Appearing winded\n with activity. Resolves with rest.\n Plan:\n Work with PT. no decision as far as d/c to rehab vs home with\n services.\n Respiration / Gas Exchange, Impaired\n Assessment:\n s/p aspiration PNA/acute hypoxia\n.7 days of antibiotics. Now afeb. On\n 2L NC. LS clear.\n Action:\n Encourage to cough/deep breath. prn nebs have not been needed.\n Uses home CPAP set up. With assist from RT.\n Response:\n No c/o SOB. Non productive strong cough.\n Took off CPAP ~ 0500- awake\n Plan:\n Contin. with NC. Prn nebs. Monitor sats with activity. CPAP at\n night.\n Knowledge, Impaired\n Assessment:\n Decrease knowledge base r/t EP/AICD and nutrition\n Action:\n Wife states that she is bringing in laptop today () so pt. can\n research more about Pacemakers/AICD\ns. has been in discussions with\n MD\n -family brought in food from home (salad, humous, pita) for pt. pt.\n also states that he drinks regular soda and a large amt. of o.j. at\n home and at work. We talked about need to watch calories and sugar\n intake.\n Talked about setting up consult with a nutritionist.\n Response:\n Pt. is agreeable to having nutrition consult.\n Plan:\n Continue with teaching.\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554409, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolypoma, also small bilateral pleural\n effusions and consolidations; no pelvic or abdominal fluid; thoracic\n compression fracture\n - off pressors all day\n - PEEP to 12, FIO2 to 50%\n - ID recs to keep abx for now\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP\n HR\n Gen: Obese, sedated, intubated, paralyzed\n HEENT: intubated\n Neck: Large\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. High A-a gradient. Pt\n continues to improve, with decreasing Fi02 and NO now off. Compliance\n improving. Methemaglobin negative.\n - Cont to wean Fi02 and PEEP as tolerated. Goal PEEP 12 pre pulm,\n decrease by intervals of 2 today, Goal Pa02>60\n - Cont. pressure support\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - nebs\n - Bubble study not indicated, TEE did not show shunt with dopplers, so\n very unlikely if PFO/ intraventricular shunt present to be\n physiologically significant. Also responded to increasing Fi02, not\n c/w shunt.\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, pt will likely need\n trach once PEEP weaned down. F/u pulm recs.\n - raise head of bed\n - Chest CT today if unable to decrease PEEP as planned above.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone.\n - Cont. amiodatrone PO 400mg tid\n - Requiring intermittent levophed, currently off\n - Consider trial of BB for HR control\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Requiring intermittend levophed, wean for MAP goal >65\n - Attempt to add BB as tolerated, low dose IV lopressor Q4 hours,\n 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Vanco\n level was persistently low, have been uptitrating dose, now\n supratherapeutic. Cultures negative thus far. Fem line removed and\n sent for culture. ? drug fever given persistant fever and no pos. cx\n data. Also given diarrhea at present and increasing leukocytosis on\n abx, c. diff a possibility.\n - Cultures from peripheral and from line NGTD\n - Fem line out, new CVL placed .\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 8, plan for 8-day course for VAP to\n possibly complete on \n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - Discuss stopping abx today given completed 8 days and no pos. blood\n cultures\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n - bronch if persistent fevers.\n - LENIs negative.\n - Consider CT sinus, chest, abdomen today.\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - continue diurese w lasix drip to goal -500-1L cc / 24 hours.\n # ARF: ATN, creatinine increased from 2.3 to 2.9 yesterday in setting\n of continued diuresis, Cr improved to 2.4 today with good UOP.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen on hold given now with diarrhea (holding off\n reglan/erythromycin for concern for ectopy/ QT prolongation), if needed\n can try low dose reglan.\n - Continue TF, f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n - got vitamin K\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-14 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 554412, "text": "TITLE:\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - CT of sinuses with partial\n obstruction on mastoid air cells, CT torso with 6cm lesion on right\n adrenal, appears to be myolypoma, also small bilateral pleural\n effusions and consolidations; no pelvic or abdominal fluid; thoracic\n compression fracture\n - off pressors all day\n - PEEP to 12, FIO2 to 50%\n - ID recs to keep abx for now\n - pulm recs to wean FIO2 and PEEP\n - SBP elevated to 150, tachy to 100s- started metoprolol 12.5 \n Medications\n Unchanged\n Physical Exam\n BP: 123 / 72 mmHg\n HR: 85 bpm\n RR: 14 insp/min\n Tmax C last 24 hours: 39.5 C\n Tmax F last 24 hours: 103.1 F\n T current C: 38.8 C\n T current F: 101.9 F\n O2 sat: 97 % on Supplemental oxygen: CPAP/PS- FiO2 50%, PEEP 12\n Previous day:\n Intake: 3,770 mL\n Output: 5,260 mL\n Fluid balance: -1,490 mL\n Today:\n Intake: 825 mL\n Output: 1,465 mL\n Fluid balance: -640 mL\n BP 110-130s/60-80s\n HR 80-100\n Gen: Obese, less sedated, intubated\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin, unchanged from\n \n Labs\n 354\n 11.5\n 94\n 2.5\n 34\n 3.7\n 93\n 108\n 155\n 33.7\n 13.3\n [image002.jpg]\n 11:09 AM\n 12:00 PM\n 05:35 PM\n 11:48 PM\n 05:57 AM\n 12:18 PM\n 02:47 PM\n 03:13 PM\n 12:36 AM\n 03:27 AM\n WBC\n 17.0\n 13.3\n Hgb\n 11.9\n 11.5\n Hct (Serum)\n 36.1\n 33.7\n Plt\n 333\n 354\n INR\n 1.7\n 1.7\n PTT\n 34.3\n 46.1\n Na+\n 143\n 148\n 148\n 155\n K + (Serum)\n 3.6\n 3.8\n 3.9\n 3.7\n Cl\n 102\n 107\n 108\n HCO3\n 30\n 31\n 34\n BUN\n 91\n 93\n 92\n 93\n Creatinine\n 2.5\n 2.4\n 2.5\n 2.5\n Glucose\n 144\n 151\n 109\n 94\n O2 sat (arterial)\n 94\n 93\n 94\n 94\n 96\n ABG: 7.44 / 50 / 81 / / 7 Values as of 03:52 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE with bubble study. High\n A-a gradient. Pt continues to improve, with decreasing Fi02 and NO now\n off. Compliance improving. Methemaglobin negative.\n - Cont to wean Fi02 and PEEP as tolerated. decrease by intervals of 2\n today, Goal Pa02>60\n - Cont. pressure support\n - decreased lasix gtt, aim net even to negative I/O 500ml\n - nebs\n - lytes with diuresis\n - wean sedation, off midazolam\n -d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - Chest CT yesterday with only small bilaterally effusions and basilar\n consolidations\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodatrone PO 400mg tid\n - titrate up BB for HR control, increase to 25mg today\n - likely will need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - MAP goal >65, (still off pressers)\n - Wean PEEP and sedative as tolerated.\n # Fevers: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to spike fevers, but\n fever curve decreasing. Still on ATC tylenol and cooling blanket. Vanco\n level was elevated, dose this AM held. Cultures negative thus far. Fem\n line removed and sent for culture with no growth. Possible drug fever\n given persistent fever and no pos. cx data. Also given diarrhea at\n present and increasing leukocytosis on abx, c. diff a possibility. CT\n with PO contrast yesterday did not show clear source of fevers. CT\n sinus did have partial opacifications of bilaterally mastoids. CVL\n placed .\n - MRSA screen positive then negative\n - Continue vanco and zosyn, day 9, consider d/c this AM\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever, standing ASA\n - bronch if persistent fevers.\n - LENIs negative.\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function.\n - decreased diuresis today\n - appreciate Children\ns congenital specialist input\n # ARF: ATN, creatinine increased in setting of continued diuresis,\n - decrease lasix gtt\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - decrease lasix gtt to 5mg/hr\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen on hold given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n # Family dynamics: family initially concerned about care of pt in the\n hospital, social work involved.\n - social work consult\n - Children\ns congenital specialist , appreciate input\n - Cont. frequent updates\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554676, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 102. Remains off antibiotics.\n Action:\n Conts on ATC Tylenol. PRN cooling blanket. Pt recultured this pm.\n Response:\n Cultures negative to date. Fever felt to be drug related.\n Plan:\n Stool sent for C dif. Cont to check cultures. Follow ID\n recommendations.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received on 50% 12 PS 10 peep. Pt conts to desat with activity.\n Action:\n Able to wean down Fio2 to 40%. spontaneous breathing trial this pm\n 8/0.\n Response:\n Able to tolerate for short period pt very restless O2 sats 86-94% TV\n 300-500\ns RR 20\n Plan:\n Placed back on 12 PS 10 peep. Sedate over nite for rest. ? extubation\n in am.\n Altered mental status (not Delirium)\n Assessment:\n Pt much lighter this am. Able to follow commands. MAE.\n Action:\n Fentanyl weaned off.\n Response:\n Pt more awake and responsive. Having difficult time with ETT.\n Plan:\n Sedate overnite for rest. Repeat trial in am.\n" }, { "category": "Nursing", "chartdate": "2151-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554933, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n EVENTS: Extubated successfully ,\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Tolerating extubation. Episodes of sleep apnea with decrease in sats to\n low 90\n Action:\n Encouraged to keep 02 on-requiring freq reinforcement.\n Response:\n Stable sats when keeping O2 on.\n Plan:\n ^Wean O2 as tolerated. Bipap (pt own equip) for sleep.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile. Contin on ASA & Tylenol.\n Action:\n ASA & Tylenol as ordered.\n Response:\n Afebrile.\n Plan:\n Contin follow T. ?DC ASA & Tylenol.\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone & Lopressor po. IV D5W @150cc/hr for elevated NA.\n Action:\n Lytes WNL. On D5W increased to 200cc/hr continous.\n Response:\n rare. PVC\ns. BP stable on lopressor and lisnopril\n Plan:\n Montor HR/BP closely. Monitor lytes and replete prn.\n Altered mental status (not Delirium)\n Assessment:\n Responsive. Appropriate. Cooperative. Sl forgetful @ times.\n Action:\n Adeq safety measures. Freq reorientation.\n Response:\n Improving mental status.\n Plan:\n Freq reorientation. Adeq safety measures.\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555417, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely PMP next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED\n BALANCE, IMPAIRED\n KNOWLEDGE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n TRANSFERS, IMPAIRED\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555418, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely PMP next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: CCU for now, PT and OT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555419, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely PMP next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 420 K/uL\n 10.7 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.8 mEq/L\n 41 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.6 %\n 11.8 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: CCU for now, PT and OT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554588, "text": "CCU Intern Progress Note:\n 24 Hour Events:\n - cont weaning ventilatory support --> FIO2 down to 45%, PEEP down to\n 10%, but pt becoming more hypoxemic, so FIO2 back to 50%\n - cont to have fever - Tmax 103.6, bl cx drawn, curve downtrending this\n AM\n - will check TSH, cortisol level today (cosyntropin-stim test), CK and\n LFTs as other causes\n - Na 154 - free water deficit ~6-7 L --> free water flushes + D5W\n - stopped lasix, antibiotics (vanc/zosyn)\n - increased metoprolol to 50 , started lisinopril 2.5mg daily\n - CT sinus - new sinusitis - ? fungal\n - ID: d/c abx given possiblity for drug-related fever\n - pulm: concur, will consider BAL if continues to be febrile or new\n spike;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.8\nC (100\n HR: 77 (73 - 103) bpm\n BP: 116/66(80) {103/57(71) - 153/86(103)} mmHg\n RR: 14 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,104 mL\n 1,239 mL\n PO:\n TF:\n 1,205 mL\n 312 mL\n IVF:\n 1,929 mL\n 557 mL\n Blood products:\n Total out:\n 4,375 mL\n 540 mL\n Urine:\n 4,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -271 mL\n 699 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 509 (509 - 700) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.40/54/74/34/6\n Ve: 7.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Gen: Obese, less sedated, intubated, moving limbs, nodding/shaking head\n in response to questions\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin\n Labs / Radiology\n 409 K/uL\n 11.4 g/dL\n 115 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 79 mg/dL\n 111 mEq/L\n 153 mEq/L\n 35.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:35 AM\n 03:27 AM\n 03:52 AM\n 09:46 AM\n 01:01 PM\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n WBC\n 13.3\n 12.3\n Hct\n 33.7\n 35.4\n Plt\n 354\n 409\n Cr\n 2.5\n 2.1\n 1.9\n TCO2\n 35\n 35\n 34\n 34\n 36\n 35\n 35\n Glucose\n 94\n 110\n 115\n Other labs:\n PT / PTT / INR:19.2/51.1/1.8,\n ALT / AST:216/99, Alk Phos / T Bili:51/0.7,\n D-dimer: ng/mL, Fibrinogen:679 mg/dL,\n Lactic Acid:1.6 mmol/L,\n Albumin:3.2 g/dL, LDH:430 IU/L,\n Ca++:8.4 mg/dL, Mg++:3.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving. Attempted\n to wean FiO2 down to 45% from 50% but still hypoxemic so back to 50%.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c\nd diuresis for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodarone PO 400mg tid\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abz with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenan insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS.\n Continued to spike fevers, but fever curve seems to be decreasing.\n Still on ATC tylenol, aspirin and cooling blanket. Fem line removed\n and sent for culture with no growth. Possible drug fever given\n persistent fever with no pos. cx data. C. diff negative. CT with PO\n contrast did not show clear source of fevers. CT sinus did have partial\n opacifications of bilaterally mastoids. CVL placed .\n - d/c abx yesterday per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test today\n - check LFTs, CK, TSH\n - Call rheum for repeat knee tap\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n last night 8L.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat today to assess any regain of systolic funtion.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen in place given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee as above.\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n" }, { "category": "Physician ", "chartdate": "2151-03-15 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 554589, "text": "CCU Intern Progress Note:\n 24 Hour Events:\n - cont weaning ventilatory support --> FIO2 down to 45%, PEEP down to\n 10%, but pt becoming more hypoxemic, so FIO2 back to 50%\n - cont to have fever - Tmax 103.6, bl cx drawn, curve downtrending this\n AM\n - will check TSH, cortisol level today (cosyntropin-stim test), CK and\n LFTs as other causes\n - Na 154 - free water deficit ~6-7 L --> free water flushes + D5W\n - stopped lasix, antibiotics (vanc/zosyn)\n - increased metoprolol to 50 , started lisinopril 2.5mg daily\n - CT sinus - new sinusitis - ? fungal\n - ID: d/c abx given possiblity for drug-related fever\n - pulm: concur, will consider BAL if continues to be febrile or new\n spike;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 37.8\nC (100\n HR: 77 (73 - 103) bpm\n BP: 116/66(80) {103/57(71) - 153/86(103)} mmHg\n RR: 14 (12 - 33) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 4,104 mL\n 1,239 mL\n PO:\n TF:\n 1,205 mL\n 312 mL\n IVF:\n 1,929 mL\n 557 mL\n Blood products:\n Total out:\n 4,375 mL\n 540 mL\n Urine:\n 4,375 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -271 mL\n 699 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 509 (509 - 700) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 15\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n SpO2: 98%\n ABG: 7.40/54/74/34/6\n Ve: 7.6 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Gen: Obese, less sedated, intubated, moving limbs, nodding/shaking head\n in response to questions\n HEENT: intubated\n Neck: Large, right IJ in place\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: Clear anteriorly\n Cardiac: RRR, soft diast murmur in L sternum\n Abdominal / Gastrointestinal: NABS, very obese\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit),\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities- erythematous skin\n Labs / Radiology\n 409 K/uL\n 11.4 g/dL\n 115 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 3.5 mEq/L\n 79 mg/dL\n 111 mEq/L\n 153 mEq/L\n 35.4 %\n 12.3 K/uL\n [image002.jpg]\n 01:35 AM\n 03:27 AM\n 03:52 AM\n 09:46 AM\n 01:01 PM\n 05:06 PM\n 05:27 PM\n 08:05 PM\n 04:16 AM\n 04:33 AM\n WBC\n 13.3\n 12.3\n Hct\n 33.7\n 35.4\n Plt\n 354\n 409\n Cr\n 2.5\n 2.1\n 1.9\n TCO2\n 35\n 35\n 34\n 34\n 36\n 35\n 35\n Glucose\n 94\n 110\n 115\n Other labs:\n PT / PTT / INR:19.2/51.1/1.8,\n ALT / AST:216/99, Alk Phos / T Bili:51/0.7,\n D-dimer: ng/mL, Fibrinogen:679 mg/dL,\n Lactic Acid:1.6 mmol/L,\n Albumin:3.2 g/dL, LDH:430 IU/L,\n Ca++:8.4 mg/dL, Mg++:3.0 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, now intubated, with hypoxic and\n hypercarbic respiratory failure, persistent fevers.\n # Respiratory Failure: Primarily hypoxemic. Pt continues to improve,\n with decreasing Fi02 and NO now off. Compliance improving. Attempted\n to wean FiO2 down to 45% from 50% but still hypoxemic so back to 50%.\n - Cont to wean Fi02 and PEEP as tolerated. Goal Pa02>60\n - Cont. pressure support\n - d/c\nd diuresis for hypernatremia/contraction alkalosis.\n - nebs\n - d/w pulm liklihood of extubation within 14 days, vs need for trach.\n F/u pulm recs.\n - raise head of bed\n - f/u final read chest CT, per pulm recs based on prelim read, no need\n to bronch.\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Suppressed ectopy w Amiodarone. Now on Metoprolol.\n - Cont. amiodarone PO 400mg tid\n - titrate up BB for HR control, increased to 50mg .\n -added Lisionpril 2.5mg PO daily\n - likely will need EP study and possible ablation in future. Will\n likely need ICD.\n # BP: Off pressors, now elevated BP while weaning sedation. Added back\n on BB.\n - MAP goal >65,\n - Wean PEEP and sedative as tolerated.\n - added on low dose ACEI\n # Fevers: Fevers to 103-104 since admission, initially considered to be\n due to aspiration PNA. However has completed course of abz with no\n sputum production and improving pulmonary function. Chest CT did not\n show evidence for ongoing infection. Ddx at this point includes occult\n infection (abscess, acalculous cholecystitis, sinusitis), gout,\n thermoregulatory dysfunciton after cardiac arrest/non-exposure heat\n stroke, drug fever, thyroid storm, adrenan insufficiency (although less\n likely now that not hypotensive). Not exposed to any culprit meds for\n NMS.\n Continued to spike fevers, but fever curve seems to be decreasing.\n Still on ATC tylenol, aspirin and cooling blanket. Fem line removed\n and sent for culture with no growth. Possible drug fever given\n persistent fever with no pos. cx data. C. diff negative. CT with PO\n contrast did not show clear source of fevers. CT sinus did have partial\n opacifications of bilaterally mastoids. CVL placed .\n - d/c abx yesterday per ID.\n - ID following, appreciate their recs\n - Check mycolytic blood cultures, pending\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 650 qid standing for fever, standing ASA 325 PO qid\n - stim test today\n - check LFTs, CK, TSH\n - Call rheum for repeat knee tap\n # Hypernatremia - likely in setting of diuresis. Free water deficit\n last night 8L.\n -hold lasix gtt\n -D5W continuous + free water flushes for repletion\n # Chronic Systolic heart failure - Congestive Heart Failure: Has right\n and left sided heart failure, s/p tricuspid reconstruction and ASD\n repair.\n - hold digoxin\n - TEE and TTE\n showed poor systolic function. Done just after arrest.\n Repeat today to assess any regain of systolic funtion.\n - hold diuresis\n - appreciate Children\ns congenital specialist input\n - Cr stable, add back on low dose ACEI\n # ARF: ATN, creatinine increased in setting of continued diuresis. Cr\n much improved after holding diuresis.\n - d/ced lasix gtt\n - monitor UOP\n # Hypernatremia sodium of 155 from 148, free water defict of 7L, likely\n from combination of fevers and diuresis\n - d\ned lasix gtt\n - start D5W at 100ml/hr- then will reevaluate Na this PM\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl\n - Bowel regimen in place given now with diarrhea\n - Continue TF\n - f/u any nutrition recs\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - monitor LFTs given amio restarted\n #Gout: R knee swollen, concerning for gout flare, joint tapped, no\n crystals visualized. Rheum following. Holding allopurinol and\n colchicines given ARF\n -re-tap knee as above.\n FEN: agressively replete lytes\n ACCESS: Fem line d/c\nd., new IJ placed . Fever curve decreasing,\n will monitor femoral blood cultures.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Full\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 12:00 AM\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff. nothing to add\n Physical Examination\n per housestaff. nothing to add\n Medical Decision Making\n per housestaff. nothing to add\n Above discussed extensively with patient.\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n improving. unexplained fever - knee seems most likely source. will\n retap it\n drop amiodarone dose to 600 qd\n lighten sedation and consider extubation in next 48 hours\n will decide on EPS and ICD sometime post extubation\n ------ Protected Section Addendum Entered By: \n on: 08:53 ------\n" }, { "category": "Nutrition", "chartdate": "2151-03-15 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 554605, "text": "Subjective\n Intub, sedated.\n Objective\n Pertinent medications: fentanyl, heparine, abx, D5W at 100ml/hr others\n noted\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 04:16 AM\n Glucose Finger Stick\n 114\n 06:00 AM\n BUN\n 79 mg/dL\n 04:16 AM\n Creatinine\n 1.9 mg/dL\n 04:16 AM\n Sodium\n 153 mEq/L\n 04:16 AM\n Potassium\n 3.5 mEq/L\n 04:16 AM\n Chloride\n 111 mEq/L\n 04:16 AM\n TCO2\n 34 mEq/L\n 04:16 AM\n PO2 (arterial)\n 74 mm Hg\n 04:33 AM\n PCO2 (arterial)\n 54 mm Hg\n 04:33 AM\n pH (arterial)\n 7.40 units\n 04:33 AM\n pH (urine)\n 5.0 units\n 02:47 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 04:33 AM\n Albumin\n 3.2 g/dL\n 04:12 AM\n Calcium non-ionized\n 8.4 mg/dL\n 04:16 AM\n Phosphorus\n 4.1 mg/dL\n 04:16 AM\n Ionized Calcium\n 1.08 mmol/L\n 04:26 AM\n Magnesium\n 3.0 mg/dL\n 04:16 AM\n ALT\n 216 IU/L\n 04:16 AM\n Alkaline Phosphate\n 51 IU/L\n 04:16 AM\n AST\n 99 IU/L\n 04:16 AM\n Amylase\n 103 IU/L\n 04:12 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:16 AM\n WBC\n 12.3 K/uL\n 04:16 AM\n Hgb\n 11.4 g/dL\n 04:16 AM\n Hematocrit\n 35.4 %\n 04:16 AM\n Current diet order / nutrition support: Nutren Pulm 50ml/hr + 40g\n Beneprotein (1943kcal/116g pro) water flushes 250ml\n GI: very obese,\n Assessment of Nutritional Status\n 39M intubated since adm, cont on TF for full nutrition support, pt\n tolerating current TF regimen without much issue. Noted pt with\n hypernatremia (free water deficit of ~7L), likely from combination of\n fevers and diuresis, free water bolus and D5w ordered, and lasix gtt\n d/c\nd, consider change TF to regular formula to better meet pt\ns needs\n ( no need for fluid restricted TF at this time).\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding: change TF to Replete with Fiber goal 75ml/hr\n (1800kcal/112g pro)\n Check chemistry 10 panel daily, replete prn\n Cont water bolus and D5W until Na comes down, than adjust amount of\n water bolus per pt\ns needs\n Cont BG management\n Other: f/u re poc, please page if has ?\n" }, { "category": "Nutrition", "chartdate": "2151-03-15 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 554607, "text": "Subjective\n Intub, sedated.\n Objective\n Pertinent medications: fentanyl, heparine, abx, D5W at 100ml/hr others\n noted\n Labs:\n Value\n Date\n Glucose\n 115 mg/dL\n 04:16 AM\n Glucose Finger Stick\n 114\n 06:00 AM\n BUN\n 79 mg/dL\n 04:16 AM\n Creatinine\n 1.9 mg/dL\n 04:16 AM\n Sodium\n 153 mEq/L\n 04:16 AM\n Potassium\n 3.5 mEq/L\n 04:16 AM\n Chloride\n 111 mEq/L\n 04:16 AM\n TCO2\n 34 mEq/L\n 04:16 AM\n PO2 (arterial)\n 74 mm Hg\n 04:33 AM\n PCO2 (arterial)\n 54 mm Hg\n 04:33 AM\n pH (arterial)\n 7.40 units\n 04:33 AM\n pH (urine)\n 5.0 units\n 02:47 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 04:33 AM\n Albumin\n 3.2 g/dL\n 04:12 AM\n Calcium non-ionized\n 8.4 mg/dL\n 04:16 AM\n Phosphorus\n 4.1 mg/dL\n 04:16 AM\n Ionized Calcium\n 1.08 mmol/L\n 04:26 AM\n Magnesium\n 3.0 mg/dL\n 04:16 AM\n ALT\n 216 IU/L\n 04:16 AM\n Alkaline Phosphate\n 51 IU/L\n 04:16 AM\n AST\n 99 IU/L\n 04:16 AM\n Amylase\n 103 IU/L\n 04:12 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:16 AM\n WBC\n 12.3 K/uL\n 04:16 AM\n Hgb\n 11.4 g/dL\n 04:16 AM\n Hematocrit\n 35.4 %\n 04:16 AM\n Current diet order / nutrition support: Nutren Pulm 50ml/hr + 40g\n Beneprotein (1943kcal/116g pro)\n GI: very obese,\n Assessment of Nutritional Status\n 39M intubated since adm, cont on TF for full nutrition support, pt\n tolerating current TF regimen without much issue. Noted pt with\n hypernatremia (free water deficit of ~7L), likely from combination of\n fevers and diuresis, free water bolus ( 250ml q 4hours per MetaVision)\n plus D5w ordered , and lasix gtt d/c\nd. Consider change TF to regular\n formula to better meet pt\ns needs ( no need for fluid restricted TF at\n this time).\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding: change TF to Replete with Fiber goal 75ml/hr\n (1800kcal/112g pro)\n Check chemistry 10 panel daily, replete prn\n Cont water bolus and D5W until Na comes down, than adjust amount of\n water bolus per pt\ns needs\n Cont BG management\n Other: f/u re poc, please page if has ?\n" }, { "category": "Nursing", "chartdate": "2151-03-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 555347, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, shocked into VF, requiring intubation\n and pressors. Pt\n CV - Pt has been without vea x 7 days, stable on Amiodarone and\n lopressor.\n Resp -Extubation , able to tolerate NP.\n Gi\n Abd obese w/ +bs. Tolerating NAS low chol diet. OB\n stool .\n GU\n foley cath patent to amber urine.\n ID\n afebrile. Last temp spike \n Access\n RIJ TLC.\n Activity\n OOB to chair/commode w/ 2 assist.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n On o2 2ln/p. ls clear. Cough productive of small amts thick yellow\n sputum.\n Action:\n Encouraged incentive as well as c/db.\n Response:\n Denies sob.\n Plan:\n Bipap for sleep apnea. Wean O2 as tolerated. ^\n Ventricular tachycardia, sustained\n Assessment:\n On Amiodarone, lisinopril and lopressor\n Action:\n Lopressor dose decreased to 12.5mg .\n Response:\n Tolerated lopressor dose w/o difficulty.\n Plan:\n Monitor hemodynamics, lytes and replete prn.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553251, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes22\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments: pt asperated stomach fluid when cardiac arrested in ER\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure)\n Comments: Pressures were high in AM has decreased throughpout day.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: pt will continue to be monitored with PEEP levels and\n hymodyamic stability. esophogeal balloon trie dto find optimal PEEP\n but 20 of PEEP decr BP so PEEP turned back to 12\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1130\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553308, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- CK: 262 MB: 7 Trop-T: 0.36, from Trop-T: <0.01 CK:\n 267 MB: 6\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1\n Medications\n Unchanged\n Physical Exam\n General appearance: BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553309, "text": "TITLE: Cardiology Physician Note\n History of Present Illness\n Date: \n Initial visit\n Events / History of present illness: - Femoral line placed and Arterial\n line placed\n - CTA showed no PE, but +L pneumothorax with rib fractures; was\n hypotensive on pressors, surgery attempted to place chest tube and was\n not able to heart size and adhesions; IP contact- also unable;\n instead went to IR to placed chest tube, but new CT no longer showed\n pneumo, serial CXRs without new pneumo\n - head CT- wet read of no acute intracranial process\n - hypoxia- given nebs; vent adjusted for ARDS setting, pulm consulted,\n PEEP increased, esophageal balloon placed; then pressures dropped to\n 60s with PEEP of 20 and required 3 pressers; then PEEP changed to 12,\n BP improved, was able to wean neo; -PEEP increased to 16 due to\n lack of difference between peak and plataeu pressures in effort to\n recruit more aveoli;\n - CT also showed likely right sided aspiration; temp of 102 at 1400,\n cultures sent, pt started on zosyn, given 500ml bolus NS x 2 when\n hypotensive, new leukocytosis of 13.9; at 10pm vanco started (hx of 2\n yo with recent MRSA infection); still febrile at MN, given tylenol,\n reordered blood cxs this AM\n - continuing on amiodarone, having intermitent NSVT, short runs, less\n now then yesterday\n - CE trended- CK: 262 MB: 7 Trop-T: 0.36, from Trop-T: <0.01 CK:\n 267 MB: 6\n - K of 6 at 20:45, rechecked at 6.2, EKG with no p-waves seen, given 2g\n Calcium gluconate, albuterol, 10 units of R insulin, 1 amp of D50,\n Kayexalate 45g; P waves reappeared on tele\n - new renal failure, decreased urine output, Cr of 2.3\n - 2400- tachy to 120- given 500 ml bolus, improved to low 100s\n - 0320 pt is tachy to 130s, SBP in 80s, first had 3 beats NSVT then\n axis changed, temp 101, 250ml NS bolus started; appeared to be in VT,\n gave amio bolus of 300mg, K of 5.3, ABG of 7.35/40/66/23/-3. Rate\n decreased to 90s. Ionized Ca was 1.09- gave addtional 2gm calcium\n gluconate\n - decreased oxygen sats in 80s, given lasix 10mg IV with no increase in\n UO, CXR at 420AM appears to have increased edema, gave lasix 20mg IV x\n 1\n -500 pt in VT at rate of upper 110s- gave amio 150mg and increased rate\n from 0.5 to 1\n Medications\n Unchanged\n Physical Exam\n General appearance: BP 77-119/56-76\n HR 87-130s\n BP: 98 / 64 mmHg\n HR: 90 bpm\n RR: 32 insp/min\n Tmax C last 24 hours: 39.3 C\n Tmax F last 24 hours: 102.7 F\n T current C: 38.5 C\n T current F: 101.3 F\n O2 sat: 87 % on Supplemental oxygen: 100% FIO2\n Previous day:\n Intake: 3,467 mL\n Output: 340 mL\n Fluid balance: 3,127 mL\n Today:\n Intake: 1,486 mL\n Output: 110 mL\n Fluid balance: 1,376 mL\n Gen: Obese, sedated, intubated\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.3\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n Ionized Ca 1.09\n Ca 8.5\n Mg 1.7\n Phos 3.7\n ALT 400\n AST 448\n LDH 586\n T Bili 1.2\n Lactate 3.0 (from 4.1)\n 07:24 AM\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 3.8\n 5.3\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.35 / 40 / 66 / / -3 Values as of 03:25 AM\n Assessment and Plan\n ASSESSMENT AND PLAN\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Will trend cardiac enzymes to rule out\n ischemic event. Will also consult electrophysiology.\n -continue amiodarone\n -trend cardiac enzymes\n -electrophysiology consult\n .\n #Respiratory Failure: Difficulty oxygenating with Fi02 100% and\n increased PEEP. PIPs are in 40's. Per report patient had significant\n aspiration during intubation. Concern for PE given history of DVTs.\n Chest CTA showing bibasilar effusions and atelectasis, in addition to\n new left sided pneumothorax. will hold on IV heparin given history of\n brain abscesses years ago. Will ventilate according to ARDS net\n protocol. Contact CT for chest tube placement.\n -ARDS net protocol\n -CT for chest tube placement.\n -albuterol, ipratropium, racemic epinephrine nebs\n -IV heparin if PE, and if head CT is negative\n .\n #Hypotension:Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n weaned off for a short period, still requiring intermittently. Will\n try to minimize PEEP to maximize venous return. may possibly be from\n decompensated heart failure.\n -pressors as needed\n -fluids as neded\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n -hold metoprolol, lisinopril, lasix, digoxin\n -echo\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN:\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553481, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Resp. failure/ARDS secondary to pneumonia. requiring high peep and\n FIO2. remains on 70% FIO2, 20peep and nitric oxide\n Action:\n No vent changes. Suctioned for scant thick tan secretions.\n Response:\n AM ABG 7.40/36/83. sats 93-96%. LS diminished bases, clear upper\n Plan:\n Follow with pulmonary recs. ? wean nitric oxide vs FIO2. follow\n sats.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 102-103.6po. sputum Cx GPC in prs. All other cultures pnd. MRSA\n screen pnd.\n Vanco trough 6.6\n Action:\n Remains on cooling blanket. Tylenol q6hr.\n Given additional 500mg vanco IV at 0200. dose increased to 1250 mg\n next dose 2100.\n Also contin. on zysyn\n Response:\n Fever continues. WBC unchanged 13.2.\n Plan:\n Await culture results. Broad spectrum AB. Follow vanco levels.\n .H/O heart disease, congenital\n Assessment:\n No SVT or VT. BP 100-120/60\ns. HR 80\ns accelerated junctional.\n u/o 100-200cc/hr on lasix gtt.\n Action:\n Amioderone at 1mg/min. levophed weaned to .20mcq/k/min.\n Response:\n Stable BP. No hypotension. Tolerated turning and other care.\n Plan:\n Follow with EP for plan. Contin. to wean levo as tolerated. Contin.\n amio gtt. Monitor lytes.\n" }, { "category": "Physician ", "chartdate": "2151-03-07 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 553236, "text": "Date of service: \n Initial visit, Cardiology service: CCU\n History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Past medical history: 1. Ebstein anomaly, s/p tricuspid valve\n reconstruction\n - moderate to severe tricuspid regurgitation\n - right heart failure, RVEF 25% in \n 2. ASD, s/p primary closure \n 3. Left heart failure with evidence of noncompaction of LV, with\n LVEF 28% in \n 4. Hyperlipidemia\n 5. Hypertension\n 6. Obstructive sleep apnea\n 7. Obesity\n 8. DVT\n 9. Superficial phlebitis\n 10. endocarditis w/ septic emboli to brain prior to Cardiac surgery.\n CAD Risk Factors\n CAD Risk Factors Present\n Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Dyslipidemia\n Allergies:\n No Known Drug Allergies\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Edema, Palpitations, DVT\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea, Syncope,\n Presyncope, Lightheadedness, TIA / CVA, Pulmonary embolism,\n Claudication, Exertional buttock pain, Exertional calf pain\n Physical Exam\n Date and time of exam: \n General appearance: sedated, intubated, obese\n Vital signs: per R.N.\n Height: 72 Inch, 183 cm\n BP right arm:\n 95 / 67 mmHg\n Weight: 100 kg\n T current: 99.6 C\n HR: 99 bpm\n RR: 32 insp/min\n O2 sat: 93 % on Supplemental oxygen: 100%\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on left, rhonchi bilaterally.)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Skin: (mottled abdomen, cyanotic extreemities.)\n Labs\n 3.8\n [image002.jpg]\n 07:24 AM\n 09:11 AM\n 11:09 AM\n K + (Whole blood)\n 3.8\n O2 sat (arterial)\n 78\n 89\n ABG: 7.26 / 60 / 67 / / -1 Values as of 11:09 AM\n Outside / other labs: / : Cardiac MRI:\n Impression:\n 1. Normal left ventricular cavity size with globally depressed systolic\n function. The LVEF was severely decreased at 28%. No MR evidence of\n prior myocardial scarring/infarction although images technically\n suboptimal. Prominent non-compacted left ventricular myocardium that\n meet CMR criteria for non-compaction.\n 2. Abnormal and apically displaced tricuspid valve consistent with\n Ebstein's anomaly. A tricuspid annulplasty ring was present. Moderately\n depressed systolic function of the functional right ventricle with RVEF\n at 25%. Abnormal septal motion consistent with right ventricular\n pressure / volume overload. Markedly dilated inferior vena cava and\n hepatic veins consistent with elevated\n right atrial pressure.\n 3. Mild aortic regurgitation. Moderate-to-severe tricuspid\n regurgitation through tricuspid leaflets of functional right ventricle.\n Severe tricuspid regurgitation through tricuspid annulus of structural\n right ventricle. 4. The indexed diameters of the ascending and\n descending thoracic aorta were\n normal. The main pulmonary artery diameter index was normal.\n 5. Biatrial enlargement.\n Tests\n ECG: : wide complex tachycardia at rate 240, right axis\n deviation\n .\n : accelerated idioventricular rhythm at rate 90, right axis\n deviation, right bundle branch block, inferior Q waves, ST elevation in\n V2-V3.\n .\n : Sinus Tachycardia at rate 110, with left axis deviation, right\n bundle branch block, inferior Q waves\n .\n sinus rhythm, rate 99, left axis deviation, right bundle branch\n block, Q waves in inferior leads.\n Echocardiogram: (Date: ), The left atrium is mildly dilated. The\n right atrium is markedly dilated. No atrial septal defect is seen by 2D\n or color Doppler. There is moderate global left ventricular hypokinesis\n (the bsala lateral wall moves best). There is no ventricular septal\n defect. The right ventricular cavity is markedly dilated. Right\n ventricular systolic function appears severely depressed. There is\n abnormal/paradoxical septal motion/position. The aortic valve leaflets\n (3) appear structurally normal with good leaflet excursion and no\n aortic regurgitation. The mitral valve leaflets are mildly thickened.\n There is no mitral valve prolapse. Trivial mitral regurgitation is\n seen. A tricuspid valve annuloplasty ring is present. The gradients are\n higher than expected for this type of prosthesis. Moderate [2+]\n tricuspid regurgitation is seen. [Due to acoustic shadowing, the\n severity of tricuspid regurgitation may be significantly\n UNDERestimated.] The pulmonary artery systolic pressure could not be\n determined. Significant pulmonic regurgitation is seen. There is no\n pericardial effusion.\n IMPRESSION: Dilated RV with depressed RVEF. Moderate global LV\n hypokinesis. Tricuspid annuloplasty ring present with abnormally high\n transvalvular gradient and significant tricuspid regurgitation.\n Assessment and Plan\n ASSESSMENT AND PLAN\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Currently receiving amiodarone IV, remains in sinus\n tachycardia s/p resuscitation. Will trend cardiac enzymes to rule out\n ischemic event. Will also consult electrophysiology.\n -continue amiodarone\n -trend cardiac enzymes\n -electrophysiology consult\n .\n #Respiratory Failure: Difficulty oxygenating with Fi02 100% and\n increased PEEP. PIPs are in 40's. Per report patient had significant\n aspiration during intubation. Concern for PE given history of DVTs.\n Chest CTA showing bibasilar effusions and atelectasis, in addition to\n new left sided pneumothorax. will hold on IV heparin given history of\n brain abscesses years ago. Will ventilate according to ARDS net\n protocol. Contact CT for chest tube placement.\n -ARDS net protocol\n -CT for chest tube placement.\n -albuterol, ipratropium, racemic epinephrine nebs\n -IV heparin if PE, and if head CT is negative\n .\n #Hypotension:Initially secondary to ventricular tachycardia, and\n response to sedatives s/p intubation. Initially on three pressors but\n weaned off for a short period, still requiring intermittently. Will\n try to minimize PEEP to maximize venous return. may possibly be from\n decompensated heart failure.\n -pressors as needed\n -fluids as neded\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n -hold metoprolol, lisinopril, lasix, digoxin\n -echo\n .\n #Gout: holding allopurinol and colchicine\n .\n FEN:\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n CODE: Presumed full\n DISPO: CCU for now\n" }, { "category": "Nursing", "chartdate": "2151-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553243, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 PO\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553246, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished > L- sat\ns low- hypoxic by ABG\ns- CXR\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 PO @ 1400- hypotensive requiring pressors.\n Action:\n 500cc fluid bolus given- levophed gtt @ .3mcq/kg/min- Blood cultures\n X2, U/A C&S obtained & sent to lab- started on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n" }, { "category": "Nursing", "chartdate": "2151-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553244, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 PO @ 1400- hypotensive requiring pressors.\n Action:\n 500cc fluid bolus given- levophed gtt @ .3mcq/kg/min- Blood cultures\n X2, U/A C&S obtained & sent to lab- started on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n" }, { "category": "Nursing", "chartdate": "2151-03-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553407, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU , the patient is intubated with mottled\n skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP\n 125/77. Remains intubated with Aspiration PNA & ?Failure-requiring\n fio2-100% & PEEP up 16.. Pressors weaned to Levophed & Vasopressin.\n Chest Tube insertion for right pneumothorac-unsuccessful-resolved on\n own.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished throughout. Sx\nminimal thick tannish\n secretions. Sat\ns low 88-91% with PO2 70-80. CXR-Aspiration PNA,\n resolved pneumothorac, & ?failure. Renal Failure with elevated Creat &\n decreased urinary output.\n Action:\n Adjusted vent settings with goal maintaining sat >90. Pulm toilet.\n Lasix sm doses to gently diurese. Paralized with cisatricurium.\n Response:\n Sats <90% despite Peep-16. Fio2 remain @ 100%. Po2 mid 70\ns Without\n response to Lasix 10mg then 20mg ivp. Awaitng results of paralytic.\n Plan:\n ?Pulm Consult. Contin adjust vent to optimized resp status. ?PA Line\n placement to determine volume status. ?Continue diuresis attempt with\n Lasix.\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT. Episodes of Sustained Slow VT-130\ns with\n stable BP.\n Action:\n EKG with rhythm strip. Rebolus with Amiodarone X2-1^st 300mg with\n repat 150mg with resolution of rhythm.Amiodarone gtt increased to\n 1.0mg/min. with episode received 500ml NS. Lido bolus & gtt for\n recurrent slow vt.\n Response:\n Post second bolus & gtt increase without further episodes of Slow VT.\n Convert to sr with lido-required vasopressin due to decrease in maps.\n Plan:\n EP consult. Contin Amiodarone & Lido gtts.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile. T Max-101.8 po. Cultured previous shift. BCx2 sent\n with Am labs.\n Action:\n 500cc fluid bolus given- levophed gtt @ .4mcq/kg/min & vasopressin gtt\n @ 2.4u/hr- Blood cultures X2, U/A C&S obtained & sent to lab- started\n on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n Ineffective Coping\n Assessment:\n Difficult situation. Wife understanding-dealing with events. Mom very\n angry-thinks that son is not receiving appropriate care. Wanting to\n move son to . Focused on EW events-CPR resulting in broken ribs.\n When in pt room only communication with mom results in explosive\n outbursts.\n Action:\n Resident attempted to talk with Mom.\n Response:\n success. Mom wants Experts to care for son.\n :\n Contin to support as indicated & tolerated. SS consult.\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553638, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .H/O heart disease, congenital\n Assessment:\n Biventricular systolic dysfunction. TEE did not estimate EF. No\n ASD with well seated tricuspid valve ring (from corrective surgery\n). Consult from congenital cardiology \n new reccomendations.\n s/p cardiac arrest req. shock, pressors, intubation with witnessed\n emesis/aspiration.\n Stable overnight off vasopressin. Contin. on levophed IV\n Diuresing with lasix gtt 20mg/hr.\n Action:\n Weaned levo to .13mcq/k/min. lasix at 20mg/hr.\n Response:\n HR 90-100\ns SR/ST. BP 100-110/50\ns when sedated/calm. Up to 130-140/\n when more awake/stimulated.\n u/o 100-200cc/hr. neg. 1.2L for .\n Plan:\n Contin. Diuresis. Monitor lytes. Contin. To wean levo as tolerated.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n s/p CV arrest c/b profound hypoxia/ARDS/PNA requiring 100% FIO2, high\n peep and nitric oxide. Tolerating FIO2 wean and nitric oxide wean\n .\n Sats stable 95-98% on 60%/20peep and nitric oxide 10ppm\n Action:\n Discussed weaning nitric oxide in the eve with team\n given increase in\n VEA overnight, decided to hold off until AM to d/c (discussed with\n RT).\n Suctioned for small amts of thick tan secretions. cough.\n Depressed gag.\n Response:\n Maintained on current settings. Stable ABG and sats. Decreased BS.\n Breathing over vent. No RSBI.\n Plan:\n Plan to d/c nitric oxide in AM and monitor pt. carefully for de sats.\n . monitor sats and ABG.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.7po. MRSA nasal screen positive (from admission).\n Action:\n Contin. on vanco and zosyn for aspiration PNA. Tylenol q6hr.\n holding ibuprofen for renal/liver issues.\n Response:\n Contin. febrile. Cultures neg. to date. Last blood cultures from\n . WBC stable ~ 13.\n Plan:\n ? need to d/c right fem. Central line .\n Ventricular tachycardia, sustained\n Assessment:\n HR 90-100\ns SR with more freq. PVC\ns with couplets and rare triplet.\n Amio d/c\nd .\n K+/Mg+ WNL.\n Action:\n HO made aware. Fresh hands off pads placed on pt. contin. with\n bedside defibrillator monitor.\n Response:\n BP stable.\n Plan:\n Follow lytes. Monitor for increase in VEA.\n Altered mental status (not Delirium)\n Assessment:\n s/p paralytics and IV sedation. d/c\nd . eyes opening to painful\n stimuli such as with suctioning/coughing. Squeezed hands to command\n although not consistent. Moving arms up toward chest\n restraints\n placed. Moving legs on bed.\n Grimacing with oral care, suctioning. BP elevated to 140-160/ with\n stimulation.\n Action:\n Fentanyl 50mcq q2-4 hours and versed 1mg q2-4 hours\n Pt . verbally oriented to place , time and circumstance.\n Wrist restraints placed bilat. For safety.\n Response:\n Good effect with fent/versed. BP stable after boluses.\n Pt. appears to be able to follow some commands.\n Plan:\n Prn fent/versed as needed. Contin. To assess mental status, orient pt.\n and update family .\n Wife and mother stayed overnight again. Expressing some anxiety now\n that pt. is more awake, coughing etc.\n Support given and assurance given that pt. was being closely monitored\n with 1:1 nursing care etc.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553580, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Brown / Plug\n Sputum source/amount: Expectorated / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: on nitric oxide\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Specialized Gas Therapy\n Nitric Oxide\n PPM used: 20 ppm\n Indication: ARDS\n Effect of therapy: >=15% increase in PaO2[]\n Nitric Oxide trial:\n Comments: attempting to wean\n" }, { "category": "Respiratory ", "chartdate": "2151-03-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553922, "text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes; Comments: Pt desating while being\n repositioned or bathe.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH; Comments: Able to wean PEEP to 18 from 19, and FIO2 to\n 55%from 60%.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Homodynamic instability, underlying illness not resolved\n Esophageal balloon pressure obtained, it showed pt under PEEP by approx\n 8 cmH2O. Team still wants PEEP to be weaned, pt saturating 94% on PEEP\n 18 and FiO2 55%.\n" }, { "category": "Nursing", "chartdate": "2151-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553985, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure, renal failure, & aspiration PNA.\n Social:1/30-1^st night that patients wife & mother have gone home to\n spend night, both feeling more comfortable with care & that patient is\n starting to improve. Both have been seen by Social Service.\n Precautions:MSRA screen positive. All cultures-pending.\n ACCESS: RIJ TLC & R Radial Aline.\n Events1/29 Weaned off pressor on AM shift. Restarted @ approx 0400 \n due to decreased SBP/MAPS, Sats, & urinary output. Improved #\ns on\n Levophed 0.05mcg.kg.min.\n Ventricular tachycardia, sustained\n Assessment:\n Short runs VT noted. Minimal perfusion with VT.\n Action:\n Amiodarone po as ordered.\n Response:\n Continues with PVC\ns. Short runs VT noted.\n Plan:\n Ck AM Labs-replace as indicated. Contin po Amiodarone.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lasix gtt @ 20mg/hr. LS diminished throughout. Remains intubated-PEEP\n decreased to 18 with stable ABG. Fentanyl gtt up @ 50mcg/hr.\n Action:\n Lasix gtt. Fentanyl gtt.\n Response:\n Diuresing to Lasix gtt, but remains approx 4L positive over all.\n Stable Sats/ABGs. Comfortable on low dose fentanyl gtt-easily arousable\n to noxious stimuli/presently not following commands. Required Levophed\n restart due to decreased SBP, Sats, & urinary output.\n Plan:\n Cont diuresis. Contin low dose Fentanly gtt. ?Wean FiO2 or PEEP as\n tolerated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains febrile (low grade) despite cooling blanket, Tylenol/ASA, &\n Abx.\n Action:\n Cooling blanket. Abx. Antipyretics.\n Response:\n Remains febrile.\n Plan:\n Con\nt cooling blanket. Con\nt to monitor temps. Con\nt Abx &\n antipyretics.\n" }, { "category": "Physician ", "chartdate": "2151-03-08 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 553398, "text": "Date of service: \n Initial consultation: CCU\n Presenting complaint: Arrhythmia\n History of present illness: 39 yo M with PMH of ebstein's anomaly s/p\n tricuspid valve reconstruction, right and left sided congestive heart\n failure, presenting with palpitations which awoke him from sleep. The\n patient presented to the ED morning of where he was found to be\n in VT 230bpm. He began to experience chest pain, given amiodarone 150mg\n IV x 1, followed by amio gtt. He became diaphoretic, given etomidate\n and shocked with 200J, followed by vifib, becoming unresponsive and\n apneic. CPR was initiated, epinephrine x 1, CPR continued, shocked at\n 360J, returning to vtach @ 240. He was intubated, returning to sinus\n rhythm, aspriating vomit; noted to have right bronchus intubation and\n ETT repositioned. Due to hypotension SBP 40's started on levophed,\n neosynephrine, and vasopressin with BP increasing to 124/77.\n Subsequently developed left pneumothroax with attempted chest tube\n placement failed, had esophageal ballon placed. Early this morning had\n two recurrent runs of a WCT for which he was treated with amiodarone\n 300mg IV then with the second run received 100mg IV lidocaine with\n initiation of lidocaine gtt. EP consultation for management of\n ventricular tachyarrythmias.\n Past medical history: 1. Ebstein anomaly s/p TV reconstruction\n -- moderate to severe TR\n --RHF, RVEF 25% in \n 2. ASD s/p primary closure \n 3. LHF with evidence of noncompaction of LV, with LVEF 28% in \n 4. Hyperlipidemia\n 5. HTN\n 6. OSA/Obesity\n 7. DVT\n 8. Superficial phlebitis\n 9. Endocarditis w/ septic emboli to brain prior to Cardiac surgery\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies: NKDA\n No Known Drug Allergies\n Current medications: Home Meds:\n Allopurinol 300mg daily\n Atorvastation 20mg daily\n Colchicine 0.6mg daily\n Digoxin 0.125mg daily\n Lasix 40mg daily\n Lisinopril 10mg daily\n Claritin 10mg prn\n CURRENT MEDICATIONS:\n Lidocaine gtt\n Amio gtt\n Norepi gtt\n Vasopressin gtt\n Zosyn IV\n Vanco IV\n Midazolam IV gtt\n Irpratropium Neb\n Albuterol Neb\n Cardiovascular ROS\n Cardiovascular ROS Details: Inubated and Sedated.\n Review of Systems\n ROS Details: Intubated and Sedated.\n Social History\n Family history: Unable to obtain.\n Social history details: Unable to obtain\n Physical Exam\n Date and time of exam: 9:00am\n General appearance: Morbidly obese gentleman. Intubated and Sedated.\n Vital signs: per R.N.\n Height: 72 Inch, 183 cm\n Weight: d kg\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible)\n Respiratory: (Effort: Intubated), (Auscultation: Decreased breath\n sounds btl, no wheeze)\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: Sedated), (Muscle strength and tone: Sedated), (Edema: Right:\n 1+, Left: 1+)\n Skin: ( WNL)\n Labs\n 338\n 14.2\n 126\n 2.6\n 22\n 5.2\n 30\n 101\n 134\n 42.9\n 13.4\n [image002.jpg]\n 09:11 AM\n 11:09 AM\n 01:25 PM\n 02:56 PM\n 05:08 PM\n 08:29 PM\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n WBC\n 13.9\n 17.7\n 13.4\n Hgb\n 14.4\n 15.0\n 14.2\n Hct (Serum)\n 42.7\n 44.6\n 42.9\n Hct (Whole blood)\n 44\n Plt\n 326\n 326\n 338\n INR\n 1.9\n PTT\n 37.5\n Na+\n 134\n 134\n K + (Serum)\n 4.4\n 6.0\n 6.2\n 5.6\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 98\n 101\n HCO3\n 21\n 22\n BUN\n 26\n 30\n Creatinine\n 2.3\n 2.6\n Glucose\n 112\n 126\n CK\n 262\n 740\n CK-MB\n 7\n 9\n Troponin T\n 0.36\n 0.30\n O2 sat (arterial)\n 78\n 89\n 88\n 91\n ABG: 7.31 / 42 / 62 / / -4 Values as of 07:36 AM\n Tests\n ECG:\n -- sinus rhythm, RBBB, LAHB\n -- WCT 240bpm\n -- WCT 140bpm, RBBB, LAHB\n Telemetry:\n Current -- sinus rhythm 88 bpm\n Holter -- average sinus rhythm 100bpm, moderate frequent apb's\n and vpb's.\n Echocardiogram: -- dilated RV with depressed RVEF, global LV\n hypokinesis EF 30-35%, RA 7.2cm, 2+ TR\n Assessment and Plan\n 39 yo with PMH of Ebstein's anomaly s/p reconstruction, ASD s/p\n repair (), LV noncompaction, biventricular heart failure, morbid\n obesity, obstructive sleep apnea\n who is in critical condition following presentation with a wide complex\n tachycardia likely originating from sites of his past intracardiac\n surgery repairs, at this time requiring vasopressor\n support and mechanical ventilation:\n 1. Ventricular Tachycardia -- at this time continue current management\n with cardiopulmonary support with continuation ofamiodarone and\n lidocaine IV gtts. Monitor K and Mg levels\n with repletion as necessary. To discuss with EP attending regarding\n possible discontinuation of amiodarone and continuation of lidocaine\n gtt at this time. Once hemodynamically improving, with\n overall improvement will at that time discuss EPS with ablation\n therapy.\n ------ Protected Section ------\n Patient seen, discussed and examined with Dr. . The etiology of\n his VT remains uncertain, likely secondary to CM, since ASD repair and\n tricuspid ring wouldn not be expected to give an RVOT type VT. Also a\n question of whether his has junctional tachycardia secondary to meds or\n SVT due to a bypass tract, which is common in Ebsteins anomaly. Cause\n of myopathy uncertain, but possibly, tachy related. He will need an EPS\n when Hemodynamically stable. He may do better in NSR so I will give\n adenosine to stop current rhythm.\n Pager \n ------ Protected Section Addendum Entered By: , MD\n on: 14:41 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553630, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .H/O heart disease, congenital\n Assessment:\n Biventricular systolic dysfunction. TEE did not estimate EF. No\n ASD with well seated tricuspid valve ring (from corrective surgery\n). Consult from congenital cardiology \n new reccomendations.\n s/p cardiac arrest req. shock, pressors, intubation with witnessed\n emesis/aspiration.\n Stable overnight off vasopressin. Contin. on levophed IV\n Action:\n Weaned levo to\n Response:\n HR 90-100\ns SR/ST. BP 100-110/50\ns when sedated/calm. Up to 130-140/\n when more awake/stimulated.\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.7po. MRSA nasal screen positive (from admission).\n Action:\n Contin. on vanco and zosyn for aspiration PNA. Tylenol q6hr.\n holding ibuprofen for renal/liver issues.\n Response:\n Contin. febrile. Cultures neg. to date. Last blood cultures from\n . WBC stable ~ 13.\n Plan:\n ? need to d/c right fem. Central line .\n Ventricular tachycardia, sustained\n Assessment:\n HR 90-100\ns SR with more freq. PVC\ns with couplets and rare triplet.\n Amio d/c\nd .\n K+/Mg+ WNL.\n Action:\n HO made aware. Fresh hands off pads placed on pt. contin. with\n bedside defibrillator monitor.\n Response:\n BP stable.\n Plan:\n Follow lytes.\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553632, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .H/O heart disease, congenital\n Assessment:\n Biventricular systolic dysfunction. TEE did not estimate EF. No\n ASD with well seated tricuspid valve ring (from corrective surgery\n). Consult from congenital cardiology \n new reccomendations.\n s/p cardiac arrest req. shock, pressors, intubation with witnessed\n emesis/aspiration.\n Stable overnight off vasopressin. Contin. on levophed IV\n Action:\n Weaned levo to\n Response:\n HR 90-100\ns SR/ST. BP 100-110/50\ns when sedated/calm. Up to 130-140/\n when more awake/stimulated.\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.7po. MRSA nasal screen positive (from admission).\n Action:\n Contin. on vanco and zosyn for aspiration PNA. Tylenol q6hr.\n holding ibuprofen for renal/liver issues.\n Response:\n Contin. febrile. Cultures neg. to date. Last blood cultures from\n . WBC stable ~ 13.\n Plan:\n ? need to d/c right fem. Central line .\n Ventricular tachycardia, sustained\n Assessment:\n HR 90-100\ns SR with more freq. PVC\ns with couplets and rare triplet.\n Amio d/c\nd .\n K+/Mg+ WNL.\n Action:\n HO made aware. Fresh hands off pads placed on pt. contin. with\n bedside defibrillator monitor.\n Response:\n BP stable.\n Plan:\n Follow lytes.\n Altered mental status (not Delirium)\n Assessment:\n s/p CV arrest c/b profound hypoxia/ARDS requiring 100% FIO2, high peep\n and nitric oxide. Tolerating FIO2 wean and nitric oxide wean .\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553634, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .H/O heart disease, congenital\n Assessment:\n Biventricular systolic dysfunction. TEE did not estimate EF. No\n ASD with well seated tricuspid valve ring (from corrective surgery\n). Consult from congenital cardiology \n new reccomendations.\n s/p cardiac arrest req. shock, pressors, intubation with witnessed\n emesis/aspiration.\n Stable overnight off vasopressin. Contin. on levophed IV\n Action:\n Weaned levo to\n Response:\n HR 90-100\ns SR/ST. BP 100-110/50\ns when sedated/calm. Up to 130-140/\n when more awake/stimulated.\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n s/p CV arrest c/b profound hypoxia/ARDS requiring 100% FIO2, high peep\n and nitric oxide. Tolerating FIO2 wean and nitric oxide wean .\n Sats stable 95-98% on 60%/20peep and nitric oxide 10ppm\n Action:\n Discussed weaning nitric oxide in the eve with team\n given increase in\n VEA overnight, decided to hold off until AM to d/c (discussed with\n RT).\n Suctioned for small amts of thick tan secretions.\n Response:\n Maintained on current settings. Stable ABG and sats.\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TM 101.7po. MRSA nasal screen positive (from admission).\n Action:\n Contin. on vanco and zosyn for aspiration PNA. Tylenol q6hr.\n holding ibuprofen for renal/liver issues.\n Response:\n Contin. febrile. Cultures neg. to date. Last blood cultures from\n . WBC stable ~ 13.\n Plan:\n ? need to d/c right fem. Central line .\n Ventricular tachycardia, sustained\n Assessment:\n HR 90-100\ns SR with more freq. PVC\ns with couplets and rare triplet.\n Amio d/c\nd .\n K+/Mg+ WNL.\n Action:\n HO made aware. Fresh hands off pads placed on pt. contin. with\n bedside defibrillator monitor.\n Response:\n BP stable.\n Plan:\n Follow lytes.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1058829, "text": " 6:16 PM\n CT CHEST W/O CONTRAST; Clip # \n Reason: PNEUMOTHORAX, CHEST TUBE PLACEMENT\n Admitting Diagnosis: CARDIAC ARREST\n ********************************* CPT Codes ********************************\n * CT CHEST W/O CONTRAST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pneumothorax after chest compressions. Unable to place\n bedside chest tube, mechanical ventilation and ongoing risk for tension\n pneumothorax\n REASON FOR THIS EXAMINATION:\n place chest tube\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 11:42 AM\n No residual pneumothorax in the covered portion of the chest. One air bubble\n in the anterior mediastinum. No pericardial effusion or mediastinal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST\n\n REASON FOR EXAM: 39-year-old man with pneumothorax after chest compression,\n unable to place bedside chest tube, mechanical ventilation and ongoing risk\n for tension pneumothorax, please place chest tube.\n\n TECHNIQUE: Chest MDCT of the upper two-thirds of the chest was performed\n using 5-mm axial slice thickness.\n\n FINDINGS: This study was performed for localization prior to chest tube\n placement.\n\n In comparison to earlier today, there is no residual pneumothorax. One tiny\n air bubble is in the anterior mediastinum. Note that only the upper two-\n thirds of the chest were covered. There is no pericardial effusion or\n mediastinal hematoma. Subcutaneous hematoma was not included in the field of\n view.\n\n There is no other change since earlier today in bilateral dependent opacities,\n right peribronchial consolidation, severe cardiomegaly and rib fractures.\n\n IMPRESSION:\n 1. No residual pneumothorax in the upper two-thirds of the chest. One\n residual air bubble in the mediastinum. No chest tube was installed.\n\n 2. No other change since earlier today.\n\n (Over)\n\n 6:16 PM\n CT CHEST W/O CONTRAST; Clip # \n Reason: PNEUMOTHORAX, CHEST TUBE PLACEMENT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1058830, "text": ", J. 6:16 PM\n CT CHEST W/O CONTRAST; Clip # \n Reason: PNEUMOTHORAX, CHEST TUBE PLACEMENT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pneumothorax after chest compressions. Unable to place\n bedside chest tube, mechanical ventilation and ongoing risk for tension\n pneumothorax\n REASON FOR THIS EXAMINATION:\n place chest tube\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No residual pneumothorax in the covered portion of the chest. One air bubble\n in the anterior mediastinum. No pericardial effusion or mediastinal hematoma.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059190, "text": " 11:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumo thorax change on left, and for infiltrat\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with VT, now intubated, sedated, febrile\n REASON FOR THIS EXAMINATION:\n evaluate for pneumo thorax change on left, and for infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM\n PFI: No pneumothorax. Marked cardiac enlargement as before but no pulmonary\n vascular congestion. Possible atelectasis in left lower lobe area covered by\n enlarged heart, recommend lateral view to differentiate between atelectasis\n and pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Evaluate for pneumothorax. Patient with ventricular tachycardia,\n now intubated, sedated and febrile.\n\n FINDINGS: AP single view chest with patient in semi-upright position is\n analyzed in direct comparison with a similar preceding study dated . The patient remains intubated, the ETT terminating in the trachea in\n unchanged position. The same holds for NG tube which reaches far below the\n diaphragm. No pneumothorax can be identified. Status post sternotomy and the\n presence of a semi-circular metallic ring in the bicuspid valve area is\n consistent with a history of old tricuspid annuloplasty. Comparison\n demonstrates that whereas the previous study the patient was slightly rotated\n to the right he is now straight position. The generally enlarged mediastinal\n and cardiac structures reach now the left-sided lateral wall consistent with\n previously (including CT) identified marked cardiac enlargement consistent\n with Ebstein deformity. The accessible pulmonary vasculature does not\n demonstrate any pulmonary congestive pattern and no pneumothorax is present in\n the apical area. There is a somewhat crowded appearance of the pulmonary\n vasculature in the retrocardiac space on the left base consistent with\n atelectasis. A lateral view would be helpful to evaluate this area for\n possible infiltrates versus pleural effusion. Review of the latest chest CT\n of demonstrated no evidence of pleural effusion but rather sizable\n atelectasis bilaterally in the dependent pulmonary lower lobe areas.\n\n IMPRESSION: Stable chest findings paying attention to different patient\n position. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059191, "text": ", J. 11:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumo thorax change on left, and for infiltrat\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with VT, now intubated, sedated, febrile\n REASON FOR THIS EXAMINATION:\n evaluate for pneumo thorax change on left, and for infiltrates\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax. Marked cardiac enlargement as before but no pulmonary\n vascular congestion. Possible atelectasis in left lower lobe area covered by\n enlarged heart, recommend lateral view to differentiate between atelectasis\n and pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1058776, "text": " 10:08 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: INTRACRANIAL ABSCESS, OLD CVA, ANEURYSM OR MALFORMATION\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congenital heart disease, hx of LE DVTs and recent leg\n swelling and intracranial abscess; now admitted with VT, intubated, needs\n anticoagulation\n REASON FOR THIS EXAMINATION:\n CTA of chest and head to r/o PE in chest, and of head to r/u intracranial\n pathology of old CVA, aneursym, or malformation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp 3:29 PM\n No acute IC process - await recons GWlms\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male with congenital heart disease, history of lower\n extremity DVT and recent leg swelling and intracranial abscess. Now with VT\n and needs anticoagulation. Rule out intracranial pathology.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed through\n the brain during infusion of Omnipaque intravenous contrast material. Images\n were processed on a separate workstation with display of curved reformats,\n volume-rendered images, and maximum intensity projection images.\n\n COMPARISON: No prior study available for comparison.\n\n FINDINGS:\n\n HEAD CT: There is no evidence of acute hemorrhage, edema, mass, mass effect,\n or infarction. Of note, there is a low-attenuation area in the right\n occipital pole, consistent with encephalomalacia with an associated ex vacuo\n enlargement of the right lateral ventricle trigone, most likely related to\n prior insult.\n\n Air-fluid levels in the paranasal sinuses is noted and likely reflective of\n the patient's intubated status.\n\n HEAD CTA: The carotid and vertebral arteries and their major branches are\n patent without evidence of stenosis. There is no evidence of aneurysm\n formation or other vascular abnormality.\n\n IMPRESSION:\n 1. No acute intracranial pathology.\n\n 2. Encephalomalacia of the right occipital pole with associated ex vacuo\n dilatation of the right lateral ventricular occipital suggestive of prior\n cerebral injury.\n (Over)\n\n 10:08 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: INTRACRANIAL ABSCESS, OLD CVA, ANEURYSM OR MALFORMATION\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1058778, "text": " 10:09 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA of chest and head to r/o PE in chest, and of head to r/u\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congenital heart disease, hx of LE DVTs and recent leg\n swelling and intracranial abscess; now admitted with VT, intubated, needs\n anticoagulation\n REASON FOR THIS EXAMINATION:\n CTA of chest and head to r/o PE in chest, and of head to r/u intracranial\n pathology of old CVA, aneursym, or malformation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST WITH AND WITHOUT CONTRAST\n\n REASON FOR EXAM: 39-year-old man with congenital heart disease. History of\n LEDVTs and recent leg swelling and intracranial abscess, now admitted with VT\n intubated, needs anticoagulation, rule out PE.\n\n TECHNIQUE: Chest MDCT was performed following 80 cc of intravenous Optiray\n using 5-mm and 2.5-mm axial slice thickness. Coronal, sagittal, and MIP\n reformations were also obtained.\n\n FINDINGS: No prior studies for comparison.\n\n Prior sternotomy was performed for tricuspid plasty. ETT is in expected\n position. The nasogastric tube tip is not imaged.\n\n Mediastinal lipomatosis is severe. There is no pulmonary embolism to the\n segmental level. There is no aortic dissection.\n\n Cardiomegaly is severe with marked enlargement of the right atrium and right\n ventricle in this patient with known Ebstein malformation.\n\n Scattered mediastinal lymph nodes are up to 12 mm in the paraaortic region and\n 1 cm in the right paratracheal region, likely reactive. Moderate bilateral\n dependent opacities, right upper and right middle lobe peribronchial opacities\n could be due to massive aspiration and atelectasis.\n\n A left pneumothorax is small, likely related to acute left third and fourth\n rib fractures. Other rib deformities are bilateral with no frank visible\n fracture. There is no pleural or pericardial effusion. Airways are patent to\n the subsegmental level.\n\n Prior rib resection on the right is unchanged since a chest x-ray from ,\n with minimal lung herniation, likely postoperative.\n\n This study was not tailored for subdiaphragmatic evaluation except to note\n right hepatic vein to middle hepatic vein shunt in this patient with enlarged\n hepatic veins and IVC. A soft tissue filling defect in the abnormal\n connection between these two hepatic veins.\n (Over)\n\n 10:09 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA of chest and head to r/o PE in chest, and of head to r/u\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Small left pneumothorax, likely related to acute left rib fractures. Other\n rib deformities are bilateral.\n\n 2. Bibasilar and peribronchial opacities, could be due to massive aspiration,\n associated with atelectasis.\n\n 3. Severe cardiomegaly with marked enlargement of right atrium and right\n ventricle in this patient with known Ebstein malformation and prior sternotomy\n for tricuspid plasty.\n\n 4. Mediastinal lipomatosis.\n\n 5. Venous shunt between the right and the middle hepatic veins, could be due\n to old Budd-Chiari disease. Tiny filling defect in the abnormal connection\n could be branching vessels or thrombus, likely old..\n\n Results were discussed on the phone with Dr. at 1 p.m.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058744, "text": " 5:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tub placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with arrest and intubation\n REASON FOR THIS EXAMINATION:\n eval for tub placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Arrest with intubation.\n\n COMPARISON: chest radiograph.\n\n FINDINGS: Patient is intubated with endotracheal tube tip within the right\n mainstem bronchus. Recommend withdrawing endotracheal tube approximately 5\n cm. NG tube courses through the mediastinum with tip below the diaphragm out\n of field of view. Evaluation of the lungs is limited by low lung volumes.\n Veil like opacity over the left lung is most likely atelectasis after right\n mainstem intubation.\n\n New, marked enlargement of the cardiac silouette and severe widening of the\n superior mediastinum could be due to pericardial effusion with tamponade,\n aortic dissection and/or mediastinal hematoma, before being ascribed to\n distension of central venous circulation exaggerated by supine positionning.\n Dr discussed with the physician caregiver that transesophageal echo be\n performed to exclude these diagnostic possiblities.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058821, "text": " 4:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval balloon placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with esophageal balloon placed\n REASON FOR THIS EXAMINATION:\n eval balloon placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Esophageal balloon placement.\n\n COMPARISON: , 2:41 p.m.\n\n FINDINGS: Status post esophageal balloon placement. No evidence of\n complications. Otherwise, unchanged radiographic appearance as compared to\n the previous radiograph.\n\n\n" }, { "category": "Physician ", "chartdate": "2151-03-09 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553545, "text": "CCU Intern Progress Note:\n History of Present Illness\n \n - continues to be febrile 102-103, received tylenol 2gm max/day, no\n motrin ARF/CRF, on vanc/zosyn\n - UOP improved, urine lytes showed FeBUN 16.7% (<35) --> prerenal\n - vanc trough = 6.6 (LOW) --> gave 500mg IV x 1 and increased daily\n dose to 1250mg IV q24h\n - TEE - No atrial septal defect by 2D or color Doppler. Well seated\n tricuspid annular ring with mild-moderate tricuspid regurgitation.\n Severe right ventricular cavity enlargement with depressed\n biventricular systolic function.\n - AXR, CXR - stable (though difficult to see anything); CXR -\n Unchanged cardiomegaly with bilateral retrocardiac atelectasis,\n unchanged mediastinal widening.\n - evaluated by BACH service ( congenital cards) -\n continue management (nothing revolutionary)\n - pulm - continue iNO, consider Swan-Ganz for pressures\n -still on nitric oxide, vasopressin and levo\n -tele- frequent 3-4 beat runs of NSVT\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 40.4 C\n Tmax F last 24 hours: 104.8 F\n T current C: 39 C\n T current F: 102.2 F\n Previous day:\n Intake: 5,273 mL\n Output: 2,123 mL\n Fluid balance: 3,150 mL\n Today:\n Intake: 1,050 mL\n Output: 940 mL\n Fluid balance: 110 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 32, FiO2 70%, SpO2 99%, nitric oxide\n at 20\n VS: HR 81, 91-93; BP 98-61; 96-110/61-79\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 239\n 13.0\n 170\n 3.2\n 23\n 4.4\n 48\n 96\n 129\n 38.2\n 13.2\n [image002.jpg]\n ABG 7.4/36/83/23\n ALT 1211, AST 1132\n AP 53\n T Bili 1.8\n Alb 3.3\n Ca 8.2, mag 1.7, phos 5.0\n FDP 80-160, Fibrinogen 546\n Urine lytes- UreaN 199, Cr 93, Na 38, Osml 346\n Sputum cx\n oral flora prelim\n Urine cx- 8000 GP bacteria\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n 04:53 PM\n 03:33 AM\n WBC\n 13.4\n 14.1\n 13.2\n Hgb\n 14.2\n 14.1\n 13.0\n Hct (Serum)\n 42.9\n 41.0\n 38.2\n Plt\n 338\n 270\n 239\n INR\n 1.9\n 2.5\n 2.2\n PTT\n 37.5\n 39.6\n 42.7\n Na+\n 134\n 132\n 129\n K + (Serum)\n 6.2\n 5.6\n 5.3\n 4.4\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 101\n 99\n 96\n HCO3\n 22\n 23\n 23\n BUN\n 30\n 41\n 48\n Creatinine\n 2.6\n 3.2\n 3.2\n Glucose\n 126\n 129\n 170\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n 92\n ABG: 7.40 / 36 / 83 / / -1 Values as of 03:44 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Intrapulmonary shunt\n through consolidations still possibility. However, patient also seems\n to have improved FiO2 requirement after starting furosemide gtt\n yesterday.\n - Wean FiO2, nitric and PEEP as tolerated.\n - Discontinue paralytics as tolerated by ability to ventilate.\n - continuing lasix gtt, aim net negative I/O, start by increasing lasix\n gtt and IV metolazone\n - ARDS net protocol\n - nebs\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs.\n - Appreciate electrophysiology\n - Discontinue amiodarone today\n - may need EP study and possible ablation\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Discontinue vasopressin today as tolerated, and titrate levophed if\n able.\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 4, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low\n - follow sputum, urine, and blood cxs\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - consider diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen\n - Consider Tube feeds if good bowel function\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone\n - Discontinue amiodarone\n - monitor liver function\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - patient relations/advocate consults\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Physician ", "chartdate": "2151-03-09 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553546, "text": "CCU Intern Progress Note:\n History of Present Illness\n \n - continues to be febrile 102-103, received tylenol 2gm max/day, no\n motrin ARF/CRF, on vanc/zosyn\n - UOP improved, urine lytes showed FeBUN 16.7% (<35) --> prerenal\n - vanc trough = 6.6 (LOW) --> gave 500mg IV x 1 and increased daily\n dose to 1250mg IV q24h\n - TEE - No atrial septal defect by 2D or color Doppler. Well seated\n tricuspid annular ring with mild-moderate tricuspid regurgitation.\n Severe right ventricular cavity enlargement with depressed\n biventricular systolic function.\n - AXR, CXR - stable (though difficult to see anything); CXR -\n Unchanged cardiomegaly with bilateral retrocardiac atelectasis,\n unchanged mediastinal widening.\n - evaluated by BACH service ( congenital cards) -\n continue management (nothing revolutionary)\n - pulm - continue iNO, consider Swan-Ganz for pressures\n -still on nitric oxide, vasopressin and levo\n -tele- frequent 3-4 beat runs of NSVT\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 40.4 C\n Tmax F last 24 hours: 104.8 F\n T current C: 39 C\n T current F: 102.2 F\n Previous day:\n Intake: 5,273 mL\n Output: 2,123 mL\n Fluid balance: 3,150 mL\n Today:\n Intake: 1,050 mL\n Output: 940 mL\n Fluid balance: 110 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 32, FiO2 70%, SpO2 99%, nitric oxide\n at 20\n VS: HR 81, 91-93; BP 98-61; 96-110/61-79\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 239\n 13.0\n 170\n 3.2\n 23\n 4.4\n 48\n 96\n 129\n 38.2\n 13.2\n [image002.jpg]\n ABG 7.4/36/83/23\n ALT 1211, AST 1132\n AP 53\n T Bili 1.8\n Alb 3.3\n Ca 8.2, mag 1.7, phos 5.0\n FDP 80-160, Fibrinogen 546\n Urine lytes- UreaN 199, Cr 93, Na 38, Osml 346\n Sputum cx\n oral flora prelim\n Urine cx- 8000 GP bacteria\n 09:49 PM\n 03:01 AM\n 03:25 AM\n 07:36 AM\n 09:16 AM\n 11:06 AM\n 01:18 PM\n 02:59 PM\n 04:53 PM\n 03:33 AM\n WBC\n 13.4\n 14.1\n 13.2\n Hgb\n 14.2\n 14.1\n 13.0\n Hct (Serum)\n 42.9\n 41.0\n 38.2\n Plt\n 338\n 270\n 239\n INR\n 1.9\n 2.5\n 2.2\n PTT\n 37.5\n 39.6\n 42.7\n Na+\n 134\n 132\n 129\n K + (Serum)\n 6.2\n 5.6\n 5.3\n 4.4\n K + (Whole blood)\n 5.3\n 5.2\n Cl\n 101\n 99\n 96\n HCO3\n 22\n 23\n 23\n BUN\n 30\n 41\n 48\n Creatinine\n 2.6\n 3.2\n 3.2\n Glucose\n 126\n 129\n 170\n O2 sat (arterial)\n 91\n 96\n 97\n 97\n 92\n ABG: 7.40 / 36 / 83 / / -1 Values as of 03:44 AM\n Assessment and Plan\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Intrapulmonary shunt\n through consolidations still possibility. However, patient also seems\n to have improved FiO2 requirement after starting furosemide gtt\n yesterday.\n - Wean FiO2, nitric and PEEP as tolerated.\n - Discontinue paralytics as tolerated by ability to ventilate.\n - continuing lasix gtt, aim net negative I/O, start by increasing lasix\n gtt and IV metolazone\n - ARDS net protocol\n - nebs\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs.\n - Appreciate electrophysiology\n - Discontinue amiodarone today\n - may need EP study and possible ablation\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - Discontinue vasopressin today as tolerated, and titrate levophed if\n able.\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - MRSA screen and precautions\n - Continue vanco and zosyn, day 4, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low\n - follow sputum, urine, and blood cxs\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold metoprolol, lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - consider diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen\n - Consider Tube feeds if good bowel function\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone\n - Discontinue amiodarone\n - monitor liver function\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - patient relations/advocate consults\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: NPO\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Critical care time 60 minutes. Remains critically ill, intubated and\n on pressors but oxygenation slightly better and making urine. Will\n continue diuresis and attempt to lighten sedation a bit now that\n paralytics are off. Will stop Amiodarone in light of LFT abnormalities\n and junctional rhythm. Likely etiology of liver abnormalities, though\n is hepatic congestion from RV dysfunction and from hepatic injury due\n to arrest.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:05 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553616, "text": "Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Resp. failure/ARDS secondary to pneumonia. requiring high peep and\n FIO2. remains on 70% FIO2, 20peep and nitric oxide\n Action:\n No vent changes. Suctioned for scant thick tan secretions.\n Response:\n AM ABG 7.40/36/83. sats 93-96%. LS diminished bases, clear upper\n Plan:\n Follow with pulmonary recs. ? wean nitric oxide vs FIO2. follow\n sats.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 102-103.6po. sputum Cx GPC in prs. All other cultures pnd. MRSA\n screen pnd.\n Vanco trough 6.6\n Action:\n Remains on cooling blanket. Tylenol q6hr.\n Given additional 500mg vanco IV at 0200. dose increased to 1250 mg\n next dose 2100.\n Also contin. on zysyn\n Response:\n Fever continues. WBC unchanged 13.2.\n Plan:\n Await culture results. Broad spectrum AB. Follow vanco levels.\n .H/O heart disease, congenital\n Assessment:\n No SVT or VT. BP 100-120/60\ns. HR 80\ns accelerated junctional.\n u/o 100-200cc/hr on lasix gtt.\n Action:\n Amioderone at 1mg/min. levophed weaned to .20mcq/k/min.\n Response:\n Stable BP. No hypotension. Tolerated turning and other care.\n Plan:\n Follow with EP for plan. Contin. to wean levo as tolerated. Contin.\n amio gtt. Monitor lytes.\n" }, { "category": "Nursing", "chartdate": "2151-03-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553628, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .H/O heart disease, congenital\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2151-03-10 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 553710, "text": "Subjective\n Intub, sedated\n Objective\n Pertinent medications: lasix, vasopressin, norepinephrine, colace,\n lactulose, protonix, hep, abx, colace, others noted\n Labs:\n Value\n Date\n Glucose\n 143 mg/dL\n 05:00 AM\n BUN\n 60 mg/dL\n 05:00 AM\n Creatinine\n 2.5 mg/dL\n 05:00 AM\n Sodium\n 135 mEq/L\n 05:00 AM\n Potassium\n 4.1 mEq/L\n 05:00 AM\n Chloride\n 99 mEq/L\n 05:00 AM\n TCO2\n 25 mEq/L\n 05:00 AM\n PO2 (arterial)\n 96. mm Hg\n 05:14 AM\n PCO2 (arterial)\n 38 mm Hg\n 05:14 AM\n pH (arterial)\n 7.44 units\n 05:14 AM\n pH (urine)\n 5.0 units\n 10:34 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 05:14 AM\n Albumin\n 3.3 g/dL\n 03:33 AM\n Calcium non-ionized\n 8.2 mg/dL\n 05:00 AM\n Phosphorus\n 4.2 mg/dL\n 05:00 AM\n Ionized Calcium\n 1.09 mmol/L\n 03:25 AM\n Magnesium\n 2.2 mg/dL\n 05:00 AM\n ALT\n 1286 IU/L\n 05:00 AM\n Alkaline Phosphate\n 54 IU/L\n 05:00 AM\n AST\n 864 IU/L\n 05:00 AM\n Total Bilirubin\n 1.7 mg/dL\n 05:00 AM\n WBC\n 14.4 K/uL\n 05:00 AM\n Hgb\n 12.9 g/dL\n 05:00 AM\n Hematocrit\n 38.0 %\n 05:00 AM\n Current diet order / nutrition support: Nutren Pulm at 10ml/hr, TF c/s\n GI: absent BS,\n Assessment of Nutritional Status\n 39M w/ h/o Ebstein's anomaly, s/p tricuspid valve reconstruction, CHF,\n presenting with unstable ventricular tachycardia, s/p resuscitation\n with return to sinus tachycardia, now intubated d/t respiratory\n failure. Pt started on TF last night, currently tol TF at 10ml/hr,\n spoke to RN, pt tol TF so far, residual <10ml despite unable to hear\n BS. Noted pt is fluid overload, on Lasix gtt (goal -IL.day).\n Medical Nutrition Therapy Plan - Recommend the Following\n Goal TF: Nutren Pulm @ 50ml/hr +40g Beneprotein , start at 10ml and\n adv as tol , this will provide 1940kcal and 116g pro (21.2kcal/1.27g\n pro/KG adj BW)\n Check chemistry 10 panel daily, replete prn\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u re poc, please page if has ?\n" }, { "category": "Physician ", "chartdate": "2151-03-10 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553688, "text": "TITLE:\n History of Present Illness\n - off amio elevated LFTs. Junctional rhythm changed to NSR, but\n increasing ectopy overnight.\n - lasix increased to 20 in the morning and continued all day\nnegative 1\n L\n - NO at 10 all day and stopped in the evening, FiO2 weaned to 60%\n - midazolam gtt off (bolus 1-2 mg q2-4h), also getting fentanyl 50 mcg\n ~q2h\n - vasopressin stopped, levophed decreased to .1 mcg/kg/min\n - no bowel sounds, no bowel movement\nincreased bowel regimen\n - started TF, nutrition consult\n - vitamin K repleted\n - still febrile to 101.7\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 39.2 C\n Tmax F last 24 hours: 102.6 F (0800 )\n T current C: 38.6 C\n T current F: 101.4 F\n Previous day:\n Intake: 2,631 mL\n Output: 3,820 mL\n Fluid balance: -1,189 mL\n Today:\n Intake: 321 mL\n Output: 680 mL\n Fluid balance: -359 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 28, FiO2 60%, SpO2 95%, nitric oxide\n at 10\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 249\n 12.9\n 137\n 3.1\n 23\n 4.6\n 55\n 96\n 132\n 38.0\n 14.4\n [image002.jpg]\n 04:53 PM\n 03:33 AM\n 08:43 AM\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n WBC\n 13.2\n 14.4\n Hgb\n 13.0\n 12.9\n Hct (Serum)\n 38.2\n 38.0\n Plt\n 239\n 249\n INR\n 2.2\n PTT\n 42.7\n Na+\n 129\n 132\n K + (Serum)\n 4.4\n 4.6\n Cl\n 96\n 96\n HCO3\n 23\n 23\n BUN\n 48\n 55\n Creatinine\n 3.2\n 3.1\n Glucose\n 170\n 137\n CK\n 4046\n O2 sat (arterial)\n 92\n 98\n 94\n 89\n 94\n 97\n 98\n ABG: 7.44 / 38 / 97 / / 1 Values as of 05:14 AM\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO. Compliance improving.\n - NO down to 5 PPM, attempt to d/c today,wean Fi02 preferentially over\n PEEP as tolerated. Consider decreasing PEEP once Fi02 <50%.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy\n - Appreciate electrophysiology input, have signed off.\n - off amiodatrone\n - Agressively wean and attempt to d/c levophed to improve ectopy,\n tolerate MAP >60. If tolerates stopping pressors and has room on BP\n with persistent ectopy, increase BB and consider dialing down on PEEP\n to leave BP room for BB. Trial of IV lopressor 2.5-5mg IV Q4 hours\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today, decreaseing PEEP if necessary. Attempt to add BB\n as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - fem line out, consider PICC once afebrile vs CVL line under fluoro/\n in cath lab.\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 5, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low, next\n level tonight\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - Discontinued amiodarone\n - monitor liver function\n -got vitamin K yesterday\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: right femoral line, art line. Fever curve decreasing, will\n monitor femoral blood cultures. Fem line out , attempt CVL\n placement today.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n" }, { "category": "Social Work", "chartdate": "2151-03-11 00:00:00.000", "description": "Social Work Progress Note", "row_id": 553902, "text": "SOCIAL WORK: Case discussed with team. RN reports family seem\n less distressed re: pt's treatment. SW met with pt's wife \n and mother in family waiting area. They spoke about\n pt's progress being up and down, and today they are more worried\n about pt's status. Wife tearful, expressing fear of unknown.\n She spoke of challenges of being present to pt here in hospital,\n and wanting to attend to her children, particularly their 2 year\n old, who has not tolerated her absence well. Pt's teenage\n children visited last night, and wife feels that went well as she\n had adequately prepared them in advance. SW normalized wife's\n struggles and fears and offered empathic support. She also spoke\n of challenges of trying to keep the many friends and family\n updated. SW provided link to care pages and advised wife she\n could use internet access at the Learning Center to set it up.\n Also arranged use of showers at Be-Well for wife and mother as\n they have been staying with pt in the hospital.\n A/P: family remain understandably worried about uncertainty of\n pt's illness, but less frustrated with care and communication.\n SW will continue to follow with team.\n , LICSW\n" }, { "category": "Physician ", "chartdate": "2151-03-10 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 553708, "text": "TITLE:\n History of Present Illness\n - off amio elevated LFTs. Junctional rhythm changed to NSR, but\n increasing ectopy overnight.\n - lasix increased to 20 in the morning and continued all day\nnegative 1\n L\n - NO at 10 all day and stopped in the evening, FiO2 weaned to 60%\n - midazolam gtt off (bolus 1-2 mg q2-4h), also getting fentanyl 50 mcg\n ~q2h\n - vasopressin stopped, levophed decreased to .1 mcg/kg/min\n - no bowel sounds, no bowel movement\nincreased bowel regimen\n - started TF, nutrition consult\n - vitamin K repleted\n - still febrile to 101.7\n Medications\n Unchanged\n Physical Exam\n Tmax C last 24 hours: 39.2 C\n Tmax F last 24 hours: 102.6 F (0800 )\n T current C: 38.6 C\n T current F: 101.4 F\n Previous day:\n Intake: 2,631 mL\n Output: 3,820 mL\n Fluid balance: -1,189 mL\n Today:\n Intake: 321 mL\n Output: 680 mL\n Fluid balance: -359 mL\n Vent- CMV/AS PEEP 20, TV 450, RR 28, FiO2 60%, SpO2 95%, nitric oxide\n at 10\n VS: BP 119/69, HR 101, RR 28, O2 Sat 95%\n Gen: Obese, sedated, intubated, paralyzed\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: ET tube in place, unable to assess oral\n cavity\n Neck: (Jugular veins: Not visible), (Thyroid: WNL)- very large neck\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Auscultation: diminished on bilaterally, L>R\n Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:\n WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),\n (Pulsatile mass: No), (Hepatosplenomegaly: No)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit), fem line in place\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+),\n (Edema: Right: 0, Left: 0)\n Warm extremities\n Labs\n 249\n 12.9\n 137\n 3.1\n 23\n 4.6\n 55\n 96\n 132\n 38.0\n 14.4\n [image002.jpg]\n 04:53 PM\n 03:33 AM\n 08:43 AM\n 10:14 AM\n 11:42 AM\n 03:19 PM\n 03:29 PM\n 08:25 PM\n 05:00 AM\n 05:14 AM\n WBC\n 13.2\n 14.4\n Hgb\n 13.0\n 12.9\n Hct (Serum)\n 38.2\n 38.0\n Plt\n 239\n 249\n INR\n 2.2\n PTT\n 42.7\n Na+\n 129\n 132\n K + (Serum)\n 4.4\n 4.6\n Cl\n 96\n 96\n HCO3\n 23\n 23\n BUN\n 48\n 55\n Creatinine\n 3.2\n 3.1\n Glucose\n 170\n 137\n CK\n 4046\n O2 sat (arterial)\n 92\n 98\n 94\n 89\n 94\n 97\n 98\n ABG: 7.44 / 38 / 97 / / 1 Values as of 05:14 AM\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n INEFFECTIVE COPING\n VENTRICULAR TACHYCARDIA, SUSTAINED\n .H/O HEART DISEASE, CONGENITAL\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, )\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n 39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n # Respiratory Failure: Primarily hypoxemic. Shunt versus volume\n overload. Improvement with nitric suggests some shunt physiology,\n although intracardiac shunt not evident on TEE. Pt continues to\n improve, with decreasing Fi02 and NO. Compliance improving.\n - NO down to 5 PPM, attempt to d/c today,wean Fi02 preferentially over\n PEEP as tolerated. Consider decreasing PEEP once Fi02 <50%.\n - continuing lasix gtt, aim net negative I/O 500-1L , start by\n increasing lasix gtt, pt tolerated increased diuresis well with\n improved oxygenation.\n - ARDS net protocol\n - nebs\n - lytes with diuresis\n # Ventricular Tachycardia: Likely result of scarring from ebstein\n anomaly/repairs. Increasing ectopy\n - Appreciate electrophysiology input, have signed off.\n - off amiodatrone\n - Agressively wean and attempt to d/c levophed to improve ectopy,\n tolerate MAP >60. If tolerates stopping pressors and has room on BP\n with persistent ectopy, increase BB and consider dialing down on PEEP\n to leave BP room for BB. Trial of IV lopressor 2.5-5mg IV Q4 hours\n - may need EP study and possible ablation in future.\n # Hypotension: Initially secondary to VT, now probably contribution\n from sedatives, positive pressure ventilation especially in the setting\n of marked RV dysfunction. also be intravscularly volume depleted,\n but total body overloaded. Sepsis less likely at this point, given\n broad spectrum antibiotic coverage, negative culture data, although\n stil febrile.\n - d/c levophed today, decreaseing PEEP if necessary. Attempt to add BB\n as tolerated, low dose IV lopressor Q4 hours, 2.5-5mg\n - Wean PEEP and sedative as tolerated.\n # Sepsis: Leukocytosis/fever/right lobe infiltrate- likely aspiration\n PNA, witnessed emesis during intubation. Continued to be febrile\n overnight and this morning. Vanco level was low, dose increased\n - Cultures from peripheral and from line\n - fem line out, consider PICC once afebrile vs CVL line under fluoro/\n in cath lab.\n - MRSA screen positive, on precautions\n - Continue vanco and zosyn, day 5, plan for 8-day course for VAP to\n complete on \n - Following vanco levels, increased dose since previous level low, next\n level tonight\n - blood cultures NGTD, urine small growth GPC, sputum is oral flora.\n Continue to monitor.\n - Tylenol 2g daily standing for fever\n # Chronic Systolic - Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Will hold\n metoprolol, lisinopril, lasix, and digoxin in setting of hypotension.\n - hold lisinopril, digoxin\n - TEE and TTE\n showed poor systolic function, EF not estimated\n - continue diurese w lasix drip to goal -500 cc / 24 hours\n # ARF: ATN, creatinine has plateaued so may be resolving.\n - monitor UOP\n - renally dose vancomycin, pip-Tazo\n - no NSAIDs for now\n # Bowel motility/nutrition\n Monitor for improvement after lightening\n fentanyl and\n - Bowel regimen, increase as tolerated (holding off reglan/erythromycin\n for concern for ectopy/ QT prolongation), if needed can try low dose\n reglan.\n - On trophic tube feeds, f/u nutrition recs\n -? PO naloxone\n - standing lactulose TID\n # Transaminitis: Multifactorial from shock liver, CHF and amiodarone.\n Improving\n - Discontinued amiodarone\n - monitor liver function\n -got vitamin K yesterday\n # Family dynamics: family concerned about care of pt in the hospital,\n mother wants transfer to ,\n - social work consult\n - Children\ns congenital specialist , appreciate input\n #Gout: holding allopurinol and colchicine\n FEN: agressively replete lytes\n ACCESS: right femoral line, art line. Fever curve decreasing, will\n monitor femoral blood cultures. Fem line out , attempt CVL\n placement today.\n PROPHYLAXIS:\n -DVT ppx with pneumoboots, sub q heparin\n - bowel regimen (Colace, Pantoprazole)\n CODE: Full\n DISPO: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Initially improving with reduction in pressors and oxygenation. Off\n Vasopressin and Levophed but dropped pressure while turning\n necessitating increased oxygen supplementation and reinitiation of\n pressors. need reinitiation of Amiodarone but concern for liver\n effect. With decreasing liver enzymes may rechallenge and if there are\n signs of adverse effect, will have to discontinue. Will discuss with\n EP. Critical care 60 minutes. Continued attempts to initiate oral\n feeding.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:01 ------\n" }, { "category": "Respiratory ", "chartdate": "2151-03-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 553975, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Respiratory Care;\n Pt remains intubated and vented, no parameter changes made this shift.\n Still ^ fluid on board. Not able to tolerate further weaning yet.\n" }, { "category": "Respiratory ", "chartdate": "2151-03-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 554076, "text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n :\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2151-03-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 554127, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure, renal failure, & aspiration PNA.\n .H/O heart disease, congenital\n Assessment:\n Tele sinus rhythm with frequent PVC\ns including short self limiting\n runs. Creat ^\nd to 2.9. Levo conts at .05mcgs/kg/min.\n Action:\n Conts on Amiodarone 400mg TID. Lasix drip decreased to 10mg/hr.\n Response:\n MAP > 60 HUO > 80cc\n Plan:\n I&O to run even to slightly negative. Check lytes.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T100.9-102 orally. All cultures negative to date. MRSA screen positive.\n Action:\n Tylenol 650mg Q6hrs. Pt remains on cooling blanket. Pt re cultured\n today. Blood including fungal, urine and sputum. No change in\n antibiotics at this point. Seen by rheumatology. R knee biopsied ?\n flair of gout. LE ultrasound done to r/o DVT.\n Response:\n Temp remains elevated. ? etiology.\n Plan:\n Check cultures, Tylenol ATC.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt received intubated A/C 55% 450 28 18. O2 sats 92-94%. Lungs\n diminished. Pt remains on 50mcgs of Fentanyl .\n Action:\n Pt placed on CPAP/PS 12, 16 peep.\n Response:\n Good abg. TV 600-700 RR 18-24\n Plan:\n To remain on present settings as long as PO2 is > 60.\n" }, { "category": "Nursing", "chartdate": "2151-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 553256, "text": "History of present illness: 39M w/ pmh significant for ebstein's\n anomaly s/p tricuspid valve reconstruction, right and left sided\n systolic congestive heart failure, presenting with palpitations which\n awoke him from sleep. The patient presented to the ED where he\n appeared pale and was found to be in VT to the 230's. He began to\n experience chest pain and was given amiodarone 150mg IV X1, followed by\n amiodarone gtt. He became diaphoretic and was therefore given\n etomidate and shocked with 200J. His rhythm then became fine V-fib, he\n became unresponsive and apneic. CPR was initiated, epinephrine given\n X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240,\n Intubated, returned to sinus rhyhthm, aspirated vomitus. had right\n bronchus intubation and ETT was pulled back in ED. Blood pressures\n dropped to 48/43, started on levophed, pressure increased to 124/77.\n .\n On presentation to the CCU, the patient is intubated with mottled skin,\n on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Lung sounds diminished > L- sat\ns low- hypoxic by ABG\ns- CXR\n consolidation R\n Action:\n Chest CT done- pneumothorax noted- in- CT attempted L but\n unsuccessful- esophageal balloon placed- PEEP increased 20\n Response:\n Hypotensive w/ high PEEP-> decreased to 12\n Plan:\n CT guided chest tube placement @ IR\n .H/O heart disease, congenital\n Assessment:\n Tele: SR w/ freq runs VT\n Action:\n Amiodarone gtt @ .5mg/min- trending enzymes.\n Response:\n No sustained runs of VT.\n Plan:\n EP consult.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.7 PO @ 1400- hypotensive requiring pressors.\n Action:\n 500cc fluid bolus given- levophed gtt @ .3mcq/kg/min- Blood cultures\n X2, U/A C&S obtained & sent to lab- started on zosyn.\n Response:\n MAPs > 60\n Plan:\n Maintain MAPs >60- tritrate gtts accordingly.\n" }, { "category": "Radiology", "chartdate": "2151-03-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1058998, "text": " 2:45 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for distention, ileus\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ebsteins\n REASON FOR THIS EXAMINATION:\n eval for distention, ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for distention or ileus.\n\n TWO SUPINE AP RADIOGRAPHS OF THE ABDOMEN\n\n COMPARISON: None.\n\n FINDINGS: Patient is status post median sternotomy with four visualized\n cerclage wires in appropriate appearance. There is a prosthetic ring in the\n expected location of the tricuspid valve, consistent with patient's history of\n Ebstein's anomaly A nasogastric tube courses through the esophagus and into\n the stomach. There is a nonspecific bowel gas pattern with non-dilated loops\n of small and large bowel. A femoral line projects over the area of the right\n hip, and the tip projects over the inferior aspect of the right sacroiliac\n joint. No free air is seen. There is scoliosis deformity. There is a\n deformity to the right inferior ribs which may be related to patient's prior\n surgical procedure.\n\n IMPRESSION: Nonspecific bowel gas pattern without evidence for obstruction or\n perforation. Nasogastric tube in stomach and a femoral line projecting over\n the patient's right pelvis.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058748, "text": " 7:25 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with v-tach, intubated\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:48 AM, ON .\n\n HISTORY: Ventricular tachycardia. Intubated. Check ET tube placement.\n\n COMPARISON: AP chest compared to and :\n\n Some of the substantial increase in upper mediastinal caliber between and today could be due to supine positioning, but the change in caliber and\n in the contours of the right side of the mediastinum suggests more is\n involved, including at least substantial increase in caliber of mediastinal\n veins or alternatively the aorta and possibly development of mediastinal\n hematoma. As such, possibility of hemodynamically significant pericardial\n effusion or aortic dissection that needs to be excluded.\n\n Endotracheal tube has been withdrawn from the right main bronchus to the\n thoracic inlet, nasogastric tube passes into the stomach and out of view. No\n radiopaque central venous catheter is seen. No pneumothorax or pleural\n effusion. There is no pulmonary edema. Partial obscuration of the border of\n the left heart could be divided with change in its geometry, due to worsening\n cardiomegaly and/or pericardial effusion or, alternatively new consolidation\n of atelectasis in the lingula. No pneumothorax.\n\n Findings and their clinical significance were discussed by Dr. with the\n physician caregiver 8:15 a.m. this morning.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058879, "text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, interval change, evidence of pneumo\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with hx of congenital heart disease admitted with VT, now\n intubated, poor saturation\n REASON FOR THIS EXAMINATION:\n evaluate for edema, interval change, evidence of pneumo\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb MON 11:12 AM\n No significant interval change with no overt evidence for pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male with history of congenital heart disease,\n admitted with ventricular tachycardia.\n\n COMPARISON: Multiple priors, the most recent CXR dated .\n Comparison also made to CTA chest .\n\n SUPINE CHEST: Cardiomegaly is unchanged with mediastinal widening likely\n reflecting, at least in part, mediastinal lipomatosis as identified on the\n recent CTA chest. There is no significant change in appearance of the lung\n fields and there is no overt evidence for pneumothorax. The endotracheal and\n nasogastric tubes appear unchanged in position. Median sternotomy wires again\n noted.\n\n IMPRESSION: No significant interval change without evidence for pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058925, "text": " 9:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ebstein's, s/p arrest\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ebstein's anomaly status post arrest.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n change. Again there is huge enlargement of the cardiac silhouette with\n extensive mediastinal lipomatosis. The lungs are essentially clear.\n Endotracheal tube and nasogastric tube remain in position.\n\n\n" }, { "category": "Rehab Services", "chartdate": "2151-03-26 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 556863, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: vfib / 427.5\n Reason of referral: Eval & tx\n History of Present Illness / Subjective Complaint: 39 yo M with h/o\n anomaly admitted with unstable v-tach converted to v-fib\n arrest s/p resuscitation and requiring intubation, now s/p unsuccessful\n ablation and may require PPM placement.\n Past Medical / Surgical History: see initial eval\n Medications: lisinopril, heparin, tylenol, aspirin, metoprolol,\n furosemide, amiodarone, cochicine\n Radiology: no new imaging\n Labs:\n 32.2\n 10.6\n 514\n 8.9\n [image002.jpg]\n Other labs:\n pO2 116\n pCO2 50\n pH 7.33\n Activity Orders: activity as tolerated\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: a&o x3, pleasant and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 70\n 122/60\n 96% on 3.5L NC\n Sit\n /\n Activity\n 82\n 120/57\n 90% on 3L NC\n Stand\n /\n Recovery\n 67\n /\n 96% on 3.5L NC\n Total distance walked: 200'\n Minutes:\n Pulmonary Status: increased WOB with ambulation, no cough noted\n Integumentary / Vascular: L PIV x2, tele, O2 via NC, 2+edema B LE's\n Sensory Integrity: grossly intact to light touch\n Pain / Limiting Symptoms: denies pain\n Posture: obese\n Range of Motion\n Muscle Performance\n LE's grossly WNL, limited by body habitus\n grossly WNL B\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: steady functional gait pushing w/c, limited by c/o\n SOB\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\n\n\n\n\n Transfer:\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n T\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S static/dynamic standing activities, no gross LOB with\n mobility\n Education / Communication: Reviewed PT and encouraged ambulation\n daily. Communicated with nsg re: status\n Intervention:\n Other: several 4-5 beat runs of v-tach after ambulation, while seated.\n Pt reported slight fluttering sensation but otherwise asymptomatic.\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n Clinical impression / Prognosis: 39 yo M s/p vfib arrest p/w above\n impairments a/w cardiovascular pump dysfunction. He is most limited by\n deconditioning and SOB with mobility, today with runs of v-tach after\n ambulating. He is otherwise at overall independent level and will\n likely be safe for home when medically appropriate. He will benefit\n from continued PT to progress endurance, and to assess stairs when\n ready for d/c.\n Goals\n Time frame: 1 week\n 1.\n independent with all mobility/stairs\n 2.\n Ambulates 300' and does flight of stairs with stable HDR\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1-2x\n transfers, ambulation, stairs, strengthening, endurance, education, d/c\n planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2151-03-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556976, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce. Admitted to CCU post procedure\n for management & observation.\n Remains with frequent self limiting ( ) beats of VT. Patient\n asymptomatic. Less ectopy noted with HR in the 50\ns. SBP 110\ns/50\n Wearing BIpap at night. Wife at bedside. Anticipate call out to\n telemetry floor in am\n" }, { "category": "Physician ", "chartdate": "2151-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 556972, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Pt had multiple short runs of NSVT while working with PT\n - Drs and met with Pt, wife, and mother and\n discussed plan\n - Increased amio per EP\n - Increased metoprolol from 12.5mg PO BID to TID for NSVT\n - Ordered amiodarone level\n - Gave lorazepam for anxiety\n - Pt will need to f/u with Dr. 1 month for possible ICD\n EKG - At 08:00 AM\n ARTERIAL LINE - STOP 11:25 AM\n EKG - At 03:10 PM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 64 (63 - 78) bpm\n BP: 117/69(81) {105/41(40) - 145/76(147)} mmHg\n RR: 12 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,450 mL\n 0 mL\n Urine:\n 2,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,670 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+. Groin with bilat puncture sites, no\n bleeding, hematoma, or bruit\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 514 K/uL\n 10.6 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 32.2 %\n 8.9 K/uL\n [image002.jpg]\n 04:39 AM\n WBC\n 8.9\n Hct\n 32.2\n Plt\n 514\n Cr\n 1.1\n Glucose\n 95\n Other labs: PT / PTT / INR:17.0/32.5/1.5, CK / CKMB /\n Troponin-T:102/6/, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 39M w/ pmh of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VT and no pacemaker placed. Plan to\n re-visit pacemaker issue as an outpatient. Considering heart\n transplant.\n .\n # Ventricular Tachycardia: Likely result of natural history of Ebstein\n anomaly. Amiodarone now at 200TID. EP study , \n discuss ICD insertion with family today.\n - continue amiodarone 200 TID (increased from dosing per EP)\n -cont low dose beta blocker Metoprolol 12.5 PO TID (increased from \n for recurrent NSVT)\n - Aspirin 325mg PO daily\n - Plan is to continue amio loading and discharge. Will meet with EP in\n 1 month for possible ICD. Will also begin evaluation for heart\n transplant\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and aspirin as above\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n - Started Lisinopril 2.5mg PO daily. Tolerating well.\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient gets outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: Home v to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:15 PM\n 18 Gauge - 11:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-03-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 555382, "text": "39M w/ PMhx of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, shocked into VF, requiring intubation\n and pressors. Pt\n CV - Pt has been without vea x 7 days, stable on Amiodarone and\n lopressor.\n Resp -Extubation , able to tolerate NP.\n Gi\n Abd obese w/ +bs. Tolerating NAS low chol diet. OB\n stool .\n GU\n foley cath patent to amber urine.\n ID\n afebrile. Last temp spike . off antibiotics. Positive nasal\n swab for MRSA- on contact precautions.\n Access\n RIJ TLC.\n Activity\n OOB to chair/commode w/ 2 assist.\n Ventricular tachycardia, sustained\n Assessment:\n s/p VT/shock on admit to EW. Now stable on po amio and lopressor.\n Action:\n Discussing need for pacer/AICD with family. Dr. and EP in\n discussion.\n Response:\n pt. and wife have discussed need for EP study and possible AICD. Now\n the question is whether he stays in hospital prior to study or goes\n home first.\n Plan:\n Contin. to follow plan and discussions with family.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n Intubated x10days\n now deconditioned and working with PT.\n Action:\n OOB x2 times . using chair back and 2 assist to stand up and\n shuffle to bed or chair.\n Response:\n c/o pain in back of calves when standing or walking. Appearing winded\n with activity. Resolves with rest.\n Plan:\n Work with PT. no decision as far as d/c to rehab vs home with\n services.\n Respiration / Gas Exchange, Impaired\n Assessment:\n s/p aspiration PNA/acute hypoxia\n.7 days of antibiotics. Now afeb. On\n 2L NC. LS clear.\n Action:\n Encourage to cough/deep breath. prn nebs have not been needed.\n Response:\n No c/o SOB. Non productive strong cough.\n Plan:\n Contin. with NC. Prn nebs. Monitor sats with activity.\n Knowledge, Impaired\n Assessment:\n Decrease knowledge base r/t EP/AICD and nutrition\n Action:\n Wife states that she is bringing in laptop today () so pt. can\n research more about Pacemakers/AICD\ns. has been in discussions with\n MD\n -family brought in food from home (salad, humous, pita) for pt. pt.\n also states that he drinks regular soda and a large amt. of o.j. at\n home and at work. We talked about need to watch calories and sugar\n intake.\n Talked about setting up consult with a nutritionist.\n Response:\n Pt. is agreeable to having nutrition consult.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555503, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely ICD next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 431 K/uL\n 10.7 g/dL\n 84 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 39 mg/dL\n 102 mEq/L\n 140 mEq/L\n 32.9 %\n 11.6 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: c/o to floor, PT and OT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n Medical Decision Making\n Continues to do well. Goal for today is transfer to telemetry floor and\n schedule timing for ICD that needs to be performed prior to discharge.\n Above discussed extensively with patient.\n Total time spent on patient care: 20 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:29 ------\n" }, { "category": "Physician ", "chartdate": "2151-03-27 00:00:00.000", "description": "EP fellow", "row_id": 557001, "text": "TITLE: EP fellow\n Feels well, no particular complaints.\n Tele: sinus rhythm with NSVT 3-6 beats, more during day yesterday\n Vitals with stable SBP 100-120\n A/P Ebstein\ns, LV non-complaction, VT\n - plan is to medically manage arrhythmias for now with\n Amiodarone and beta blocker after family discussion\n - will f/u in clinic and further discussion will be had\n regarding ICD implant and considering evaluation for heart transplant\n - c/w amio current dose\n - titrate up beta blocker as tolerated\n" }, { "category": "Physician ", "chartdate": "2151-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 557002, "text": "TITLE: CCU Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - Pt had multiple short runs of NSVT while working with PT\n - Drs and met with Pt, wife, and mother and\n discussed plan\n - Increased amio per EP\n - Increased metoprolol from 12.5mg PO BID to TID for NSVT\n - Ordered amiodarone level\n - Gave lorazepam for anxiety\n - Pt will need to f/u with Dr. 1 month for possible ICD\n EKG - At 08:00 AM\n ARTERIAL LINE - STOP 11:25 AM\n EKG - At 03:10 PM\n CALLED OUT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies chest pain, shortness of breath, abdominal\n pain\n Flowsheet Data as of 06:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.7\nC (98\n HR: 64 (63 - 78) bpm\n BP: 117/69(81) {105/41(40) - 145/76(147)} mmHg\n RR: 12 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 780 mL\n PO:\n 780 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,450 mL\n 0 mL\n Urine:\n 2,450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,670 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+. Groin with bilat puncture sites, no\n bleeding, hematoma, or bruit\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 514 K/uL\n 10.6 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 32.2 %\n 8.9 K/uL\n [image002.jpg]\n 04:39 AM\n WBC\n 8.9\n Hct\n 32.2\n Plt\n 514\n Cr\n 1.1\n Glucose\n 95\n Other labs: PT / PTT / INR:17.0/32.5/1.5, CK / CKMB /\n Troponin-T:102/6/, Ca++:8.7 mg/dL, Mg++:1.7 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n 39M w/ pmh of Ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VT and no pacemaker placed. Plan to\n re-visit pacemaker issue as an outpatient. Considering heart\n transplant.\n .\n # Ventricular Tachycardia: Likely result of natural history of Ebstein\n anomaly. Amiodarone now at 200TID. EP study , \n discuss ICD insertion with family today.\n - continue amiodarone 200 TID (increased from dosing per EP)\n -cont low dose beta blocker Metoprolol 12.5 PO TID (increased from \n for recurrent NSVT)\n - Aspirin 325mg PO daily\n - Plan is to continue amio loading and discharge. Will meet with EP in\n 1 month for possible ICD. Will also begin evaluation for heart\n transplant\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and aspirin as above\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n - Started Lisinopril 2.5mg PO daily. Tolerating well.\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient gets outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: Home v to floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:15 PM\n 18 Gauge - 11:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 557006, "text": "TITLE:\n CCU Resident Progress Note\n Chief Complaint: VF arrest\n 24 Hour Events:\n No Acute events overnight. Patient had EP procedure yesterday where\n they were unable to induce VT. Patient did not get an ICD at that time\n as it is unclear whether or not patient would benefit. Patient was\n extubated in the PACU and transferred back to CCU given that he has an\n a-line. Apparently plan for some family meeting possibly today\n regarding future plans and whether additional procedure is neeeded.\n Patient made NPO this morning in case additional procedure required.\n - >30 runs of NSVT overnight. Generally 5 beat runs\n .\n ARTERIAL LINE - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 73) bpm\n BP: 116/63(80) {113/59(77) - 141/72(92)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,220 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,500 mL\n Blood products:\n Total out:\n 2,820 mL\n 850 mL\n Urine:\n 350 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -600 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+. Groin with bilat puncture sites, no\n bleeding, hematoma, or bruit\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VT and no pacemaker placed.\n .\n # Ventricular Tachycardia: Likely result of natural history of Ebstein\n anomaly. Amiodarone now at 200TID. EP study , \n discuss ICD insertion with family today.\n - NPO since MN for possible repeat procedure\n - continue amiodarone 200 \n -cont low dose beta blocker Metoprolol 12.5 PO bid\n - Aspirin 325mg PO daily\n - follow up with EP regarding the plan for this\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and lisinopril as above, cont aspirin 325\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - Lidocaine patch daily\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient gets outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: consider once decision made about need for future procedures, PT\n has already said home with PT.\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff\n Physical Examination\n per \n Medical Decision Making\n per housestaff\n Above discussed extensively with patient.\n Additional comments:\n Discussion with dr - continue amiodarone.\n One month of high dose amiodarone then down to 200 mg\n Following reduction in dose will consider ICD\n ------ Protected Section Addendum Entered By: \n on: 11:05 ------\n" }, { "category": "Nursing", "chartdate": "2151-03-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 557017, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce.\n OOB to chair. Voiding in urnial. Wife stayed overnight, but has now\n gone home to shower, will be back this evening.\n ACCESS: 2 PIV. Blood drawn by phlebotomy this morning.\n MRSA\n contact precautions.\n Ventricular fibrillation (VF)\n Assessment:\n Continued episodes of self-limiting VT overnite. Attempting to control\n recurrance of VT with Amiodarone 200mg po TID & Lopressor 12.5mg po\n TID. to EP Lab for attempted ablation-unsuccessful-unable to\n induce.\n Action:\n Occ PVCs today. Taking meds well.\n Response:\n Occ PVCs. Compliant with meds. EPS in to talk to patient again today\n (Dr \n plan for continuing current medication regimine and\n eventually to have ICD placed\n plan d/c home tomorrow.\n Plan:\n Continue present management and medication. Continue med teaching and\n answering pt questions if any.\n Coping\n Assessment:\n Pt seems to be understanding of his condition more today, since talk\n with EPS yesterday. Dr in to talk again with patient and wife\n this morning.\n Action:\n Support given to wife and patient. Friends visiting today.\n Response:\n Seems to be coping well at present, no need of antianxiety meds today.\n Pt talking on phone with mother and wife and friends. visiting.\n Plan:\n Support PT & Family as indicated. Emotional support to patient.\n Education given as needed about procedures and meds. Reinforced need\n for diet changes to lose weight (discussed multiple times during admit\n to CCU with wife and patient). Social work on consult, but \n is not here today (weekend)\n social work not required/requested today.\n PLAN: call out to step down today. Plan for discharge home tomorrow\n . Needs nutrition/diet consult and physical therapy while at home.\n" }, { "category": "Nursing", "chartdate": "2151-03-26 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 556853, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce. Admitted to CCU post procedure\n for management & observation.\n OOB to chair today. Aline d/c\nd. Foley d/c\n Family meeting planned w/ EPS, and Cardiology\n multiple Attendings to\n attend\n and discuss options and plan of care. Social work met with\n family this morning, and is to be at meeting this evening.\n ACCESS: 2 PIV\n Ventricular fibrillation (VF)\n Assessment:\n Continued episodes of self-limiting VT. Attempting to control\n recurrance of VT with Amiodarone & Lopressor. to EP Lab for\n attempted ablation-unsuccessful-unable to induce.\n Action:\n Occ PVCs and small runs of VT\n self limiting and asymptomatic.\n Response:\n Asymptomatic. Taking meds well. Awaiting meeting w/ Attendings and\n family members regarding plan of care and treatment options.\n Plan:\n Continue present management. Mtg with team to address options.\n Coping\n Assessment:\n Wife & Pts Mother very concerned with outcome of EP Procedure. Both\n unsure of what is next & what should be done. Presently shielding pt\n from their discussion with EP Attending.\n Action:\n Supported Wife & Pts Mother. Discussed situation & their need to meet\n with Pts Primary Cardiologist & EP Attending to address Short & Long\n Term POC.\n Response:\n Planning to meet this evening () With MDs & social work\n discuss options.\n Plan:\n Mtg with MDs. Social Service ( ). Support PT & Family as\n indicated.\n" }, { "category": "Physician ", "chartdate": "2151-03-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 555481, "text": "Chief Complaint:\n 24 Hour Events:\n - PT eval recommmended home PT\n - EP recs: likely ICD next week\n - BP stable 110s/60s, HR 70s\n - ID/Pulm signed off\n - Wife expressed concern that if pt goes home prior to ICD placement,\n may not come back due to hx non-compliance\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 06:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.7\nC (98.1\n HR: 67 (58 - 71) bpm\n BP: 113/66(76) {92/18(43) - 119/75(81)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 1,770 mL\n 250 mL\n PO:\n 1,770 mL\n 250 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,340 mL\n 620 mL\n Urine:\n 2,340 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n -570 mL\n -370 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) distant heart\n sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n PULM: bilat crackles with scattered wheezes\n Abdominal: Non-tender, Bowel sounds present, Distended, Obese, gas on\n percussion\n Skin: Warm, Rash: lower extremity mottling\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 431 K/uL\n 10.7 g/dL\n 84 mg/dL\n 1.1 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 39 mg/dL\n 102 mEq/L\n 140 mEq/L\n 32.9 %\n 11.6 K/uL\n [image002.jpg]\n 04:12 PM\n 05:55 PM\n 03:55 AM\n 04:07 AM\n 12:38 PM\n 02:35 PM\n 02:43 PM\n 04:30 AM\n 07:37 PM\n 05:14 AM\n WBC\n 12.2\n 10.9\n 11.8\n Hct\n 35.1\n 34.2\n 32.6\n Plt\n 458\n 405\n 420\n Cr\n 1.6\n 1.7\n 1.5\n 1.1\n 1.1\n TCO2\n 34\n 37\n 37\n 34\n 33\n Glucose\n 101\n 113\n 105\n 113\n 95\n Other labs: PT / PTT / INR:17.3/35.2/1.6, CK / CKMB /\n Troponin-T:4046/9/0.30, ALT / AST:101/58, Alk Phos / T Bili:56/0.8,\n Amylase / Lipase:103/200, Differential-Neuts:78.9 %, Band:0.0 %,\n Lymph:16.1 %, Mono:3.2 %, Eos:1.3 %, D-dimer: ng/mL,\n Fibrinogen:679 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:3.0 g/dL, LDH:331\n IU/L, Ca++:8.1 mg/dL, Mg++:2.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, now intubated, with hypoxic and hypercarbic\n respiratory failure.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200BID, EP study at some point.\n -continue amiodarone, low-dose beta-blocker\n -trend cardiac enzymes\n .\n #Respiratory Failure: Now resolved. Multifactorial secondary to CHF,\n OSA, and restrictive ventilation due to habitus. Required mechanical\n ventilation from admission (intubated during V Fib arrrest in ED), and\n extubated on , without difficulty.\n .\n #Hypotension: Combination of arrhythmia, cardiogenic shock, and\n positive pressure ventilation, initially on 3-pressors which were\n weaned off. Not likely to be sepsis as culture data negative, although\n patient was treated empirically for VAP.\n - Maintain lisinopril and BB at low-dose. Initially secondary to\n ventricular tachycardia, and response to sedatives s/p intubation.\n Initially on three pressors but weaned off for a short period, still\n requiring intermittently.\n .\n # Chronic Systolic Congestive Heart Failure: Has right and left sided\n heart failure, s/p tricuspid reconstruction and ASD repair. Low-dose\n metoprolol and lisinopril.\n - Euvolemic for now, goal I/O even\n .\n #Gout: holding allopurinol and colchicine for renal failure\n .\n FEN: Speech and swallow eval after extubation, regular diet to resume\n ACCESS: right femoral line\n PROPHYLAXIS:\n -DVT ppx with pneumoboots\n CODE: Full\n DISPO: c/o to floor, PT and OT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Rehab Services", "chartdate": "2151-03-19 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 555483, "text": "Subjective:\n \" I feel better\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n T\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 69\n 109/60\n 97%RA\n Activity\n Stand\n 64\n 110/59\n 96% RA\n Recovery\n Sit\n 64\n 101/31\n 96% RA\n Total distance walked:\n Minutes:\n Gait: Pt was able to ambulate a total of 10' c min A of 2 providing\n hand held assist. Pt has wide BOS, increased lateral sway, and rapidly\n fatigues\n Balance: Initially retropulsive in standing requiring Min A x 2 to\n correct. Able to maintain static standing with Min A. Poor dynamic\n balance with ambulation.\n Education / Communication: Pt educated on importance of increasing\n activity\n Other: B heel cord stretch\n Assessment: 39 yo m s/p Vfib arrest with prolonged ICU stay and\n intubation continues to be functioning well below baseline; however is\n making gains in endurance and mobility. Pt will progress with continued\n PT, if pt is medically ready for d/c at this time he will require rehab\n in order to optimize safety and independence, but if he remains in\n house we will continue to work with him towards goals of d/c home.\n Anticipated Discharge: Rehab\n Plan: cont endurance, balance, gait training, trial with RW.\n" }, { "category": "Physician ", "chartdate": "2151-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 556832, "text": "TITLE:\n CCU Resident Progress Note\n Chief Complaint: VF arrest\n 24 Hour Events:\n No Acute events overnight. Patient had EP procedure yesterday where\n they were unable to induce VT. Patient did not get an ICD at that time\n as it is unclear whether or not patient would benefit. Patient was\n extubated in the PACU and transferred back to CCU given that he has an\n a-line. Apparently plan for some family meeting possibly today\n regarding future plans and whether additional procedure is neeeded.\n Patient made NPO this morning in case additional procedure required.\n - >30 runs of NSVT overnight. Generally 5 beat runs\n .\n ARTERIAL LINE - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 73) bpm\n BP: 116/63(80) {113/59(77) - 141/72(92)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,220 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,500 mL\n Blood products:\n Total out:\n 2,820 mL\n 850 mL\n Urine:\n 350 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -600 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+. Groin with bilat puncture sites, no\n bleeding, hematoma, or bruit\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VT and no pacemaker placed.\n .\n # Ventricular Tachycardia: Likely result of natural history of Ebstein\n anomaly. Amiodarone now at 200TID. EP study , \n discuss ICD insertion with family today.\n - NPO since MN for possible repeat procedure\n - continue amiodarone 200 \n -cont low dose beta blocker Metoprolol 12.5 PO bid\n - Aspirin 325mg PO daily\n - follow up with EP regarding the plan for this\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and lisinopril as above, cont aspirin 325\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - Lidocaine patch daily\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient gets outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: consider once decision made about need for future procedures, PT\n has already said home with PT.\n" }, { "category": "Nursing", "chartdate": "2151-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556917, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce. Admitted to CCU post procedure\n for management & observation.\n OOB to chair today. Aline d/c\nd. Foley d/c\nd. Called out to floor, but\n no beds available.\n Family meeting w/ EPS, and Cardiology\nDr and Dr \n and discuss options and plan of care. Social work met with family this\n morning, and is to be at meeting this evening.\n ACCESS: 2 PIV\n MRSA\n contact precautions.\n Ventricular fibrillation (VF)\n Assessment:\n Continued episodes of self-limiting VT. Attempting to control\n recurrance of VT with Amiodarone & Lopressor. to EP Lab for\n attempted ablation-unsuccessful-unable to induce.\n Action:\n Occ PVCs and small runs of VT\n self limiting and asymptomatic. After\n walk in w/ physical therapy, pt has runs of VT\n self limiting\n 4-6 beats then approx 6 beats normal sinus then back to VT\n lasting\n approx 3-5 minutes. CCU team aware and EPS notified.\n Response:\n Asymptomatic. Taking meds well. Awaiting meeting w/ Attendings and\n family members regarding plan of care and treatment options. Lopressor\n increased to 12.5mg po TID. Amiodarone increased to 200mg po TID.\n Plan:\n Continue present management. Con\nt antiarrhythmics and beta blocker.\n Coping\n Assessment:\n Wife & Pts Mother very concerned with outcome of EP Procedure. Both\n unsure of what is next & what should be done. Presently shielding pt\n from their discussion with EP Attending.\n Action:\n Supported Wife & Pts Mother. Social work ( ) in to talk with\n family today and he was there for family meeting with cardiology and\n EPS.\n Response:\n Wife and mother both aware of situation. Patient shocked and visibly\n upset with update and options for his plan of care\n Ativan 0.5mg po\n given this evening after meeting. Cheeks flushed, pt stating\nkinda a\n lot to absorb\n Plan:\n Support PT & Family as indicated.\n" }, { "category": "Physician ", "chartdate": "2151-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 556800, "text": "TITLE:\n CCU Resident Progress Note\n Chief Complaint: VF arrest\n 24 Hour Events:\n No Acute events overnight. Patient had EP procedure yesterday where\n they were unable to induce VF. Patient did not get an ICD at that time\n as it is unclear whether or not patient would benefit. Patient was\n extubated in the PACU and transferred back to CCU given that he has an\n a-line. Apparently plan for some family meeting possibly today\n regarding future plans and whether additional procedure is neeeded.\n Patient made NPO this morning in case additional procedure required.\n - >30 runs of NSVT overnight. Generally 5 beat runs\n .\n ARTERIAL LINE - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 73) bpm\n BP: 116/63(80) {113/59(77) - 141/72(92)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,220 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,500 mL\n Blood products:\n Total out:\n 2,820 mL\n 850 mL\n Urine:\n 350 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -600 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), distant\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+. Groin with bilat puncture sites, no\n bleeding, hematoma, or bruit\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VF and no pacemaker placed.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200TID. Had cardiac MRI final read pending,\n with EP study +/- ICD placement anticipated on the board for tomorrow.\n beta blocker to .\n - NPO since MN for possible repeat procedure\n - continue amiodarone 200 \n -cont low dose beta blocker Metoprolol 12.5 PO bid\n - Aspirin 325mg PO daily\n - follow up with EP regarding the plan for this\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and lisinopril as above, cont aspirin 325\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - Lidocaine patch daily\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient as outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: consider once decision made about need for future procedures, PT\n has already said home with PT.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 20 Gauge - 11:15 PM\n 18 Gauge - 11:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2151-03-26 00:00:00.000", "description": "EP fellow", "row_id": 556829, "text": "TITLE: EP fellow\n EPS yesterday, findings as noted. Unable to ablate given no sustained\n VT.\n Pt reports feeling ok, groins somewhat sore, but no pain.\n Tele- NSVT- monomorphic 3-6 beats.\n Vitals stable\n Bilateral groins without hematoma/ooze/ecchymosis. 2+ pulses, no\n bruits, clean/dry/intact dressings\n A/P: VT, LV non-compaction, Ebstein\ns, complicated hospital course\n - EPS unsuccessful\n - Continue with amio and beta blocker for now\n - Titrate up beta blocker as tolerated\n - Will have family discussion today regarding ICD implant\n which may be a complicated procedure given likely he will have a high\n defibrillation threshold given anatomy, body habitus, and use of\n amiodarone. recommend to discharge pt soon and bring him back for\n elective ICD implant in near future.\n , MD\n" }, { "category": "Physician ", "chartdate": "2151-03-26 00:00:00.000", "description": "Cardiology Physician Note", "row_id": 556806, "text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: s/p EPS yesterday and could not\n induce sustained VT, even with triples and quadruple ventricular\n extrastimuli from the RV. The best pace map was located in the RVOT in\n the anterior/septal region. Tele last night still showed occasional\n 4-5 beats of NSVT. Many of the RV signals were small and only in\n certain distal pockets and in RVOT region were the RV signals strong.\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD\n BP: 130 / 69 mmHg\n HR: 69 bpm\n Tmax C last 24 hours: 36.9 C\n Tmax F last 24 hours: 98.4 F\n T current C: 36.9 C\n T current F: 98.4 F\n Previous day:\n Intake: 1,980 mL\n Output: 2,820 mL\n Fluid balance: -840 mL\n Today:\n Output: 850 mL\n Fluid balance: -850 mL\n Cardiovascular: (Auscultation: distant but regular)\n Respiratory: (Auscultation: CTA B anterior)\n Abdomen: (Palpation: obese, soft)\n Neurological: (Orientation: A&O), (Mood / Affect: normal)\n Extremities:\n Right: (Femoral pulse: present), (Edema: trace)\n Left: (Femoral pulse: present), (Edema: trace)\n Femoral exam: Bilateral groin soft without hematoma.\n Labs\n 514\n 10.6\n 95\n 1.1\n 27\n 4.3\n 16\n 103\n 138\n 32.2\n 8.9\n [image002.jpg]\n 04:39 AM\n WBC\n 8.9\n Hgb\n 10.6\n Hct (Serum)\n 32.2\n Plt\n 514\n INR\n 1.5\n PTT\n 32.5\n Na+\n 138\n K + (Serum)\n 4.3\n Cl\n 103\n HCO3\n 27\n BUN\n 16\n Creatinine\n 1.1\n Glucose\n 95\n CK\n 102\n ABG: / / / 27 / Values as of 04:39 AM\n Assessment and Plan\n VENTRICULAR Tachycardia / FIBRILLATION (VF) - No inducible sustained\n VT with EPS yesterady and no ablation done. Will have discussion with\n family and physicians regarding need for ICD at this time. Given his\n anatomy it may be difficult to place an ICD lead in his RV and an ICD\n device to get the appropriate shock vector.\n - Continue Amiodarone 200mg , current dose for now.\n - D/C planning will depend on ICD decision. If no ICD, plan for\n discharge today/tomorrow. If we're proceeding with ICD, then will\n schedule for early next week.\n" }, { "category": "Nursing", "chartdate": "2151-03-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 557033, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce.\n OOB to chair. Voiding in urnial. Wife stayed overnight, but has now\n gone home to shower, will be back this evening.\n ACCESS: 2 PIV. Blood drawn by phlebotomy this morning. Called IV\n therapy for new PIV\n both dated \n difficult stick. Possible\n discharge tomorrow. IVs both patent, sites WNL.\n MRSA\n contact precautions.\n Ventricular fibrillation (VF)\n Assessment:\n Continued episodes of self-limiting VT overnite. Attempting to control\n recurrance of VT with Amiodarone 200mg po TID & Lopressor 12.5mg po\n TID. to EP Lab for attempted ablation-unsuccessful-unable to\n induce.\n Action:\n Occ PVCs today. Taking meds well.\n Response:\n Occ PVCs. Compliant with meds. EPS in to talk to patient again today\n (Dr \n plan for continuing current medication regimine and\n eventually to have ICD placed\n plan d/c home tomorrow.\n Plan:\n Continue present management and medication. Continue med teaching and\n answering pt questions if any.\n Coping\n Assessment:\n Pt seems to be understanding of his condition more today, since talk\n with EPS yesterday. Dr in to talk again with patient and wife\n this morning.\n Action:\n Support given to wife and patient. Friends visiting today.\n Response:\n Seems to be coping well at present, no need of antianxiety meds today.\n Pt talking on phone with mother and wife and friends. visiting.\n Plan:\n Support PT & Family as indicated. Emotional support to patient.\n Education given as needed about procedures and meds. Reinforced need\n for diet changes to lose weight (discussed multiple times during admit\n to CCU with wife and patient). Social work on consult, but \n is not here today (weekend)\n social work not required/requested today.\n PLAN: call out to step down today. Plan for discharge home tomorrow\n . Needs nutrition/diet consult and physical therapy while at home.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CARDIAC ARREST\n Code status:\n Full code\n Height:\n 68\n Admission weight:\n 137.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: Diabetes - Insulin, Renal Failure\n CV-PMH: Arrhythmias\n Additional history: ebstein's anomaly. asd repair 94'. sever tr.\n depressed bivent func. recurrent l leg cellulitis. chronic lb pain.\n obesity. sleep apnea.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:51\n Temperature:\n 99.1\n Arterial BP:\n S:126\n D:74\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94-96 %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 900 mL\n 24h total out:\n 1,325 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 11:25 AM\n Potassium:\n 4.5 mEq/L\n 11:25 AM\n Chloride:\n 100 mEq/L\n 11:25 AM\n CO2:\n 27 mEq/L\n 11:25 AM\n BUN:\n 13 mg/dL\n 11:25 AM\n Creatinine:\n 1.0 mg/dL\n 11:25 AM\n Glucose:\n 87 mg/dL\n 11:25 AM\n Hematocrit:\n 32.5 %\n 11:25 AM\n Valuables / Signature\n Patient valuables: glasses, portable music device\n Other valuables: laptop computer, cell phone and charger\n Clothes: Sent home with: wife\n / :\n No money / \n Cash / Credit cards sent home with: wife\n Jewelry: none\n Transferred from: CCU \n Transferred to: \n Date & time of Transfer: 1530hrs\n" }, { "category": "Physician ", "chartdate": "2151-03-26 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 556788, "text": "TITLE:\n CCU Resident Progress Note\n Chief Complaint: VF arrest\n 24 Hour Events:\n No Acute events overnight. Patient had EP procedure yesterday where\n they were unable to induce VF. Patient did not get an ICD at that time\n as it is unclear whether or not patient would benefit. Patient was\n extubated in the PACU and transferred back to CCU given that he has an\n a-line. Apparently plan for some family meeting possibly today\n regarding future plans and whether additional procedure is neeeded.\n Patient made NPO this morning in case additional procedure required.\n .\n ARTERIAL LINE - START 10:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 70 (64 - 73) bpm\n BP: 116/63(80) {113/59(77) - 141/72(92)} mmHg\n RR: 17 (7 - 21) insp/min\n SpO2: 94%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 2,220 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,500 mL\n Blood products:\n Total out:\n 2,820 mL\n 850 mL\n Urine:\n 350 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -600 mL\n -850 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), decreased throughout\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction,\n right and left sided systolic congestive heart failure, presenting with\n unstable ventricular tachycardia, s/p resuscitation with return to\n sinus tachycardia, s/p intubation and extubation now s/p EP procedure\n where they were unable to induce VF and no pacemaker placed.\n .\n # Ventricular Tachycardia: Likely result of natural history of ebstein\n anomaly. Amiodarone now at 200TID. Had cardiac MRI final read pending,\n with EP study +/- ICD placement anticipated on the board for tomorrow.\n beta blocker to .\n - NPO since MN for possible repeat procedure\n - continue amiodarone 200 \n -cont low dose beta blocker Metoprolol 12.5 PO bid\n - Aspirin 325mg PO daily\n - follow up with EP regarding the plan for this\n .\n # Chronic Systolic Congestive Heart Failure: Has right sided heart\n failure only, s/p tricuspid reconstruction and ASD repair.\n - Low-dose metoprolol and lisinopril as above, cont aspirin 325\n - Re-started statin. Had been held for elevated LFTs\n - follow LFTs\n - On home lasix dose 40mg PO daily\n .\n # Pain: has left sided chest wall pain fractured ribs from\n resuscitation.\n - Lidocaine patch daily\n - tylenol standing\n - breakthrough pain control as needed\n .\n #Gout: Patient as outpatient on colchicine and allopurinol although\n patient not taking allopurinol at home. Patiet with active pain on this\n admission in his knee with warm and slightly swollen knee.\n - given improvement in renal function, restart colchicine at outpatient\n dose\n .\n FEN: regular cardiac, low fat diet, replete lytes PRN\n .\n ACCESS: PIV\n .\n PROPHYLAXIS: hep sc, colace, senna, PPI daily\n CODE: Full Code\n DISPO: consider once decision made about need for future procedures, PT\n has already said home with PT.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 20 Gauge - 11:15 PM\n 18 Gauge - 11:17 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2151-03-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 556785, "text": "39 yo male admited s/p VF Arrest. Extensive PMH-see chart.\n Hospital course complicated by Prolonged Intubation, Recurrent VT,\n Aspiration PNA, & ARF. Subsequently Extubated, Recurrent VT rxed with\n Amiodarone & Lopressor, PNA rxed with ABX_resolved, but remains +MSRA\n (on Contact Precautions), & ARF resolved. to EP for VT\n Ablation-unsuccessful-unable to induce. Admitted to CCU post procedure\n for management & observation.\n Ventricular fibrillation (VF)\n Assessment:\n Continued episodes of self-limiting VT. Attempting to control\n recurrance of VT with Amiodarone & Lopressor.\n Action:\n to EP Lab for attempted ablation-unsuccessful-unable to\n induce.\n Response:\n Admitted CCU from PACU.\n Plan:\n Continue present management. Mtg with team to address options.\n Coping\n Assessment:\n Wife & Pts Mother very concerned with outcome of EP Procedure. Both\n unsure of what is next & what should be done. Presently shielding pt\n from their discussion with EP Attending.\n Action:\n Supported Wife & Pts Mother. Discussed situation & their need to meet\n with Pts Primary Cardiologist & EP Attending to address Short & Long\n Term POC.\n Response:\n Planning to meet in AM () With MDs & discuss options.\n Plan:\n Mtg with MDs. Social Service ( )-family requesting to meet\n with. Support PT & Family as indicated.\n" }, { "category": "Radiology", "chartdate": "2151-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060714, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in intubated pt\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p stemi\n REASON FOR THIS EXAMINATION:\n interval change in intubated pt\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE\n\n INDICATION: 39-year-old man status post STEMI. Evaluate for interval change.\n\n CHEST, PORTABLE AP: Comparison is made to prior examination of .\n\n There is widening of the mediastinum and cardiomegaly. This is stable. There\n is no consolidation. The lungs are clear. The pulmonary vasculature is\n normal. There is a right central venous line with its tip in the distal SVC.\n The patient has been extubated.\n\n IMPRESSION:\n 1. Stable appearance of the mediastinum and cardiac silhouette.\n\n 2. Status post extubation. No evidence of atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060483, "text": ", J. 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change, infiltrates, edema\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congenital heart disease, now intubated after VT arrest,\n continues to have fevers\n REASON FOR THIS EXAMINATION:\n Eval for interval change, infiltrates, edema\n ______________________________________________________________________________\n PFI REPORT\n PFI: Endotracheal tube terminates above the thoracic inlet, 8 cm above the\n carina.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060482, "text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change, infiltrates, edema\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congenital heart disease, now intubated after VT arrest,\n continues to have fevers\n REASON FOR THIS EXAMINATION:\n Eval for interval change, infiltrates, edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb TUE 11:55 AM\n PFI: Endotracheal tube terminates above the thoracic inlet, 8 cm above the\n carina.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male with congenital heart disease, intubated after\n VT arrest.\n\n COMPARISON: Multiple priors, the most reason CXR dated .\n\n PORTABLE CHEST: There has been no change in the appearance of the enlarged\n cardiac silhouette with some persistent retrocardiac atelectasis. No pleural\n effusion or pneumothorax is seen. The sternotomy wires remain intact and a\n right internal jugular central venous line is unchanged in position.\n The endotracheal tube has been partially withdrawn, now terminating 8 cm above\n the carina. A nasogastric tube terminates within the stomach.\n\n IMPRESSION: 1. Endotracheal tube partially withdrawn, now 8 cm above the\n carina. 2. Unchanged appearence of cardiac silhouette and mild retrocardiac\n atelectasis.\n\n Findings discussed with Dr. .\n\n" }, { "category": "ECG", "chartdate": "2151-03-25 00:00:00.000", "description": "Report", "row_id": 183318, "text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. There are Q waves in the inferior leads consistent\nwith prior myocardial infarction. There is an abnormal transition across\nthe precordium consistent with probable prior anterior myocardial infarction.\nLow voltage in the precordial leads. Compared to the previous tracing\nthe P-R interval is shorter.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-03-23 00:00:00.000", "description": "Report", "row_id": 183319, "text": "Sinus rhythm. Prolonged P-R interval. Right bundle-branch block. Possible\nold inferior myocardial infarction. Possible old septal myocardial infarction.\nCompared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2151-03-26 00:00:00.000", "description": "Report", "row_id": 183316, "text": "Sinus rhythm with first degree atrio-ventricular conduction delay. Left atrial\nabnormality. Right bundle-branch block. Left axis deviation. Left anterior\nfascicular block. Cannot exclude prior inferior myocardial infarction. Possible\nanteroseptal myocardial infarction. Diffuse non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of multiple\nabnormalities as noted persist without major change.\n\n" }, { "category": "ECG", "chartdate": "2151-03-26 00:00:00.000", "description": "Report", "row_id": 183317, "text": "Sinus rhythm. The P-R interval is prolonged. Left axis deviation. Right\nbundle-branch block with left anterior fascicular block. There are Q waves\nin the inferior leads consistent with prior infarction. There is an abnormal\nprecordial transition consistent with possible prior anterior myocardial\ninfarction. Low voltage in the precordial leads. Compared to the previous\ntracing the P-R interval is longer.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-03-20 00:00:00.000", "description": "Report", "row_id": 183320, "text": "Sinus rhythm. Probable inferior wall myocardial infarction of indeterminate\nage. Q waves in leads V1-V3. Cannot rule out anteroseptal myocardial\ninfarction of indeterminate age. Intraventricular conduction defect.\nLow QRS voltage in the precordial leads. Compared to the previous tracing\nof multiple described abnormalities persist. Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2151-03-12 00:00:00.000", "description": "Report", "row_id": 183321, "text": "Sinus rhythm at upper limits of normal rate. Marked superior axis. Possible\nQ waves versus small R waves in leads II, III and aVF with ST-T wave\nabnormalities. Consider inferior myocardial infarction. Intraventricular\nconduction delay. Low precordial voltage. Cannot rule out septal myocardial\ninfarction. Since the previous tracing of the rate has increased.\n\n" }, { "category": "ECG", "chartdate": "2151-03-11 00:00:00.000", "description": "Report", "row_id": 183322, "text": "Normal sinus rhythm, rate 82. Probable left atrial abnormality. Left anterior\nhemiblock. Right bundle-branch block. Inferior myocardial infarction of\nindeterminate age. Anterior myocardial infarction of indeterminate age.\nIntraventricular conduction delay. Compared to the previous tracing\nof anteroseptal T wave versions have resolved.\n\n" }, { "category": "ECG", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 183323, "text": "Accelerated idioventricular rhythm. Compared to tracing #4 ST segment\nelevation in the anterior leads has again improved. There is a persistent\nmyocardial injury pattern. Clinical correlation is suggested.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 183324, "text": "Acclerated idioventricuar rhythm. Compared to tracing #3 ST segment elevation\nin the anterior leads has now reappeared. Inferior ST segment elevation also\nis noted. Clinical correlation is suggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 183556, "text": "Accelerated idioventricular rhythm. Compared to tracing #2 the heart rate\nis improved. ST segment elevation in the anterior leads is improved.\nHowever, there is a persistent anterior myocardial injury pattern.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2151-03-08 00:00:00.000", "description": "Report", "row_id": 183557, "text": "Accelerated idioventricular rhythm. Compared to tracing #1 anterior\nST segment elevation is now more prominent suggestive of worsening anterior\nmyocardial infarction. There is also reciprocal lateral ST segment\ndepression. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-03-07 00:00:00.000", "description": "Report", "row_id": 183558, "text": "Accelerated idioventricular rhythm. Right bundle-branch block. Anterior\nwall myocardial injury pattern. Inferior wall myocardial infarction\nof indeterminate age. Compared to the previous tracing of multiple\ndescribed abnormalities persist. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2151-03-07 00:00:00.000", "description": "Report", "row_id": 183559, "text": "Accelerated idioventricular rhythm\nRight bundle branch block\nAnterior myocardial infarction - possibly acute\nInferior infarct - age undetermined\nSince previous tracing of the same date, ventricular tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2151-03-07 00:00:00.000", "description": "Report", "row_id": 183560, "text": "Ventricular tachycardia\nSince previous tracing of , ventricular tachycardia present\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058844, "text": " 11:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for interval change and sign of pneumo\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with resp failure, s/p VT, now intubated, s/p pneumo on left,\n with likely aspiration\n REASON FOR THIS EXAMINATION:\n evaluate for interval change and sign of pneumo\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, followup.\n\n COMPARISON: , 4:39 p.m.\n\n FINDINGS: The monitoring and support devices are unchanged. Unchanged\n cardiomegaly with bilateral retrocardiac atelectasis, unchanged mediastinal\n widening.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058814, "text": " 2:32 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaulate for chest tube placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pneumothorax, now s/p chest tube attempt with out\n placement\n REASON FOR THIS EXAMINATION:\n evaulate for tension pneumo\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:41 PM, .\n\n HISTORY: Pneumothorax. Chest tube attempt.\n\n IMPRESSION: AP chest compared to 7:48 a.m.\n\n Pneumothorax was not apparent on the earlier chest radiograph nor on this one.\n On the supine chest CT, it was small, collected anteriorly on the left. Small\n regions of consolidation also observed on a chest CT scan have now progressed\n at the base of the right lung. Large cardiomediastinal silhouette is\n unchanged. ET tube in standard placement, nasogastric tube ends in the upper\n stomach. Dr. was paged to report these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-12 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1059945, "text": ", J. 2:44 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: DVT?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man intubated, persistent fevers\n REASON FOR THIS EXAMINATION:\n DVT?\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2151-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058880, "text": ", J. 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, interval change, evidence of pneumo\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with hx of congenital heart disease admitted with VT, now\n intubated, poor saturation\n REASON FOR THIS EXAMINATION:\n evaluate for edema, interval change, evidence of pneumo\n ______________________________________________________________________________\n PFI REPORT\n No significant interval change with no overt evidence for pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1059504, "text": ", J. 3:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with central line, Right IJ\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n PFI REPORT\n Right internal jugular _____ in upper SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-22 00:00:00.000", "description": "MR CARDIAC W/FLOW/VEL NO CONTRAST", "row_id": 1061717, "text": " 1:19 PM\n MR CARDIAC W/FLOW/ CONTRAST Clip # \n Reason: DEPRESSED LV FUNCTION, VT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n Patient Name: \n\n MR#: Status: Outpatient\n Study Date: \n Indication: 40-year-old man with history of Ebstein's anomaly and LV non-\n compaction, S/P tricuspid annuloplasty, andASD repair referred for assessment\n of -ventricular function.\n\n Requesting Physician: . \n\n Height (in): 68\n Weight (lbs): 280\n Body Surface Area (m2): 2.47\n\n Hemodynamic Measurements\n\n Measurement Result\n Systemic Blood Pressure (mmHg) 120/80\n Heart Rate (bpm) 76\n\n Rhythm: Sinus\n\n CMR Measurements\n\n Measurement Result Prior Study Male Normal\n Range\n LV End-Diastolic Dimension (mm) 55 54 <62\n LV End-Diastolic Dimension Index\n (mm/m2) 17 20 <32\n LV End-Systolic Dimension (mm) 33 47\n LV End-Diastolic Volume (ml) 172 156 <196\n LV End-Diastolic Volume Index (ml/m2) 70 60 <95\n LV End-Systolic Volume (ml) 99 113\n LV Stroke Volume (ml) 73 44\n LV Ejection Fraction (%) *42 ***28 >54\n LV Anteroseptal Wall Thickness (mm) 8 8 <12\n LV Inferolateral Wall Thickness (mm) 7 4 <11\n LV Mass (g) 85 116\n LV Mass Index (g/m2) 34 44 <80\n\n Functional RV End-Diastolic Volume\n (ml) 328 296\n Functional RV End-Diastolic Volume\n Index (ml/m2) *133 113 <114\n Functional RV End-Systolic Volume\n (ml) 231 221\n (Over)\n\n 1:19 PM\n MR CARDIAC W/FLOW/ CONTRAST Clip # \n Reason: DEPRESSED LV FUNCTION, VT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Functional RV Stroke Volume (ml) 97 74\n Functional RV Ejection Fraction (%)***29 ***25 >46\n\n Structural RV End-Diastolic Volume\n (ml) 532 545\n Structural RV End-Diastolic Volume\n Index (ml/m2) ***215 ***208 <114\n Structural RV End-Systolic Volume\n (ml) 324 392\n Structural RV Stroke Volume (ml) 189 153\n Structural RV Ejection Fraction (%)***35 ***28 >46\n\n\n QFlow Net Aortic Forward Stroke Volume\n (QS net, ml) 70 45\n QFlow Net Pulmonary Artery Forward\n Stroke Volume (Qp net, ml) 78 52\n QP/QS 1.11 1.2 0.8-1.2\n QFlow Aortic Cardiac Output (l/min) 5.8 4.7\n QFlow Aortic Cardiac Index (l/min/m2) 2.3 *1.8 >2.0\n QFlow Aortic Valve Regurgitant Volume\n (ml) 6 4\n QFlow Aortic Valve Regurgitant Fraction\n (%) *8 *8 <5\n Mitral Valve Regurgitant Volume (ml) 0 0\n Mitral Valve Regurgitant Fraction (%) 0 0 <5\n Effective Forward LVEF (%) *41 ***29 >54\n Pulmonic Valve Regurgitant Volume (ml) 1 0\n Pulmonic Valve Regurgitant Fraction (%) 1 0 <5\n Tricuspid Valve Regurgitant Volume (ml)\n for functional RV 18 22\n Tricuspid Valve Regurgitant Fraction\n (%) for functional RV **19 ***30 <5\n Tricuspid Valve Regurgitant Volume\n (ml) for Structural RV 110 104\n Tricuspid Valve Regurgitant Fraction\n (%) for Structural RV ***58 ***67 <5\n\n Aortic Valve Area (2-D) (cm2) 4.7 3.4 >3.0\n Aortic Valve Area Index (cm2/m2) 1.9 1.3\n\n Ascending Aorta diameter (mm) 30 30 <39\n Ascending Aorta diameter Index (mm/m2) 12 11 <20\n Transverse Aorta diameter (mm) 23 24 <31\n Descending Aorta diameter (mm) 22 23 <28\n Descending Aorta Index (mm/m2) 9 9 <14\n (Over)\n\n 1:19 PM\n MR CARDIAC W/FLOW/ CONTRAST Clip # \n Reason: DEPRESSED LV FUNCTION, VT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Main Pulmonary Artery diameter (mm) 24 22 <29\n Main Pulmonary Artery diameter Index\n (mm/m2) 10 8 <15\n Left Atrium (Parasternal Long Axis)\n (mm) 25 20 <40\n Left Atrium Length (4-Chamber) (mm) **63 **64 <52\n Right Atrium (4-Chamber) (mm) **66 51 <50\n Pericardial Thickness (mm) 2 2 <4\n Coronary Sinus diameter (mm) 14 *16 <15\n * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal\n\n CMR Technical Information:\n CMR Technologists: , RT\n Nursing support: , RN\n\n Total Gd-DTPA (Magnevist ) contrast: 0 ml (0mmol/kg)\n\n Complications: Patient was claustrophobic and unable to cooperate with breath\n holding.\n\n 1) Structure: Axial dual-inversion T1-weighted images of the myocardium were\n obtained\n 2) Function: Non breath-hold cine SSFP images were acquired in the left\n ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8-\n mm slices with 2-mm gaps), sagittal and coronal orientations of the left\n ventricular outflow tract, sagittal orientation of the right ventricular\n outflow tract, and aortic valve short axis orientations. Breath-hold real time\n SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, and\n mid-papillary short axis slices.\n 3) Flow: Phase-contrast cine images were obtained transverse to the aorta\n (axial plane) and main pulmonary artery (oblique plane).\n\n\n Findings:\n Structure and Function\n There was prominent epicardial and mediastinal fat. The myocardium appeared to\n have homogenous signal intensity. The pericardial thickness was normal. There\n were no pericardial or pleural effusions. The origins of the left main and\n right coronary arteries were identified in their customary positions. The\n indexed diameters of the ascending and descending thoracic aorta were normal.\n The main pulmonary artery diameter index was normal. The left atrial AP\n dimension was normal. The right and left atrial lengths in the 4-chamber view\n were moderately increased. The coronary sinus diameter was normal. The\n inferior vena cava and hepatic veins were markedly dilated.\n The left ventricular end-diastolic dimension index was normal. The end-\n diastolic volume index was normal. The calculated left ventricular ejection\n (Over)\n\n 1:19 PM\n MR CARDIAC W/FLOW/ CONTRAST Clip # \n Reason: DEPRESSED LV FUNCTION, VT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fraction was mildly decreased at 42%. The anteroseptal and inferolateral wall\n thicknesses were normal. There were prominent trabeculations from the mid to\n apical segments of the left ventricle with maximum ratio of non-compacted\n myocardium to compacted myocardium during diastole of 3.5 in the mid\n inferolateral wall. This is consistent with diagnosis of LV non-compaction.\n The left ventricular mass index was normal (excluding volume of non compacted\n ventricle). The inter-ventricular septum was flattened (D-shape) in diastole\n consistent with RV volume overload.\n The functional right ventricular end-diastolic volume index was mildly\n increased. The calculated right ventricular ejection fraction of the\n functional RV was severely decreased at 29%. The right ventricular end-\n diastolic volume index of the structural RV (including atrialized RV) was\n severely increased. The calculated right ventricular ejection fraction of the\n structural RV was severely decreased at 35%\n The aortic valve was tri-leaflet with normal valve area. The tricuspid valve\n had abnormalities consistent with Ebstein's anomaly with mobile leaflets, a\n mobile posterior that was markedly displaced apically. A well seated tricuspid\n annuloplasty ring was present. A signal void was seen in the anatomic right\n atrium during systole consistent with tricuspid regurgitation.\n\n Quantitative Flow\n There was no significant intra-cardiac shunt. Aortic flow demonstrated mild\n aortic regurgitation. The calculated mitral valve regurgitant fraction was\n consistent with no mitral regurgitation. The resultant effective forward LVEF\n was mildly decreased at 41%.\n The right ventricular stroke volume and pulmonic flow demonstrated no\n significant pulmonic regurgitation. Using volumetric data from the functional\n RV, there was moderate tricuspid regurgitation. Using volumetric data from the\n structural RV, there was severe tricuspid regurgitation through the tricuspid\n annulus.\n\n Non-Cardiac Findings\n The patient is s/p sternotomy. Also noted are slight anterior wedge\n compression fractures in the lower thoracic spine, with narrowing of\n intervening disc space, similar to previous CMR findings on .\n\n Impression:\n 1. Normal left ventricular cavity size with mild global left ventricular\n hypokinesis. The LVEF was mildly decreased at 42%. The effective forward LVEF\n was mildly decreased at 41%. Prominent non-compacted left ventricular\n myocardium that meet CMR criteria for non-compaction.\n 2. Mild functional right ventricular enlargement with evidence of RV volume\n overload. Severe structural RV enlargement. Severe right ventricular systolic\n dysfunction with RVEF at 29%. Severely decreased structural RV systolic\n function with RVEF at 35%.\n 3. Markedly dilated inferior vena cava and hepatic veins consistent with\n (Over)\n\n 1:19 PM\n MR CARDIAC W/FLOW/ CONTRAST Clip # \n Reason: DEPRESSED LV FUNCTION, VT\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n elevated right atrial pressure.\n 4. Abnormal and apically displaced tricuspid valve consistent with Ebstein's\n anomaly. A well seated tricuspid annuloplasty ring was present. Moderate\n tricuspid regurgitation through tricuspid leaflets of functional right\n ventricle. Severe tricuspid regurgitation through tricuspid annulus of\n structural right ventricle.\n 5. Mild aortic regurgitation.\n 6. The indexed diameters of the ascending and descending thoracic aorta were\n normal. The main pulmonary artery diameter index was normal.\n 7. Moderate -atrial enlargement.\n 8. No CMR evidence of residual intra-cardiac shunt. (post ASD patch repair)\n 9. A note is made of previously noted compression fractures in the lower\n thoracic spine compared with prior CMR study of .\n\n The images were reviewed by Drs. , , ,\n , , and .\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1059503, "text": " 3:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with central line, Right IJ\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc WED 5:34 PM\n Right internal jugular _____ in upper SVC. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE\n\n REASON FOR EXAM: Right internal jugular catheter.\n\n Since yesterday, right internal jugular catheter was installed ending in the\n upper SVC. Other tubes and catheters are in unchanged position. Severe\n cardiomegaly is unchanged in this patient with known anomaly. There\n is no pneumothorax. Left basilar atelectasis improved. Old right clavicular\n fracture is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059571, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congential heart disease, now admitted with VT, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Patient with congenital heart disease.\n\n Comparison is made with prior study performed the day earlier.\n\n ET tube is in a standard position, right IJ catheter remains in place. NG\n tube tip is out of view, below the diaphragm. There is no of pleural\n effusions. Enlarged cardiac silhouette and widening mediastinum are stable.\n The lungs are grossly clear.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2151-03-13 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1060081, "text": " 1:16 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Please perform non-contrast CT given renal failure to assess\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL ADDENDUM\n MR HEAD CAN BE CONSIDERED TO ASSESS FOR ANY INTRACRANIAL ABNORMALITY AT THE\n SITE OF DEMINERALIZED CRIBRIFORM PLATES OF ETHMOID GIVEN THE OPACIFICATION IN\n THE NASAL CAVITY.\n\n\n\n 1:16 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Please perform non-contrast CT given renal failure to assess\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man, intubated with persistent fevers\n REASON FOR THIS EXAMINATION:\n Please perform non-contrast CT given renal failure to assess for sinusitis.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 8:48 PM\n Progression of opacification of all the nasal sinuses. New partial bilateral\n mastoid air cell opacification. No definite osseous destruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male intubated, with persistent fevers. Evaluate for\n sinusitis.\n\n COMPARISON: None available in the PACS.\n\n TECHNIQUE: Axial imaging was performed through the paranasal sinuses without\n IV contrast. Coronal and standard tissue algorithm reformations were\n provided.\n\n CT SINUSES WITHOUT IV CONTRAST: There is bilateral extensive opacification of\n the maxillary sinuses, sphenoid sinuses, ethmoid sinuses, and frontal sinuses.\n Although sphenoid sinus opacification can be seen in the setting of\n intubation, involvement of the remainder of the paranasal sinus system\n extensively, especially the frontal sinuses, is suggestive of acute sinusitis.\n Some of the areas of opacification are dense and can be due to inspisatted or\n proteniceous secretions or related to fungal etiology, if appropriate. There\n is demineralization fo the ethmoid septae and cribriform plates of ethmoid.\n There is partial opacification of the mastoid air cells bilaterally. These\n findings are more extensive than in the head CT 6 days prior. Soft tissues\n are grossly unremarkable but not completely assessed.\n\n IMPRESSION:\n\n 1. Progression of opacification of maxillary, sphenoid, ethmoid and frontal\n sinuses, with aerosolized secretions suggestive of acute sinusitis along with\n a chronic component. Fungal etiology cannot eb completely excluded, if\n clinically appropriate history is present.\n\n 2. New partial opacification of mastoid air cells.\n\n\n\n (Over)\n\n 1:16 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Please perform non-contrast CT given renal failure to assess\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2151-03-13 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 1060082, "text": ", J. 1:16 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Please perform non-contrast CT given renal failure to assess\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man, intubated with persistent fevers\n REASON FOR THIS EXAMINATION:\n Please perform non-contrast CT given renal failure to assess for sinusitis.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n PFI REPORT\n Progression of opacification of all the nasal sinuses. New partial bilateral\n mastoid air cell opacification. No definite osseous destruction\n\n" }, { "category": "Radiology", "chartdate": "2151-03-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1060083, "text": " 1:17 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Although non-contrast study is less diagnostic for intra-abd\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man, intubated with persistent fevers, ? Pneumonia vs.\n intra-abdominal fluid collection.\n REASON FOR THIS EXAMINATION:\n Although non-contrast study is less diagnostic for intra-abdominal fluid\n collection, wish to perform without contrast for now, given renal failure.\n Please assess for intra-abdominal fluid collections and lung infiltrates.\n Please administer oral contrast.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CJMt SAT 8:03 PM\n PFI: There is a right adrenal myelolipoma. There is no drainable\n intra-abdominal fluid collection. There is basal pulmonary\n collapse/consolidation. There is mediastinal lipomatosis.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: Fevers. Evaluate for pneumonia versus intra-abdominal fluid\n collection. Non-contrast examination due to renal failure.\n\n TECHNIQUE: Non-contrast CT thorax, abdomen and pelvis was performed.\n Multiplanar reformations were carried out.\n\n COMPARISON: CT chest, .\n\n FINDINGS:\n\n CT CHEST:\n\n Widening of the mediastinum by increased amount of mediastinal fat is noted,\n compatible with mediastinal lipomatosis. The heart is enlarged. Evidence of\n prior tricuspid valve surgery is noted. Relatively small caliber thoracic\n aorta is also noted, measuring 1.9 cm at the level of the descending thoracic\n aorta.\n\n There is no evidence of mediastinal lymphadenopathy. There are bibasal small\n pleural effusions. There is bibasal collapse/consolidation. A tiny\n nonspecific 3-mm nodule is seen in the right lower lobe.\n\n Abnormal appearance of the right posterior rib cage may relate to prior chest\n surgery. There is evidence of previous left rib fracture.\n\n CT ABDOMEN AND PELVIS: There is a right adrenal mass, measuring up to 6.2 cm\n in diameter. The mass demonstrates evidence of large areas of fat\n attenuation. It is compatible with an adrenal myelolipoma. The left adrenal\n (Over)\n\n 1:17 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Although non-contrast study is less diagnostic for intra-abd\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gland is normal. No focal renal lesion is identified.\n\n The pancreas is normal. No splenic or liver lesion is identified. There is\n no intra-abdominal or pelvic fluid collection.\n\n Incidental note is made of evidence of prior AVN at the anterior aspect of the\n right femoral head. There has been previous instrumentation of the right\n proximal femur, likely a core decompression. There is evidence of kyphosis at\n the lower lumbar spine.\n\n IMPRESSION:\n 1. No evidence of intra-abdominal fluid collection.\n 2. Basal pulmonary consolidation with small pleural effusions.\n 3. Mediastinal lipomatosis.\n 4. Right adrenal myelolipoma.\n 5. Evidence of previous right hip AVN.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1060084, "text": ", J. 1:17 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Although non-contrast study is less diagnostic for intra-abd\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man, intubated with persistent fevers, ? Pneumonia vs.\n intra-abdominal fluid collection.\n REASON FOR THIS EXAMINATION:\n Although non-contrast study is less diagnostic for intra-abdominal fluid\n collection, wish to perform without contrast for now, given renal failure.\n Please assess for intra-abdominal fluid collections and lung infiltrates.\n Please administer oral contrast.\n CONTRAINDICATIONS for IV CONTRAST:\n Renal failure\n ______________________________________________________________________________\n PFI REPORT\n PFI: There is a right adrenal myelolipoma. There is no drainable\n intra-abdominal fluid collection. There is basal pulmonary\n collapse/consolidation. There is mediastinal lipomatosis.\n\n" }, { "category": "Radiology", "chartdate": "2151-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060153, "text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema and infiltrates, interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with congenital heart disease, now intubated after VT arrest,\n continues to have fevers\n REASON FOR THIS EXAMINATION:\n evaluate for edema and infiltrates, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n A single portable radiograph of the chest demonstrates no change in the\n enlarged cardiomediastinal silhouette when compared to . The\n bibasilar atelectasis seen on the CT exam of is not readily\n appreciated on the current radiograph. No effusion is detected. The support\n lines are unchanged from . No pneumothorax is seen. Sternotomy\n wires are intact. Overall, there is little interval change when compared to\n the previous radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-03-12 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1059944, "text": " 2:44 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: DVT?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man intubated, persistent fevers\n REASON FOR THIS EXAMINATION:\n DVT?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DFDdp 6:09 PM\n PFI: No DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fevers, intubated. Evaluate for deep venous\n thrombosis.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler son\n of both common femoral, both superficial femoral, and both popliteal veins\n were performed. Normal compressibility, waveforms, augmentation, and color\n flow were demonstrated in all these veins. No intraluminal thrombus was\n identified.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n DFDdp\n\n" } ]

[ { "category": "Radiology", "chartdate": "2135-09-26 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 927491, "text": " 9:57 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 45-year-old woman with trauma.\n\n CHEST, SINGLE SUPINE AP: No prior studies. The heart size is normal. The\n mediastinal and hilar contours are unremarkable. There are no pleural\n effusions or pneumothorax. Visualized osseous structures are unremarkable.\n\n PELVIS, SINGLE AP VIEW: No prior studies are available for comparison. There\n is no evidence of a fracture, dislocation, or bony destruction. There is a\n transitional vertebral body at the lumbosacral junction.\n\n IMPRESSION: No evidence of acute injury.\n\n" }, { "category": "Radiology", "chartdate": "2135-09-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 927493, "text": " 10:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: HIT BY CAR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc TUE 3:02 AM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 45-year-old woman status post trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intra- or extra-axial hemorrhage. The\n ventricles, cisterns, and sulci are unremarkable without effacement. There is\n no mass effect, hydrocephalus, or shift of the normally midline structures.\n There is ethmoid sinus mucosal thickening, but no evidence of a fracture. The\n visualized mastoid air cells are clear.\n\n IMPRESSION: No evidence of acute injury.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-09-27 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 927555, "text": " 10:56 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: - please CTA to eval vasc injury\n Admitting Diagnosis: C2 FRACTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p bike crash w/ bilateral pedicle fx of C2 and partial\n sublux at R C1-2 -> please eval for vascular injury.\n REASON FOR THIS EXAMINATION:\n - please CTA to eval vasc injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old woman status post bicycle accident with bilateral\n pedicle fracture of C2 and partial subluxation of C1 on C2. Please evaluate\n for vascular injury.\n\n COMPARISON: CT head without contrast and CT C-spine without contrast .\n\n TECHNIQUE: Non-contrast head CT was performed followed by a contrast-enhanced\n CT scan of the head and neck in the arterial phases. Multiplanar as well as\n snapshot volumetric reconstructions of the vessels were performed.\n\n FINDINGS:\n CT HEAD: There is no evidence of intra- or extra-axial hemorrhage, mass\n effect, shift of normally midline structures, hydrocephalus, or acute major\n vascular territorial infarction. The ventricles, cisterns, and sulci are\n normal in size. The surrounding osseous structures show no evidence for\n fracture. The surrounding visualized paranasal sinuses show only a mild\n ethmoid air cell thickening and a left maxillary sinus mucus retention cyst.\n\n CT ANGIOGRAM OF THE HEAD: The major arterial branches of the circle of \n opacify appropriately with contrast. There is no evidence of dissection or\n other arterial injury. There is no evidence of aneurysm.\n\n CT ANGIOGRAM OF THE NECK: The cervical vertebral and internal carotid\n arteries opacify appropriately with contrast. The vertebral arteries course\n normally through the transverse foramina. The known fractures to the\n posterior elements of C2 do not involve these structures. There is no\n evidence of arterial injury including dissection, aneurysm, or pseudoaneurysm.\n There is evidence of high attenuation in a crescentic shape in the epidural\n space at the C2 level, which most likely represents a focal epidural venous\n hematoma. The surrounding soft tissue structures are unremarkable. The\n surrounding osseous structures show no other osseous abnormalities than the\n known C2 fractures. Again, there is mild subluxation of C1 on C2 as described\n on the CT C-spine of .\n\n IMPRESSION:\n 1. No evidence of vertebral or internal carotid arterial injury including in\n the region of the known C2 fractures. These fractures do not involve the\n transverse foramina.\n\n (Over)\n\n 10:56 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: - please CTA to eval vasc injury\n Admitting Diagnosis: C2 FRACTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. A crescentic focus of high attenuation within the ventral spinal canal, at\n the C2 level which most likely represents a focal epidural venous hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2135-09-27 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 927561, "text": " 11:13 AM\n MR CERVICAL SPINE Clip # \n Reason: eval for cord/ligamentous injury\n Admitting Diagnosis: C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p bike vs. MVC with bilat pedicle fx's of C2; partial\n sublux at R C1-2, normal neuro exam\n REASON FOR THIS EXAMINATION:\n eval for cord/ligamentous injury\n ______________________________________________________________________________\n FINAL REPORT\n EMERGENCY CERVICAL SPINE IMAGING\n\n HISTORY: Motor vehicle collision with bilateral C2 pedicle fractures and\n partial subluxation on the right at C1-2. Evaluate for cord or ligamentous\n injury.\n\n TECHNIQUE: Sagittal T1, T2, and STIR images of the cervical spine, with\n axial gradient echo and T2 weighted scans acquired.\n\n\n FINDINGS: There is high T2 signal within the posterior paramedian spinal soft\n tissues extending from C3 through C5 levels with some slight extension into\n the interspinous ligaments. In the setting of the known C2 pedicle fractures,\n this finding is quite suspicious for ligamentous injury. There is no definite\n abnormal T2 signal seen within the cervical spinal cord. Axial gradient echo\n scans were also obtained, and there is no sign of magnetic susceptibility\n within the cord in the area covered (C2-3 through C7-T1 levels) to suggest the\n presence of blood products. There is no spinal cord compression, and at this\n time, no subluxation of the component vertebrae. Foramen magnum and its\n contents are unremarkable. There is a probable minute Tornwaldt cyst in the\n midline posterior nasopharyngeal soft tissues.\n\n CONCLUSION: Probable ligamentous injuries in the paraspinal soft tissues in\n the midcervical spine, as detailed above.\n\n We discussed the findings by telephone with Dr. (covering for Dr.\n at 16:41 on the day of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-09-26 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 927494, "text": " 10:04 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: HIT BY CAR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AEBc TUE 12:42 AM\n bilateral pedicle fx's of C2 with 1-2 ap distraction; partial subluxation at\n right c1-c2 (less than ap dimension)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 45-year-old woman status post trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained,\n and sagittal and coronal reconstructions were also performed.\n\n FINDINGS: There are bilateral pedicle fractures anteriorly in the C2\n vertebral body which are distracted in the AP dimension up to 2 mm. There is\n partial retrolisthesis of the right facet joint of C1 on C2 on the right side\n only by perhaps one quarter of the AP distance of the lateral mass. There is\n no fracture of the dens. No other fractures identified. There is no\n listhesis. Soft tissue swelling is minimal. Although CT is not ideal for\n evaluation of the thecal sac, the intrathecal contents appear unremarkable.\n\n The lung apices appear clear. There is stranding in the superficial soft\n tissues overlying the neck posteriorly on the right at the C2 level.\n\n IMPRESSION: Bilateral pedicle fractures of C2. Partial subluxation of\n right facet at C2 on C1.\n\n\n" }, { "category": "Radiology", "chartdate": "2135-09-29 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 927868, "text": " 12:50 PM\n C-SPINE NON-TRAUMA VIEWS; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: HALO APPLICATION\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Halo application.\n\n A single lateral intraoperative fluoroscopic view of the cervical spine was\n obtained without a radiologist present. Image demonstrates the upper portion\n of the cervical spine. For additional details, please consult the operative\n report.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-09-27 00:00:00.000", "description": "Report", "row_id": 1442596, "text": "ADM, NOTE\nBICYCLE VS CAR, C2 FX\n\nPT CAME IN FROM ED 1AM A+OX3 , NEURO INTACT, C2 FX LATERAL HORNS W/O CORD INVOLMENT (BY CT). VS STABLE, REMAINS ON LOGROLL, C/COLLAR IN PLACE, MORPHINE FOR BACK PAIN. ON RA, DENIES SOB, NPO,\n\nPLAN: MRI NECK/SPINE, ?HALO VS COLLAR VS SURGERY, CLEAR OFF LOGROLL,\n?TRANFER TO REG FLOOR\n" }, { "category": "Nursing/other", "chartdate": "2135-09-28 00:00:00.000", "description": "Report", "row_id": 1442599, "text": "7a-7p\nsee transfer note\n" }, { "category": "Nursing/other", "chartdate": "2135-09-29 00:00:00.000", "description": "Report", "row_id": 1442600, "text": "TSICU NPN 11p-7a\nS/O-\n\nPt pre-op for halo palcement today. Pt had sleeper last evening and slept well most of shift.\n\n pt alert and oriented, MAE's w/ full strength, denies any numbness or tingling in extremities. Does c/o some aching pain at rest in the midposterior neck area, medicated times one w/ percocet one tab w/ good results noted. J collar intact and pt for halo this AM.\n\n pt stable w/ rate 55-65 in sinus, no ectopy. BP 125-135/60-65, AM labs wnl's. Extremities warm and dry w/ easily palpable pulses.\n\n pt on RA w/ RR 16-20 non labored. Breath sounds clear in all areas.\n\n pt NPO after midnight, IVF of D 5 1/2 NS at 70cc's hr via left peripheral IV. Abd soft nondistended. No nausea over night.\n\nGU- voiding w/o diff via foley cath.\n\nSkin- intact except right elbow.\n\nID- afebrile, endo- no coverage required.\n\nA/P- Halo placement today, con't pain mangement, DVT prophalaxis.\n" }, { "category": "Nursing/other", "chartdate": "2135-09-29 00:00:00.000", "description": "Report", "row_id": 1442601, "text": "FULL CODE Universal Precautions\nAllergies: erthromycin, codeine\n\n\nPt 3, MAEx4 spont/command w/o any difficulty, hand grasps/pedal pushes strong bilat - no deficits. c/o neck discomfort - relieved w/ percocet. HR=60s, NSR, no ectopy, BP=120/50s, +pedal pulses, extrems warm, no edema. On r/a w/ 02sats 98%, lungs clear, no cough. Abd soft, +BS, no BM, NPO since midnight for procedure. #18 in L Antec. R elbow abrasion - scabbed, heels/buttocks intact. Mom at bedside this am - updated by team.\n\nTX to PACU/CC6 after procedure\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-09-27 00:00:00.000", "description": "Report", "row_id": 1442597, "text": "npn 0700-1900;\nevents; cta and mrix2 pt reviewed by dr for surgical consultation.\ninjuries cta shows C2 pedicle fracture with bilateral displacement of mm ? Y2-T# disrupution exteriorly.\nmri; showed no ligamnetous soft tissue injury;soft tissue edema C4-C7\ns/b drs and who discussed options of hard c-collar for 3months with 50- 60% of . vest with fusion 70-75%. or surgical fusion C1-C. pts parent and brother of discussion asking appropriate questons.pt will think over options and decide in am. please see unsined reports.\ntls cleared by trauma team.\n\nros; neuro intact mae to command sensation intact denies any numbness or tinglingperla 2-3mmvery pleasnt and cooperative angry at times becomes very quiet when parents in visitng refferred to lisw.c/o of headache withnausea stated that it is as if she needs to eat something.\n\nresp; lungs clear diminished at bases encouraged to cdb rr sats 97% onra. c/o of stuffy nose.\n\ncvs; tmax 98.2 po nsr 59-75 no ectopy noted bp stable 120-135/60\n\ngu;passsing good amounts clear urine via foley\n\ngi; npo for most of day d/o of nausea resolved with anzemeet x2 and eating dry toast pos bs c/o of feeeling urge to stool but unable to use bedpan no coverage onriss.\n\nskin ; small abrasion onelbow with min serous drainage\n\naccess 18g in both anticubs lr to kvo\nsoc; brother for most of day very supportive.\n\na/p continue with frequent neiuro checks q2will advance to q4 if remains stable\noffer emotional support topt and pt's family\nawait pts decion re hard collar versus halo vest iin am.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2135-09-28 00:00:00.000", "description": "Report", "row_id": 1442598, "text": "T/SICU Nursing 19-07\nNeuro: A&Ox3, pleasant and cooperative. MAE with normal strength, GCS=15. PERRL. Requested and gave ambien for sleep with good effect.\n\nPain: At 04 complained of midsternal pain rated down to 2/10 with position change. No increase with deep breathing, pt states it has been present since injury. MD aware.\n\nResp: Lung sounds clear, equal bilaterally. No cough, denies dyspnea. SPO2 high 90's on room air.\n\nCV: Sinus rhythm with rate 60's-70's. BP WNL. P-boots on. Heparin sc.\n\nGI: Ate chocolate cake, enjoyed. Refuses any other food. Drinks H20 to thirst. Bowel sounds present.\n\nGU: Foley to gravity, CYU output.\n\nEndo: RISS with no coverage required.\n\nLytes: WNL.\n\nSkin: Intact, sm abrasion to right elbow scabbing over.\n\nAccess: PIVx1.\n\nPlan:\nMaintain safety\nPain management\nq4 hr neuro checks\nEmotional support\nSurgery vs collar vs halo\n?Transfer to floor depending on plan\n" } ]

[ { "category": "Physician ", "chartdate": "2101-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465924, "text": "Chief Complaint:\n 24 Hour Events:\n - Blood cultures grew MRSA\n - Urine cultures grew VRE->changed vanc to linezolid\n - Went to MRI spine for ?abscess->Wet read: No epidural abscess.\n Multilevel degenerative changes in the lumbar spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n - Hct to 24. Sent guaiac and hapto/TBili (pending)\n - O2 weaned to 1L NC during day then back to 3L NC overnight\n - HRs into 120s with BPs 120s/70s. Tried fluid bolus with no change.\n Gave 5mg lopressor with good effect->HRs to 80s-90s and BPs stable.\n - DFA was inadequate sample so re-sent\n - Weaned off pressors in am and remained off all day.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Linezolid - 10:36 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 11:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96\n HR: 97 (92 - 131) bpm\n BP: 139/81(95) {83/42(51) - 139/83(95)} mmHg\n RR: 19 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,093 mL\n 151 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,613 mL\n 151 mL\n Blood products:\n Total out:\n 1,420 mL\n 340 mL\n Urine:\n 1,420 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,673 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT dry mm\n Lungs: CTAB\n HEART: Irregularly irregular.\n ABD: Soft. Nt/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 323 K/uL\n 7.8 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 134 mEq/L\n 23.8 %\n 5.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n 01:30 AM\n WBC\n 8.7\n 7.2\n 5.5\n Hct\n 26.0\n 24.2\n 23.8\n Plt\n 299\n 335\n 323\n Cr\n 0.5\n 0.5\n 0.4\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n 103\n Other labs: PT / PTT / INR:14.4/69.8/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.2,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.8 mg/dL\n MRI L-Spine:\n No epidural abscess. Multilevel degenerative changes in the lumbar\n spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n # Fever: MRSA bacteremia and VRE UTI with hypothermia and tachycardia\n - Appreciate ID recs.\n - Consider TEE today for w/u of MRSA bacteremia and time course of abx\n as MRI negative for abscess and no other localizing symptoms for source\n - Cte linezolid and expand sensitivities on urine culture to make sure\n sensitive\n - Consider D/C zosyn as no GNs growing from cultures\n - F/u cx including viral resp culture as first sample inadequate\n - Pull femoral line if able today as now off pressors\n - cte flagyl while on abx for C diff history\n # Hypotension: Resolved. Likely from combination of rapid atrial\n fibrillation + sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n # Atrial fibrillation: Patient hypotensive in the setting of rapid a\n fib.\n - Holding home antihypertensive for now\n - Started amio as was slightly hypotensive initially but overnight\n tolerated IV lopressor so would favor transition to PO amio today and\n also PO beta blocker for rate control as amio has not converted her\n - IV heparin gtt for now->eventually conversion to coumadin\n # Anemia: Hct has dropped from 30->24 since admission. Suspect volume\n overload but also started ASA for demand ischemia in ED.\n - guaiac stools\n - Hemolysis labs not consistent with hemolysis (hapto 258)\n - hct today\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension but may be able to start today\n given off pressors and BPs stable but would favor beta blockade for AF\n first and if tolerates then lasix.\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control with amio as above\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n ICU Care\n Nutrition: HH diet\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: hep gtt\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: with patient and dtr\n status: Full code\n Disposition: ICU->transfer to floor pending d/c amio gtt\n" }, { "category": "Physician ", "chartdate": "2101-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465945, "text": "Chief Complaint:\n 24 Hour Events:\n - Blood cultures grew MRSA\n - Urine cultures grew VRE->changed vanc to linezolid\n - Went to MRI spine for ?abscess->Wet read: No epidural abscess.\n Multilevel degenerative changes in the lumbar spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n - Hct to 24. Guaiac and hemolysis labs not c/w hemolysis\n - O2 weaned to 1L NC during day then back to 3L NC overnight\n - HRs into 120s with BPs 120s/70s. Tried fluid bolus with no change.\n Gave 5mg lopressor with good effect->HRs to 80s-90s and BPs stable.\n - DFA was inadequate sample so re-sent\n - Weaned off pressors in am and remained off all day.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Linezolid - 10:36 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 11:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96\n HR: 97 (92 - 131) bpm\n BP: 139/81(95) {83/42(51) - 139/83(95)} mmHg\n RR: 19 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,093 mL\n 151 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,613 mL\n 151 mL\n Blood products:\n Total out:\n 1,420 mL\n 340 mL\n Urine:\n 1,420 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,673 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT dry mm\n Lungs: CTAB\n HEART: Irregularly irregular.\n ABD: Soft. Nt/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 323 K/uL\n 7.8 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 134 mEq/L\n 23.8 %\n 5.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n 01:30 AM\n WBC\n 8.7\n 7.2\n 5.5\n Hct\n 26.0\n 24.2\n 23.8\n Plt\n 299\n 335\n 323\n Cr\n 0.5\n 0.5\n 0.4\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n 103\n Other labs: PT / PTT / INR:14.4/69.8/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.2,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.8 mg/dL\n MRI L-Spine:\n No epidural abscess. Multilevel degenerative changes in the lumbar\n spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n # MRSA bacteremia and VRE UTI: Overnight hypothermia and tachycardia,\n but no elevation of WBC\n - Appreciate ID recs.\n - Cte linezolid and expand sensitivities on urine culture to make sure\n sensitive\n - Consider D/C zosyn if no GNs growing from sputum cultures\n - F/u cx including viral resp culture as first sample inadequate\n - Pull femoral line if able today as now off pressors\n - cte flagyl while on abx for C diff history\n - Consider TEE today for w/u of MRSA bacteremia and time course of abx\n as MRI negative for abscess and no other localizing symptoms for source\n # Hypotension: Resolved. Likely from combination of rapid atrial\n fibrillation + sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n # Atrial fibrillation: Patient hypotensive in the setting of rapid a\n fib.\n - Holding home antihypertensive for now\n - Started amio as was slightly hypotensive initially but overnight\n tolerated IV lopressor so would favor transition to PO amio today\n - Start PO beta blocker for rate control as amio has not converted her\n - IV heparin gtt for now->eventually conversion to coumadin\n # Anemia: Hct has dropped from 30->24 since admission while on heparin\n gtt. Suspect volume overload but also started ASA for demand ischemia\n in ED.\n - guaiac stools\n - Hemolysis labs not consistent with hemolysis (hapto 258)\n - d/c heparin for now\n - Consider CT abd for RP bleed if Hct continues to trend down.\n - hct today\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension but may be able to start today\n given off pressors and BPs stable but would favor beta blockade for AF\n first and if tolerates then lasix.\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control with amio as above -> transition to PO\n - PO betablocker\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n ICU Care\n Nutrition: HH diet\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: boots, d/c hep gtt\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: with patient and daughter\n status: Full code\n Disposition: ICU->transfer to floor pending d/c amio gtt\n" }, { "category": "Echo", "chartdate": "2101-06-10 00:00:00.000", "description": "Report", "row_id": 72076, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 64\nWeight (lb): 154\nBSA (m2): 1.75 m2\nBP (mm Hg): 143/71\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 14:58\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: No atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No masses or vegetations on aortic valve. Mild AS (area 1.2-1.9cm2).\nTrace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Moderate mitral annular calcification. Calcified tips of\npapillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. No TEE related complications. The rhythm appears to\nbe atrial fibrillation.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. LV systolic function\nappears mildly depressed. There are three moderately thickened, calcified\naortic valve leaflets. No masses or vegetations are seen on the aortic valve.\nThere is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\ntricuspid regurgitation is seen. No vegetation/mass is seen on the pulmonic\nvalve. There is no pericardial effusion. The visualized portions of the aorta,\nto 30 cm distal to the incisors, were free of significant atheroma.\n\nIMPRESSION: No intracardiac vegetation. Mild calcific aortic stenosis.\nModerate mitral and tricuspid regurgitation.\n\n\n" }, { "category": "Echo", "chartdate": "2101-06-07 00:00:00.000", "description": "Report", "row_id": 72077, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 124\nBSA (m2): 1.60 m2\nBP (mm Hg): 101/50\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal IVC diameter\n(<2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(0-10mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Normal regional LV systolic function. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR].\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n[Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TVP. Moderate to\nsevere [3+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. The\nestimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness,\ncavity size, and global systolic function are normal (LVEF>55%). Regional left\nventricular wall motion is normal. The right ventricular cavity is mildly\ndilated with normal free wall contractility. [Intrinsic right ventricular\nsystolic function is likely more depressed given the severity of tricuspid\nregurgitation.] The aortic valve leaflets are moderately thickened. There is\nmild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. Tricuspid\nvalve prolapse is present. Moderate to severe [3+] tricuspid regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal systolic function (EF 65%). Moderate-severe tricuspid\nregurgitation. Mild aortic stenosis. Moderate mitral regurgitation. Moderate\npulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , the TR is more\napparent with an increase in pulmonary pressures. The right ventricle is now\ndilated. Mitral regurgitation is increased.\n\n\n" }, { "category": "Respiratory ", "chartdate": "2101-06-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 465495, "text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Bedside Procedures:\n Nasal aspiration (2300)\n" }, { "category": "Physician ", "chartdate": "2101-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465497, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Remained in afib overnight but HR better controlled after bolus dose\n of diltiazem\n - Bcx growing out GPC in pairs and clusters in 4 of 4 bottles.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.7 mcg/Kg/min\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:20 PM\n Heparin Sodium - 06:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.9\nC (96.7\n HR: 94 (89 - 136) bpm\n BP: 110/60(72) {77/44(34) - 119/81(89)} mmHg\n RR: 17 (11 - 33) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Mixed Venous O2% Sat: 46 - 46\n Total In:\n 4,001 mL\n 234 mL\n PO:\n TF:\n IVF:\n 601 mL\n 234 mL\n Blood products:\n Total out:\n 400 mL\n 540 mL\n Urine:\n 150 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,601 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 299 K/uL\n 8.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n WBC\n 8.7\n Hct\n 26.0\n Plt\n 299\n Cr\n 0.5\n TropT\n 0.12\n 0.12\n Glucose\n 91\n Other labs: PT / PTT / INR:14.8/53.6/1.3, CK / CKMB /\n Troponin-T:27//0.12, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Ca++:7.2 mg/dL, Mg++:1.6 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; source unclear but may be\n from recent surgery. Pt afebrile overnight without leukocytosis on\n broad spectrum abx. Ddx includes urosepsis given + UA, ?pneumonia,\n viral syndrome, or recurrent C diff colitis.\n - Cont vanc for GPC, d/c cipro and zosyn\n - F/u sputum culture & DFA for viral antigen\n - F/u final CT chest\n - Consider thoracentesis\n - C diff unlikely given nl WBC\n - f/u culture data\n .\n # Hypotension: :Likely from combination of rapid atrial fibrillation +\n sepsis. See above for treatment of infection.\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - Dilt IV boluses prn for RVR; holding po doses for now in setting of\n hypotension on pressors\n - Consider amiodarone bolus if not responsive to dilt or BP unable to\n tolerate\n - Consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # H/o perforated ulcer: stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition: Low Na, Heart healthy\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Hep gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code, confirmed with pt\n Disposition: ICU until BP stable off pressors\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465482, "text": "Chief Complaint: fatigue (per admit resident note)\n HPI:\n Ms. is a yo woman with COPD & hypertension with recent ex-lap\n and omental patch for perforated duodenal ulcer (), percutaneous\n drainage of perihepatic abscess and recent C diff colitis. She was\n referred to the ED from rehab for fevers x 4 days and hypoxia. She was\n first noted to have fever to 102 on , she was begun on vancomycin.\n Levofloxacin was added on for persistent fever & bilateral\n infiltrates on CXR. Today her T was noted to be 100.2 and she was\n hypoxic to 80% on 2L n/c, improved with repositioning.\n .\n In the ED she was hypotensive to 77/59, febrile to 102.8, and had\n atrial fibrillation in 110's. She had numerous failed attempts at a\n L-IJ CVL; eventually received a L femoral line. She received 3L NS,\n vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o\n ischemic changes & CE's positive. She received aspirin, but no BB or\n CCB for her tachycardia. She was started on levophed shortly before\n transfer for hypotension to 80's systolic.\n .\n On transfer to the ICU Ms. complains of feeing fatigued. She also\n endorses chest pressure & mild dsypnea. She denies light-headedness,\n syncope, or recent falls. She is unaware of cough, abdominal pain, or\n diarrhea. She is unsure why she was sent to the hospital, although she\n is oriented to name, place, and general time.\n Shift Events:\n Admit to unit, transistioned from levophed to phenylephrine\n gtt for maps at or above 60\n Initiated heparin gtt. At 1000 units hr. First ptt under\n 40\n Oxygen, asa, beta blocker given, serial cardiac enzymes done\n Sepsis without organ dysfunction\n Assessment:\n Na 133, K wnl, mg. wnl, mucous membranes dry, urine output minimal.\n Awake and alert x3, mae, perl\n Action:\n Labs done, cipro given, vanco and zosyn started in ER, on contact\n precautions for (started rx prior to admit, 500cc fluid bolus\n given on admit\n Response:\n Stable bp on phenylephrine at .8 mcq/kgm/min\n Plan:\n Titrate pressors to maintain map at or above 60\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies chest pain, trop. .12 on second set cardiac enzymes, occasional\n ectopy no runs noted\n Action:\n Repeated card enzyments second set, oxygen, asa given, lopressor 5 mgm\n iv given\n Response:\n Evolving MI\n Plan:\n Repeat card enzymes 0800, cont. oxygen, asa daily, bedrest, monitor\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this night, blood cultures done x 2 in ER.,\n Action:\n Monitor fevers, contact precautions for (receiving treatment prior\n to admit) and droplet precautions until nasal swabs for resp . cutures\n returns\n Response:\n Stable\n Plan:\n Monitor temperature, respond as need with Tylenol., followup on blood\n cutures, droplet and contact precautions in place,\n Atrial fibrillation (Afib)\n Assessment:\n afib, denies chest pain, but does say she feel\nheavy\n in chest with hr\n 140\ns, , unclear if this is new afib or chronic\n Action:\n Diltiazem 5 mgm IV x 2 given with little response, lopressor 5 mgm IV\n given x 1 with response of decreasing hr to 90\ns. second dose held, HO\n noted hr , will hold on amiodorone for now, ekg done, heparin gtt\n started\n Response:\n Hr 80-90 with sleep, 90-100 with rest. No further heaviness\n Plan:\n Next ptt due 1130, adjust according to wt. based heparin scale\n Pleural effusion, acute\n Assessment:\n Lung fields clear to diminished at bases, no cough, no productive cough\n Action:\n On 3 liters nc , need 4-5 liters through night with sleep at\n pt. mouth breaths, sats 97%\n Response:\n Sats 97%\n Plan:\n Titrate oxygen to maintain sats above 90%, cough and deep breath, in am\n will add incentive spiromentry\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465593, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt growing GPC in blood cultures question source. Pt has bilateral\n consolidations on CXR, question urosepsis versus CDIFF. Pt afebrile.\n SBP 80-110s.\n Action:\n Continues on IV ABX, stool culture sent for CDIFF, on low dose levophed\n for hypotension. 500cc bolus this morning in attempt to wean off\n levophed. Attempted to wean off levophed completely this afternoon.\n Response:\n Remains afebrile, stool culture pending, SBP dropped to low 80s when\n levophed weaned down, reset to previous rate.\n Plan:\n Monitor temp curve, WBC, follow up stool spec, wean levophed as\n tolerated by pt. ID consulted.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from previous\n set.\n Plan:\n Follow up ECHO results, third set drawn at 1600 pending.\n Atrial fibrillation (Afib)\n Assessment:\n Pt with new AFIB, HR 80-120, occasional PVC.\n Action:\n On heparin gtt. PTT drawn at 1200\n Response:\n 1200/1800 PTT results therapeutic at 93/87.\n Plan:\n Will titrate heparin gtt according to PTTs.\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465794, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt with GPC bacteremia, +VRE, + MRSA. Unknown source at this time\n however team questioning urosepsis given WBC in urine, also questioning\n CDIFF. Pt remains afebrile. Received pt on low dose neo. SBP ranging\n 90-120s. OU >30cc/hr. Pt with documented back pain upon admission to\n unit.\n Action:\n Continues to receive broad spectrum ABX coverage, received 500cc bolus\n this AM in successful attempt to wean neo off. UO better with SBP\n >110. Taken for MR L spine this afternoon.\n Response:\n WBC WNL, neo weaned this AM remains off at this writing. Pt\n maintaining SBP >90. MRI results pending.\n Plan:\n Continue to trend temp and WBC, IV ABX as ordered, goal SBP >90,\n monitor UO. Follow up NR L spine results.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in AFIB 80-110s, up to 130s with stimulation.\n Action:\n On heparin gtt. Loaded and started on amiodarone gtt after pt having\n sustained HR in 130s.\n Response:\n PTT checked this AM, therapeutic at 74. Amiodarone gtt currently\n infusing at 1mg/min, started at 11:15am, decreased to 0.5mg/min at\n 5:15pm, due to be shut off at 1:15pm . HR continues to be erratic,\n 80-100s AFIB, up to 130s with stimulation.\n Plan:\n PTT to be rechecked at 1700, amio gtt due be shut off at 1:15pm .\n Continue to monitor rate and rhythm.\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465663, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:30 AM\n STOOL CULTURE - At 10:00 AM\n \n - Continued to require Pressors so A-line attempted.\n - Multiple attempts, but unable to get a-line.\n - ID recommended 1) continuing Zosyn. 2) TTE. 3) MR spine if\n unrevealing. 4) Consider Para/ if above unrevealing.\n - ECHO IMPRESSION: Normal systolic function (EF 65%). Moderate-severe\n tricuspid regurgitation. Mild aortic stenosis. Moderate mitral\n regurgitation. Moderate pulmonary hypertension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n HYPOXEMIA\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n PLEURAL EFFUSION, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465664, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:30 AM\n STOOL CULTURE - At 10:00 AM\n \n - Continued to require Pressors so A-line attempted.\n - Multiple attempts, but unable to get a-line.\n - ID recommended 1) continuing Zosyn. 2) TTE. 3) MR spine if\n unrevealing. 4) Consider Para/ if above unrevealing.\n - ECHO IMPRESSION: Normal systolic function (EF 65%). Moderate-severe\n tricuspid regurgitation. Mild aortic stenosis. Moderate mitral\n regurgitation. Moderate pulmonary hypertension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n HYPOXEMIA\n SEPSIS WITHOUT ORGAN DYSFUNCTION\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n ATRIAL FIBRILLATION (AFIB)\n PLEURAL EFFUSION, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465665, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 09:30 AM\n STOOL CULTURE - At 10:00 AM\n \n - Continued to require Pressors so A-line attempted.\n - Multiple attempts, but unable to get a-line.\n - ID recommended 1) continuing Zosyn. 2) TTE. 3) MR spine if\n unrevealing. 4) Consider Para/ if above unrevealing.\n - ECHO IMPRESSION: Normal systolic function (EF 65%). Moderate-severe\n tricuspid regurgitation. Mild aortic stenosis. Moderate mitral\n regurgitation. Moderate pulmonary hypertension.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; source unclear but may be\n from recent surgery in which case may be concern for VRE. also be\n from PNA. Could also have urosepsis as UA with WBCs. Continue\n vanc/flagyl.\n - Consider dapto for empiric treatment of VRE until sensitivities, d/c\n cipro and zosyn\n - F/u sputum culture & DFA for viral antigen\n - Consider TTE for endocarditis\n - F/u final CT chest\n - Consider thoracentesis if TTE negative\n - Consult ID re:enterococcal coverage with dapto/linezolid until\n sensitivities back.\n - C diff unlikely given nl WBC. Cte flagyl IV.\n - f/u culture data\n .\n # Hypotension: :Likely from combination of rapid atrial fibrillation +\n sepsis. See above for treatment of infection.\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - consider amio/dig for rate control given hypotension with AF\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - Dilt IV boluses prn for RVR; holding po doses for now in setting of\n hypotension on pressors\n - Consider amiodarone or dig for persistent hypotension if rates\n uncontrolled\n - Consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # H/o perforated ulcer: stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465786, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt with GPC bacteremia, +VRE, + MRSA. Unknown source at this time\n however team questioning urosepsis given WBC in urine, also questioning\n CDIFF. Pt remains afebrile. Received pt on low dose neo. SBP ranging\n 90-120s. OU >30cc/hr. Pt with documented back pain upon admission to\n unit.\n Action:\n Continues to receive broad spectrum ABX coverage, received 500cc bolus\n this AM in successful attempt to wean neo off. UO better with SBP\n >110. Taken for MR L spine this afternoon.\n Response:\n WBC WNL, neo weaned this AM remains off at this writing. Pt\n maintaining SBP >90. MRI results pending.\n Plan:\n Continue to trend temp and WBC, IV ABX as ordered, goal SBP >90,\n monitor UO. Follow up NR L spine results.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in AFIB 80-110s, up to 130s with stimulation.\n Action:\n On heparin gtt. Loaded and started on amiodarone gtt after pt having\n sustained HR in 130s.\n Response:\n PTT checked this AM, therapeutic at 74. Amiodarone gtt currently\n infusing at 1mg/min, started at 11:15am, decreased to 0.5mg/min at\n 5:15pm, due to be shut off at 1:15pm .\n Plan:\n PTT to be rechecked at 1700, amio gtt due be shut off at 1:15pm .\n Continue to monitor rate and rhythm.\n" }, { "category": "Physician ", "chartdate": "2101-06-07 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 465582, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Remained in afib overnight but HR better controlled after bolus dose\n of diltiazem\n - Bcx growing out GPC in pairs and clusters in 4 of 4 bottles.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.7 mcg/Kg/min\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:20 PM\n Heparin Sodium - 06:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.9\nC (96.7\n HR: 94 (89 - 136) bpm\n BP: 110/60(72) {77/44(34) - 119/81(89)} mmHg\n RR: 17 (11 - 33) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Mixed Venous O2% Sat: 46 - 46\n Total In:\n 4,001 mL\n 234 mL\n PO:\n TF:\n IVF:\n 601 mL\n 234 mL\n Blood products:\n Total out:\n 400 mL\n 540 mL\n Urine:\n 150 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,601 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 299 K/uL\n 8.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n WBC\n 8.7\n Hct\n 26.0\n Plt\n 299\n Cr\n 0.5\n TropT\n 0.12\n 0.12\n Glucose\n 91\n Other labs: PT / PTT / INR:14.8/53.6/1.3, CK / CKMB /\n Troponin-T:27//0.12, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Ca++:7.2 mg/dL, Mg++:1.6 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; source unclear but may be\n from recent surgery in which case may be concern for VRE. also be\n from PNA. Could also have urosepsis as UA with WBCs. Continue\n vanc/flagyl.\n - Consider dapto for empiric treatment of VRE until sensitivities, d/c\n cipro and zosyn\n - F/u sputum culture & DFA for viral antigen\n - Consider TTE for endocarditis\n - F/u final CT chest\n - Consider thoracentesis if TTE negative\n - Consult ID re:enterococcal coverage with dapto/linezolid until\n sensitivities back.\n - C diff unlikely given nl WBC. Cte flagyl IV.\n - f/u culture data\n .\n # Hypotension: :Likely from combination of rapid atrial fibrillation +\n sepsis. See above for treatment of infection.\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - consider amio/dig for rate control given hypotension with AF\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - Dilt IV boluses prn for RVR; holding po doses for now in setting of\n hypotension on pressors\n - Consider amiodarone or dig for persistent hypotension if rates\n uncontrolled\n - Consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # H/o perforated ulcer: stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition: Low Na, Heart healthy\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Hep gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code, confirmed with pt\n Disposition: ICU until BP stable off pressors\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: F COPD, HTN, recent perf DU c/b abscess and\n c. diff. Was at rehab, developed 4d fevers and hypoxia. New AF c/b RVR\n in ED c fevers to 102.8. L fem line placed, abx, IVF, xfer to MICU. BCx\n + GPCs this AM. Currently on low dose neo.\n Exam notable for Tm 102.8 BP 110/50 HR 90 RR 20-24 with sat 96 on RA.\n Frail woman, NAD. Coarse BS B. RRR s1s2. Soft +BS, well healed scar.\n Labs notable for WBC 6K, HCT 30, K+ 4.0, Cr 0.6.\n Agree with plan to manage high grade GPC bacteremia with IV vanco for\n now. Will d/w ID re dapto or linezolid and will check echo (TTE) now.\n Will continue IVF and pressor support with goal to wran off pressors\n with IVF today. Will d/c flagyl if c. diff is negative. For AF c RVR,\n can start dig and consider amio if rate remains high; will continue\n heparin IV for now. Surgery aware of admission, CT stable, tolerating\n POs and +BM. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:19 PM ------\n" }, { "category": "Physician ", "chartdate": "2101-06-09 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465863, "text": "Chief Complaint:\n 24 Hour Events:\n - Blood cultures grew MRSA\n - Urine cultures grew VRE->changed vanc to linezolid\n - Went to MRI spine for ?abscess->Wet read: No epidural abscess.\n Multilevel degenerative changes in the lumbar spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n - Hct to 24. Sent guaiac and hapto/TBili (pending)\n - O2 weaned to 1L NC during day then back to 3L NC overnight\n - HRs into 120s with BPs 120s/70s. Gave 5mg lopressor with good effect\n - DFA was inadequate sample so re-sent\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Linezolid - 10:36 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 11:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96\n HR: 97 (92 - 131) bpm\n BP: 139/81(95) {83/42(51) - 139/83(95)} mmHg\n RR: 19 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,093 mL\n 151 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,613 mL\n 151 mL\n Blood products:\n Total out:\n 1,420 mL\n 340 mL\n Urine:\n 1,420 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,673 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 323 K/uL\n 7.8 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 134 mEq/L\n 23.8 %\n 5.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n 01:30 AM\n WBC\n 8.7\n 7.2\n 5.5\n Hct\n 26.0\n 24.2\n 23.8\n Plt\n 299\n 335\n 323\n Cr\n 0.5\n 0.5\n 0.4\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n 103\n Other labs: PT / PTT / INR:14.4/69.8/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.2,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; /spec pending. Urine\n now with >100,000 enterococcus; pending\n unclear if related\n source as could be spillover from Bcx (?source from recent surgery) or\n separate infection. Concern for endocarditis despite neg TTE. Also\n spine infection given tenderness and weakness and empyema given large\n pleural effusions. Lower on differential would be line source,\n peritonitis. Also concern for influenza.\n - Appreciate ID recs -> thought likely MRSA bacteremia. Consider MRI\n spine/TEE/. However, may be more likely enterococcus in blood and\n urine. Will d/w ID ?dapto/linezolid instead of vanco and d/c flagyl as\n cdiff neg.\n - F/u cx including viral resp culture\n - Pull femoral line when able\n - cte flagyl while on abx for C diff history\n # Hypotension: Likely from combination of rapid atrial fibrillation +\n sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - amio gtt for AF\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Holding home antihypertensive for now\n - given BP limitation w/ beta blocker and CCB, pharm conversion with\n amiodarone. Mod suggests decreased response to DCCV.\n - IV heparin gtt for now\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control with amio as above\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465643, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. Phenylephrine gtt on low dose for MAP>60. Afib 100s-110s on\n neo. A&O x 3. C/o HA, no other c/o at rest but moving pt in bed is\n uncomfortable. UOP>50cc/hr. +2 pitting edema in LE.\n Action:\n 500cc fluid bolus given. Neo gtt weaned off slowly O/N, however when pt\n needed lopressor for rate control for her Afib, her BP decreased to low\n 80s/40s with drop in UOP so neo gtt restarted. Antibx.\n Response:\n Remains afebrile. Still needs low dose neo for MAP>60. Difficult to\n manage afib with hypotension.\n Plan:\n Wean neo gtt as tolerated. Antibx. Contact and droplet precautions.\n Atrial fibrillation (Afib)\n Assessment:\n Afib 100s-110s most of the night until this AM when HR ^^ 120s-130s. On\n heparin gtt.\n Action:\n Lopressor 5 mg IV for Afib 130s. PTT 101.4 this AM->decreased gtt to\n 1000 unit/hr.\n Response:\n After lopressor HR slowed to 80s-90s, BP also decreased to low 80s/40s\n with drop in UOP. Neo gtt restarted at low dose.\n Plan:\n ? start dig or amiodarone today for Afib. Recheck PTT @ 10AM\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 465984, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n :. L fem line pulled, pt has PIVx2.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 90\ns-120\ns , BP 110s-130s/. A&O x 3. UOP < 30cc/hr.\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. Per ss.\n Action:\n Heparin and amiodarone gtts stopped, amiodarone/ beta blocker changed\n to PO\n Response:\n No significant change in HR and BP, PO lopressor tol well.\n Plan:\n Cont PO amiodarone/ lopressor, pneumo boots for DVT prophlaxsis.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results 2^nd spec\n obtained also returned inadequate.\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. 3^rd spec sent this am, sputum spec ordered, pt\n unable to produce sputum at this time.\n Response:\n Afebrile. DFA results pending.\n Plan:\n Contact and droplet precautions. Follow CX results. f/u 3^rd DFA to r/o\n flu. Antibx. ? TEE to r/o vegetation. Need stool and sputum specs when\n available.\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 465998, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n :. L fem line pulled, pt has PIVx2. pt going to US for LENI\ns at\n 14:45\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 90\ns-120\ns , BP 110s-130s/. A&O x 3. UOP < 30cc/hr.\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. Per ss.\n Action:\n Heparin and amiodarone gtts stopped, amiodarone/ beta blocker changed\n to PO\n Response:\n No significant change in HR and BP, PO lopressor tol well.\n Plan:\n Cont PO amiodarone/ lopressor, pneumo boots for DVT prophlaxsis.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results 2^nd spec\n obtained also returned inadequate.\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. 3^rd spec sent this am, sputum spec ordered, pt\n unable to produce sputum at this time.\n Response:\n Afebrile. DFA results pending.\n Plan:\n Contact and droplet precautions. Follow CX results. f/u 3^rd DFA to r/o\n flu. Antibx. ? TEE to r/o vegetation. Need stool and sputum specs when\n available.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n UROSEPSIS;NSTEMI\n Code status:\n Full code\n Height:\n 64 Inch\n Admission weight:\n 71.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact, Droplet\n PMH: COPD\n CV-PMH: Hypertension\n Additional history: COPD, HTN, PUD, Cataract surgery bilaterally\n recent exp lap,\n Surgery / Procedure and date: Exploratory lap on for perf duodenal\n ulcer. Pt currently has steri strips to abdomen.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:74\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 515 mL\n 24h total out:\n 1,090 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 01:30 AM\n Potassium:\n 3.8 mEq/L\n 01:30 AM\n Chloride:\n 103 mEq/L\n 01:30 AM\n CO2:\n 26 mEq/L\n 01:30 AM\n BUN:\n 11 mg/dL\n 01:30 AM\n Creatinine:\n 0.4 mg/dL\n 01:30 AM\n Glucose:\n 103 mg/dL\n 01:30 AM\n Hematocrit:\n 23.7 %\n 01:08 PM\n Finger Stick Glucose:\n 119\n 10:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC7\n Date & time of Transfer: 14:30\n" }, { "category": "General", "chartdate": "2101-06-07 00:00:00.000", "description": "ICU Event Note", "row_id": 465610, "text": "Clinician: Resident\n Patient was consented, time out performed, sterile prepped and draped,\n 1cc of 2% lidocaine infused subcutaneously. Arrow kit used for aline w/\n 3 successful flashes but inability to thread wire. Small hematoma at\n site. Given hematoma and patient discomfort, further attempts were\n held.\n Total time spent: 40 minutes\n Patient is critically ill.\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465735, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465715, "text": "Chief Complaint:\n 24 Hour Events:\n - Seen by ID for bcx growing coag positive staph. Thought endocarditis\n was concerning source. Enterococcus UTI may represent spill-over from\n bacteremia. Vegetation not seen on TTE. Also spine infection, empyema.\n Lower on differential would be likely line source, peritonitis. Also\n concern for influenza.\n - Received metoprolol 5mg IV x 1 for afib with RVR with response in HR\n but drop in BP. Continued to require pressors. A-line planned but\n placement unsuccessful despite multiple attempts.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Rapid resp viral screen: Ag screen not interpretable; viral cx pending.\n TTE: Normal systolic function (EF 65%). Moderate-severe tricuspid\n regurgitation. Mild aortic stenosis. Moderate mitral regurgitation.\n Moderate pulmonary hypertension.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; /spec pending. Urine\n now with >100,000 enterococcus; pending\n unclear if related\n source as could be spillover from Bcx (?source from recent surgery) or\n separate infection. Concern for endocarditis despite neg TTE. Also\n spine infection given tenderness and weakness and empyema given large\n pleural effusions. Lower on differential would be line source,\n peritonitis. Also concern for influenza.\n - Appreciate ID recs -> thought likely MRSA bacteremia. Consider MRI\n spine/TEE/. However, may be more likely enterococcus in blood and\n urine. Will d/w ID ?dapto/linezolid instead of vanco and d/c flagyl as\n cdiff neg.\n - F/u cx including viral resp culture\n - Pull femoral line when able\n - cte flagyl while on abx for C diff history\n # Hypotension: Likely from combination of rapid atrial fibrillation +\n sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - amio gtt for AF\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Holding home antihypertensive for now\n - given BP limitation w/ beta blocker and CCB, pharm conversion with\n amiodarone. Mod suggests decreased response to DCCV.\n - IV heparin gtt for now\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control with amio as above\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n ICU Care\n Nutrition: Low sodium, heart healthy\n Glycemic Control:\n Lines: Try to place PICC today\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU until HR lower\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465822, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465896, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 110s-130s, BP 110s-130s/. A&O x 3. UOP < 30cc/hr.\n Action:\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. 500cc fluid bolus given.\n PTT drawn @ 1:30.\n Response:\n No significant change in HR and BP, UOP increased after fluid.\n Lopressor 5 mg IVP given with HR slowing to 80s-90s Afib. BP remained\n in 120s/. PTT 69.8, no change in heparin gtt (therapeutic x 2).\n Plan:\n Amiodarone gtt, stop gtt today @ 11:15 AM. Heparin gtt per algorithm.\n Lopressor prn for RAF. Monitor VS and UOP in response to meds.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n in urine and +MRSA in BC x , ? urosepsis vs MRSA bacteremia. MRI\n lower spine done\nper wet read no abscess on spine. DFA sent yesterday\n inadequate for test results (2^nd spec obtained).\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. Resp will obtain another spec this AM.\n Response:\n Afebrile. BP stable off of neo gtt.\n Plan:\n Contact and droplet precautions. Follow CX results. Obtain 3^rd DFA to\n r/o flu. Antibx. ? TEE to r/o vegetation. Need stool spec when\n available.\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465698, "text": "Chief Complaint:\n 24 Hour Events:\n - Seen by ID for bcx growing coag positive staph. Thought endocarditis\n was concerning source. Enterococcus UTI may represent spill-over from\n bacteremia. Vegetation not seen on TTE. Also spine infection, empyema.\n Lower on differential would be likely line source, peritonitis. Also\n concern for influenza.\n - Received metoprolol 5mg IV x 1 for afib with RVR with response in HR\n but drop in BP. Continued to require pressors. A-line planned but\n placement unsuccessful despite multiple attempts.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Rapid resp viral screen: Ag screen not interpretable; viral cx pending.\n TTE: Normal systolic function (EF 65%). Moderate-severe tricuspid\n regurgitation. Mild aortic stenosis. Moderate mitral regurgitation.\n Moderate pulmonary hypertension.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; /spec pending. Urine\n now with >100,000 enterococcus; pending\n unclear if related\n source as could be spillover from Bcx (?source from recent surgery) or\n separate infection. Concern for endocarditis despite neg TTE. Also\n spine infection given tenderness and weakness and empyema given large\n pleural effusions. Lower on differential would be likely line source,\n peritonitis. Also concern for influenza.\n - Appreciate ID recs\n - On zosyn. Consider switching vanc to dapto for empiric treatment of\n VRE until sensitivities\n - Consider TEE for endocarditis\n - F/u cx including viral resp culture\n - Consider MRI spine, then thoracentesis if TEE negative\n - C diff neg with nl WBC although may be negative as treated early;\n cont flagyl IV for now\n .\n # Hypotension: Likely from combination of rapid atrial fibrillation +\n sepsis; requiring pressors\n - Tx infection as above\n - Currently receiving IV fluids to see if can wean off neo\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - given BP limitation w/ beta blocker and CCB, consider pharm\n conversion with amiodarone or digoxin. Mod suggests\n decreased response to DCCV.\n - IV heparin gtt for now\n .\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n ICU Care\n Nutrition: Low sodium, heart healthy\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending pressor requirement\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465700, "text": "Chief Complaint:\n 24 Hour Events:\n - Seen by ID for bcx growing coag positive staph. Thought endocarditis\n was concerning source. Enterococcus UTI may represent spill-over from\n bacteremia. Vegetation not seen on TTE. Also spine infection, empyema.\n Lower on differential would be likely line source, peritonitis. Also\n concern for influenza.\n - Received metoprolol 5mg IV x 1 for afib with RVR with response in HR\n but drop in BP. Continued to require pressors. A-line planned but\n placement unsuccessful despite multiple attempts.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Rapid resp viral screen: Ag screen not interpretable; viral cx pending.\n TTE: Normal systolic function (EF 65%). Moderate-severe tricuspid\n regurgitation. Mild aortic stenosis. Moderate mitral regurgitation.\n Moderate pulmonary hypertension.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; /spec pending. Urine\n now with >100,000 enterococcus; pending\n unclear if related\n source as could be spillover from Bcx (?source from recent surgery) or\n separate infection. Concern for endocarditis despite neg TTE. Also\n spine infection given tenderness and weakness and empyema given large\n pleural effusions. Lower on differential would be likely line source,\n peritonitis. Also concern for influenza.\n - Appreciate ID recs\n - On zosyn. Consider switching vanc to dapto for empiric treatment of\n VRE until sensitivities\n - Consider TEE for endocarditis\n - F/u cx including viral resp culture\n - Consider MRI spine, then thoracentesis if TEE negative\n - Pull femoral line when able\n - C diff neg with nl WBC although may be negative as treated early;\n cont flagyl IV for now\n .\n # Hypotension: Likely from combination of rapid atrial fibrillation +\n sepsis; requiring pressors\n - Tx infection as above\n - Currently receiving IV fluids to see if can wean off neo\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - given BP limitation w/ beta blocker and CCB, consider pharm\n conversion with amiodarone or digoxin. Mod suggests\n decreased response to DCCV.\n - IV heparin gtt for now\n .\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n ICU Care\n Nutrition: Low sodium, heart healthy\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending pressor requirement\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465893, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 110s-130s, BP 110s-130s/. A&O x 3. UOP < 30cc/hr.\n Action:\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. 500cc fluid bolus given.\n PTT drawn @ 1:30.\n Response:\n No significant change in HR and BP, UOP increased after fluid.\n Lopressor 5 mg IVP given with HR slowing to 80s-90s Afib. BP remained\n in 120s/. PTT 69.8, no change in heparin gtt.\n Plan:\n Amiodarone gtt, stop gtt today @ 13:15 PM. Heparin gtt per algorithm.\n Lopressor prn for RAF. Monitor VS and UOP in response to meds.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results (2^nd spec\n obtained).\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. Resp will obtain another spec this AM.\n Response:\n Afebrile. BP stable off of neo gtt.\n Plan:\n Contact and droplet precautions. Follow CX results. Obtain 3^rd DFA to\n r/o flu. Antibx. ? TEE to r/o vegetation. Need stool spec when\n available.\n" }, { "category": "Physician ", "chartdate": "2101-06-09 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 466020, "text": "Chief Complaint:\n 24 Hour Events:\n - Blood cultures grew MRSA\n - Urine cultures grew VRE->changed vanc to linezolid\n - Went to MRI spine for ?abscess->Wet read: No epidural abscess.\n Multilevel degenerative changes in the lumbar spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n - Hct to 24. Guaiac and hemolysis labs not c/w hemolysis\n - O2 weaned to 1L NC during day then back to 3L NC overnight\n - HRs into 120s with BPs 120s/70s. Tried fluid bolus with no change.\n Gave 5mg lopressor with good effect->HRs to 80s-90s and BPs stable.\n - DFA was inadequate sample so re-sent\n - Weaned off pressors in am and remained off all day.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 09:00 PM\n Linezolid - 10:36 PM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 11:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96\n HR: 97 (92 - 131) bpm\n BP: 139/81(95) {83/42(51) - 139/83(95)} mmHg\n RR: 19 (16 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 64 Inch\n Total In:\n 3,093 mL\n 151 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,613 mL\n 151 mL\n Blood products:\n Total out:\n 1,420 mL\n 340 mL\n Urine:\n 1,420 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,673 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT dry mm\n Lungs: CTAB\n HEART: Irregularly irregular.\n ABD: Soft. Nt/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 323 K/uL\n 7.8 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 11 mg/dL\n 103 mEq/L\n 134 mEq/L\n 23.8 %\n 5.5 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n 01:30 AM\n WBC\n 8.7\n 7.2\n 5.5\n Hct\n 26.0\n 24.2\n 23.8\n Plt\n 299\n 335\n 323\n Cr\n 0.5\n 0.5\n 0.4\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n 103\n Other labs: PT / PTT / INR:14.4/69.8/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.2,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.8 mg/dL\n MRI L-Spine:\n No epidural abscess. Multilevel degenerative changes in the lumbar\n spine most\n pronounced at L4-5 level with severe multifactorial spinal canal\n stenosis.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with .\n # MRSA bacteremia and VRE UTI: Overnight hypothermia and tachycardia,\n but no elevation of WBC\n - Appreciate ID recs.\n - Cte linezolid and expand sensitivities on urine culture to make sure\n sensitive\n - Consider D/C zosyn if no GNs growing from sputum cultures\n - F/u cx including viral resp culture as first sample inadequate\n - Pull femoral line if able today as now off pressors\n - cte flagyl while on abx for C diff history\n - Consider TEE today for w/u of MRSA bacteremia and time course of abx\n as MRI negative for abscess and no other localizing symptoms for source\n # Hypotension: Resolved. Likely from combination of rapid atrial\n fibrillation + sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n # Atrial fibrillation: Patient hypotensive in the setting of rapid a\n fib.\n - Holding home antihypertensive for now\n - Started amio as was slightly hypotensive initially but overnight\n tolerated IV lopressor so would favor transition to PO amio today\n - Start PO beta blocker for rate control as amio has not converted her\n - IV heparin gtt for now->eventually conversion to coumadin\n # Anemia: Hct has dropped from 30->24 since admission while on heparin\n gtt. Suspect volume overload but also started ASA for demand ischemia\n in ED.\n - guaiac stools\n - Hemolysis labs not consistent with hemolysis (hapto 258)\n - d/c heparin for now\n - Consider CT abd for RP bleed if Hct continues to trend down.\n - hct today\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension but may be able to start today\n given off pressors and BPs stable but would favor beta blockade for AF\n first and if tolerates then lasix.\n # Demand ischemia: In setting of afib with and sepsis\n - Rate control with amio as above -> transition to PO\n - PO betablocker\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n ICU Care\n Nutrition: HH diet\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: boots, d/c hep gtt\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments: with patient and daughter\n status: Full code\n Disposition: ICU->transfer to floor pending d/c amio gtt\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 90F COPD, HTN, recent perf DU c/b abscess and\n c. diff. Was at rehab, developed 4d fevers and hypoxia. New AF c/b \n in ED c fevers to 102.8. BCx + MRSA, UCx enterococcus. Rate control\n remains an issue, off pressors. Spine MRI complete, HCT down this AM.\n Exam notable for Tm 97.3 BP 130/50 HR 90-130 RR 20-24 with sat 99 on\n 1-3LNC. Frail woman, NAD. Coarse BS B. RRR s1s2. Soft +BS, well healed\n scar. Labs notable for WBC 7K, HCT 30, K+ 3.4, Cr 0.5.\n Agree with plan to manage high-grade GPC bacteremia and VRE UTI with\n linezolid. Will continue flagyl given recent c. diff. Will need TEE\n down the line to assess duration of rx, but would hold off until rate\n control is optimized. Will check MRI read today (prelim negative for\n focal collection). For AF , continue amio and start low dose\n PO metoprolol. Given anemia, d/c heparin for now and check abdominal CT\n if it continues to drop - ?RP bleeding, HCT goal >22. For recent ulcer\n / perforation, surgery aware of admission, CT stable, tolerating POs\n and +BM. Will d/c CVL today. OOB, ADAT, PPI. Remainder of plan as\n outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:16 PM ------\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465457, "text": "Chief Complaint: fatigue (per admit resident note)\n HPI:\n Ms. is a yo woman with COPD & hypertension with recent ex-lap\n and omental patch for perforated duodenal ulcer (), percutaneous\n drainage of perihepatic abscess and recent C diff colitis. She was\n referred to the ED from rehab for fevers x 4 days and hypoxia. She was\n first noted to have fever to 102 on , she was begun on vancomycin.\n Levofloxacin was added on for persistent fever & bilateral\n infiltrates on CXR. Today her T was noted to be 100.2 and she was\n hypoxic to 80% on 2L n/c, improved with repositioning.\n .\n In the ED she was hypotensive to 77/59, febrile to 102.8, and had\n atrial fibrillation in 110's. She had numerous failed attempts at a\n L-IJ CVL; eventually received a L femoral line. She received 3L NS,\n vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o\n ischemic changes & CE's positive. She received aspirin, but no BB or\n CCB for her tachycardia. She was started on levophed shortly before\n transfer for hypotension to 80's systolic.\n .\n On transfer to the ICU Ms. complains of feeing fatigued. She also\n endorses chest pressure & mild dsypnea. She denies light-headedness,\n syncope, or recent falls. She is unaware of cough, abdominal pain, or\n diarrhea. She is unsure why she was sent to the hospital, although she\n is oriented to name, place, and general time.\n Shift Events:\n Admit to unit, transistioned from levophed to phenylephrine\n gtt for maps at or above 60\n Initiated heparin gtt. At 1000 units hr. First ptt under\n 40\n Oxygen, asa, beta blocker given, serial cardiac enzymes done\n Sepsis without organ dysfunction\n Assessment:\n Na 133, K wnl, mg. wnl, mucous membranes dry, urine output minimal.\n Awake and alert x3, mae, perl\n Action:\n Labs done, cipro given, vanco and zosyn started in ER, on contact\n precautions for (started rx prior to admit, 500cc fluid bolus\n given on admit\n Response:\n Stable bp on phenylephrine at .8 mcq/kgm/min\n Plan:\n Titrate pressors to maintain map at or above 60\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies chest pain, trop. .12 on second set cardiac enzymes, occasional\n ectopy no runs noted\n Action:\n Repeated card enzyments second set, oxygen, asa given, lopressor 5 mgm\n iv given\n Response:\n Evolving MI\n Plan:\n Repeat card enzymes 0800, cont. oxygen, asa daily, bedrest, monitor\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this night, blood cultures done x 2 in ER.,\n Action:\n Monitor fevers, contact precautions for (receiving treatment prior\n to admit) and droplet precautions until nasal swabs for resp . cutures\n returns\n Response:\n Stable\n Plan:\n Monitor temperature, respond as need with Tylenol., followup on blood\n cutures, droplet and contact precautions in place,\n Atrial fibrillation (Afib)\n Assessment:\n Chronic afib, denies chest pain, but does say she feel\nheavy\n in chest\n with hr 140\n Action:\n Diltiazem 5 mgm IV x 2 given with little response, lopressor 5 mgm IV\n given x 1 with response of decreasing hr to 90\ns. second dose held, HO\n noted hr , will hold on amiodorone for now, ekg done, heparin gtt\n started\n Response:\n Hr 80-90 with sleep, 90-100 with rest. No further heaviness\n Plan:\n Next ptt due 0400, adjust according to wt. based heparin scale\n Pleural effusion, acute\n Assessment:\n Lung fields clear to diminished at bases, no cough, no productive cough\n Action:\n On 3 liters nc , need 4-5 liters through night with sleep at\n pt. mouth breaths, sats 97%\n Response:\n Sats 97%\n Plan:\n Titrate oxygen to maintain sats above 90%, cough and deep breath, in am\n will add incentive spiromentry\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465458, "text": "Chief Complaint: fatigue (per admit resident note)\n HPI:\n Ms. is a yo woman with COPD & hypertension with recent ex-lap\n and omental patch for perforated duodenal ulcer (), percutaneous\n drainage of perihepatic abscess and recent C diff colitis. She was\n referred to the ED from rehab for fevers x 4 days and hypoxia. She was\n first noted to have fever to 102 on , she was begun on vancomycin.\n Levofloxacin was added on for persistent fever & bilateral\n infiltrates on CXR. Today her T was noted to be 100.2 and she was\n hypoxic to 80% on 2L n/c, improved with repositioning.\n .\n In the ED she was hypotensive to 77/59, febrile to 102.8, and had\n atrial fibrillation in 110's. She had numerous failed attempts at a\n L-IJ CVL; eventually received a L femoral line. She received 3L NS,\n vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o\n ischemic changes & CE's positive. She received aspirin, but no BB or\n CCB for her tachycardia. She was started on levophed shortly before\n transfer for hypotension to 80's systolic.\n .\n On transfer to the ICU Ms. complains of feeing fatigued. She also\n endorses chest pressure & mild dsypnea. She denies light-headedness,\n syncope, or recent falls. She is unaware of cough, abdominal pain, or\n diarrhea. She is unsure why she was sent to the hospital, although she\n is oriented to name, place, and general time.\n Shift Events:\n Admit to unit, transistioned from levophed to phenylephrine\n gtt for maps at or above 60\n Initiated heparin gtt. At 1000 units hr. First ptt under\n 40\n Oxygen, asa, beta blocker given, serial cardiac enzymes done\n Sepsis without organ dysfunction\n Assessment:\n Na 133, K wnl, mg. wnl, mucous membranes dry, urine output minimal.\n Awake and alert x3, mae, perl\n Action:\n Labs done, cipro given, vanco and zosyn started in ER, on contact\n precautions for (started rx prior to admit, 500cc fluid bolus\n given on admit\n Response:\n Stable bp on phenylephrine at .8 mcq/kgm/min\n Plan:\n Titrate pressors to maintain map at or above 60\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies chest pain, trop. .12 on second set cardiac enzymes, occasional\n ectopy no runs noted\n Action:\n Repeated card enzyments second set, oxygen, asa given, lopressor 5 mgm\n iv given\n Response:\n Evolving MI\n Plan:\n Repeat card enzymes 0800, cont. oxygen, asa daily, bedrest, monitor\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this night, blood cultures done x 2 in ER.,\n Action:\n Monitor fevers, contact precautions for (receiving treatment prior\n to admit) and droplet precautions until nasal swabs for resp . cutures\n returns\n Response:\n Stable\n Plan:\n Monitor temperature, respond as need with Tylenol., followup on blood\n cutures, droplet and contact precautions in place,\n Atrial fibrillation (Afib)\n Assessment:\n afib, denies chest pain, but does say she feel\nheavy\n in chest with hr\n 140\ns, , unclear if this is new afib or chronic\n Action:\n Diltiazem 5 mgm IV x 2 given with little response, lopressor 5 mgm IV\n given x 1 with response of decreasing hr to 90\ns. second dose held, HO\n noted hr , will hold on amiodorone for now, ekg done, heparin gtt\n started\n Response:\n Hr 80-90 with sleep, 90-100 with rest. No further heaviness\n Plan:\n Next ptt due 0400, adjust according to wt. based heparin scale\n Pleural effusion, acute\n Assessment:\n Lung fields clear to diminished at bases, no cough, no productive cough\n Action:\n On 3 liters nc , need 4-5 liters through night with sleep at\n pt. mouth breaths, sats 97%\n Response:\n Sats 97%\n Plan:\n Titrate oxygen to maintain sats above 90%, cough and deep breath, in am\n will add incentive spiromentry\n" }, { "category": "Physician ", "chartdate": "2101-06-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 465447, "text": "Chief Complaint: fatigue\n HPI:\n Ms. is a yo woman with COPD & hypertension with recent ex-lap\n and omental patch for perforated duodenal ulcer (), percutaneous\n drainage of perihepatic abscess and recent C diff colitis. She was\n referred to the ED from rehab for fevers x 4 days and hypoxia. She was\n first noted to have fever to 102 on , she was begun on vancomycin.\n Levofloxacin was added on for persistent fever & bilateral\n infiltrates on CXR. Today her T was noted to be 100.2 and she was\n hypoxic to 80% on 2L n/c, improved with repositioning.\n .\n In the ED she was hypotensive to 77/59, febrile to 102.8, and had\n atrial fibrillation in 110's. She had numerous failed attempts at a\n L-IJ CVL; eventually received a L femoral line. She received 3L NS,\n vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o\n ischemic changes & CE's positive. She received aspirin, but no BB or\n CCB for her tachycardia. She was started on levophed shortly before\n transfer for hypotension to 80's systolic.\n .\n On transfer to the ICU Ms. complains of feeing fatigued. She also\n endorses chest pressure & mild dsypnea. She denies light-headedness,\n syncope, or recent falls. She is unaware of cough, abdominal pain, or\n diarrhea. She is unsure why she was sent to the hospital, although she\n is oriented to name, place, and general time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -COPD/RAD, with prior admissions for Prednisone\n -Hypertension\n -Palpitations secondary to frequent APBs\n -Dysthymia/depression, followed by Dr. ,\n psychiatry, in , MA (on escitalopram)\n -Vertigo\n -Hearing impairment with R hearing aid\n -Urge urinary incontinence\n -PUD\n -s/p LIH \n -s/p exploratory laparotomy, oversew and patch of duodenal\n perforation \n -s/p cataract surgery B eyes\n Social History:\n - rare social alcohol use, denies T/D\n - lives in in senior housing\n - currently at Rehab\n - former psychologist. retired recently\n .\n Family History:\n - non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: Chest pain, Edema, Tachycardia\n Respiratory: Dyspnea\n Flowsheet Data as of 08:59 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.2\nC (95.4\n HR: 119 (116 - 136) bpm\n BP: 91/62(67) {77/52(34) - 102/68(76)} mmHg\n RR: 23 (21 - 26) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,816 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 495 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,321 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n General Appearance: No acute distress, Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, tachycardic and irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Wheezes : ,\n Diminished: B bases, No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Source unclear, could be urosepsis given + UA, ?pneumonia,\n viral syndrome, or recurrent C diff colitis.\n - treat for emperic HAP with vancomycin, zosyn, ciprofloxacin\n - sputum culture & dfa for viral antigen\n - consider thoracentesis in morning\n - will prophylax against C diff with po flagyl\n - check C diff\n - f/u culture data\n .\n # hypotension: likely from combination of rapid atrial fibrillation +\n sepsis. see above for treatment of infection.\n - rate control as below\n - conservative fluid management as pt urinating & mentating.\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # NSTEMI: demand-related.\n - rate control\n - aspirin\n - trend enzymes\n .\n # Atrial fibrillation: patient hypotense in the setting of rapid a fib.\n - change pressors to neosynephrine\n - amiodarone IV load\n - consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # h/o perforated ulcer: stable\n - will continue PPI \n - appreciate surgical recommendations\n .\n # COPD: continue home regimen. well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition: low-sodium, heart-healthy diet.\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM. femoral line\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2101-06-06 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 465448, "text": "Chief Complaint: fatigue\n HPI:\n Ms. is a yo woman with COPD & hypertension with recent ex-lap\n and omental patch for perforated duodenal ulcer (), percutaneous\n drainage of perihepatic abscess and recent C diff colitis. She was\n referred to the ED from rehab for fevers x 4 days and hypoxia. She was\n first noted to have fever to 102 on , she was begun on vancomycin.\n Levofloxacin was added on for persistent fever & bilateral\n infiltrates on CXR. Today her T was noted to be 100.2 and she was\n hypoxic to 80% on 2L n/c, improved with repositioning.\n .\n In the ED she was hypotensive to 77/59, febrile to 102.8, and had\n atrial fibrillation in 110's. She had numerous failed attempts at a\n L-IJ CVL; eventually received a L femoral line. She received 3L NS,\n vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o\n ischemic changes & CE's positive. She received aspirin, but no BB or\n CCB for her tachycardia. She was started on levophed shortly before\n transfer for hypotension to 80's systolic.\n .\n On transfer to the ICU Ms. complains of feeing fatigued. She also\n endorses chest pressure & mild dsypnea. She denies light-headedness,\n syncope, or recent falls. She is unaware of cough, abdominal pain, or\n diarrhea. She is unsure why she was sent to the hospital, although she\n is oriented to name, place, and general time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.6 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -COPD/RAD, with prior admissions for Prednisone\n -Hypertension\n -Palpitations secondary to frequent APBs\n -Dysthymia/depression, followed by Dr. ,\n psychiatry, in , MA (on escitalopram)\n -Vertigo\n -Hearing impairment with R hearing aid\n -Urge urinary incontinence\n -PUD\n -s/p LIH \n -s/p exploratory laparotomy, oversew and patch of duodenal\n perforation \n -s/p cataract surgery B eyes\n Social History:\n - rare social alcohol use, denies T/D\n - lives in in senior housing\n - currently at Rehab\n - former psychologist. retired recently\n .\n Family History:\n - non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: Chest pain, Edema, Tachycardia\n Respiratory: Dyspnea\n Flowsheet Data as of 08:59 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.2\nC (95.4\n HR: 119 (116 - 136) bpm\n BP: 91/62(67) {77/52(34) - 102/68(76)} mmHg\n RR: 23 (21 - 26) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 1,816 mL\n PO:\n TF:\n IVF:\n 516 mL\n Blood products:\n Total out:\n 0 mL\n 495 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,321 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n General Appearance: No acute distress, Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, tachycardic and irregular\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Wheezes : ,\n Diminished: B bases, No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): 3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Source unclear, could be urosepsis given + UA, ?pneumonia,\n viral syndrome, or recurrent C diff colitis.\n - treat for emperic HAP with vancomycin, zosyn, ciprofloxacin\n - sputum culture & dfa for viral antigen\n - consider thoracentesis in morning\n - will prophylax against C diff with po flagyl\n - check C diff\n - f/u culture data\n .\n # hypotension: likely from combination of rapid atrial fibrillation +\n sepsis. see above for treatment of infection.\n - rate control as below\n - conservative fluid management as pt urinating & mentating.\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # NSTEMI: demand-related.\n - rate control\n - aspirin\n - trend enzymes\n .\n # Atrial fibrillation: patient hypotense in the setting of rapid a fib.\n - change pressors to neosynephrine\n - amiodarone IV load\n - consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # h/o perforated ulcer: stable\n - will continue PPI \n - appreciate surgical recommendations\n .\n # COPD: continue home regimen. well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition: low-sodium, heart-healthy diet.\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM. femoral line\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Pt seen and evaluated with housestaff. Please see above note for our\n collaborative plan and comprehensive physical exam.\n Time Spent = 45 min\n Briefly, yr old woman with recent hx of perf duod ulcer complicated\n by recurrent infection, C Diff transferred to rehab where she\n did well until several days ago when she began to spike fevers. Sent\n back to our ED where she was noted to be hypotensive, started on\n pressors, covered with broad spectrum ab and sent to MICU.\n Despite hypotension she has remained alert and coherent with good urine\n output. She does have bilateral pleural effusions in the setting of new\n afib with RVR.\n On exam she is oriented X 3, and in no resp distress. She has no\n wheezes, crackles but is consistently tachy at 120\ns despite dilt/ and\n lopressor X1. Requiring low dose neo to maintain MAP >60. Moderate\n peripheral edema\n Labs + for elevated Trop (0.1) and large effusions with atelectasis v\n PNA on CT.\n Will attempt to control rate with Amio load, consider\n cardioversion/cards consult if not responding. Agree with hep gtt.\n Will run her even given effusions, edema. Suspect BP wil incr and her\n pressor requirement decr when she has better rate control.\n If she spikes thru Ab\n consider thoracentesis in AM.\n ------ Protected Section Addendum Entered By: , MD\n on: 21:11 ------\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465565, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from\n previous.\n Plan:\n Follow up ECHO results, third\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465566, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt growing GPC in blood cultures question source. Pt has bilateral\n consolidations on CXR, question urosepsis versus CDIFF. Pt afebrile.\n SBP 80-110s.\n Action:\n Continues on IV ABX, stool culture sent for CDIFF, on low dose levophed\n for hypotension. 500cc bolus this morning in attempt to wean off\n levophed. Attempted to wean off levophed completely this afternoon.\n Response:\n Remains afebrile, stool culture pending, SBP dropped to low 80s when\n levophed weaned down.\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from previous\n set.\n Plan:\n Follow up ECHO results, third set to be drawn at 1600.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465567, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt growing GPC in blood cultures question source. Pt has bilateral\n consolidations on CXR, question urosepsis versus CDIFF. Pt afebrile.\n SBP 80-110s.\n Action:\n Continues on IV ABX, stool culture sent for CDIFF, on low dose levophed\n for hypotension. 500cc bolus this morning in attempt to wean off\n levophed. Attempted to wean off levophed completely this afternoon.\n Response:\n Remains afebrile, stool culture pending, SBP dropped to low 80s when\n levophed weaned down, reset to previous rate.\n Plan:\n Monitor temp curve, WBC, follow up stool spec, wean levophed as\n tolerated by pt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from previous\n set.\n Plan:\n Follow up ECHO results, third set to be drawn at 1600.\n Atrial fibrillation (Afib)\n Assessment:\n Pt with new AFIB, HR 80-120, occasional PVC.\n Action:\n On heparin gtt. PTT drawn at 1200, therapeutic at 93\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465569, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt growing GPC in blood cultures question source. Pt has bilateral\n consolidations on CXR, question urosepsis versus CDIFF. Pt afebrile.\n SBP 80-110s.\n Action:\n Continues on IV ABX, stool culture sent for CDIFF, on low dose levophed\n for hypotension. 500cc bolus this morning in attempt to wean off\n levophed. Attempted to wean off levophed completely this afternoon.\n Response:\n Remains afebrile, stool culture pending, SBP dropped to low 80s when\n levophed weaned down, reset to previous rate.\n Plan:\n Monitor temp curve, WBC, follow up stool spec, wean levophed as\n tolerated by pt.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from previous\n set.\n Plan:\n Follow up ECHO results, third set to be drawn at 1600.\n Atrial fibrillation (Afib)\n Assessment:\n Pt with new AFIB, HR 80-120, occasional PVC.\n Action:\n On heparin gtt. PTT drawn at 1200\n Response:\n 1200 PTT results therapeutic at 93.\n Plan:\n Next PTT due at 1800. Will titrate heparin gtt according to order.\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465570, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt growing GPC in blood cultures question source. Pt has bilateral\n consolidations on CXR, question urosepsis versus CDIFF. Pt afebrile.\n SBP 80-110s.\n Action:\n Continues on IV ABX, stool culture sent for CDIFF, on low dose levophed\n for hypotension. 500cc bolus this morning in attempt to wean off\n levophed. Attempted to wean off levophed completely this afternoon.\n Response:\n Remains afebrile, stool culture pending, SBP dropped to low 80s when\n levophed weaned down, reset to previous rate.\n Plan:\n Monitor temp curve, WBC, follow up stool spec, wean levophed as\n tolerated by pt. ID consulted.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt ruling in for MI. Pt denies chest pain/pressure.\n Action:\n Bedside ECHO this AM, on daily PO aspirin, second set cardiac enzymes\n sent at 0800.\n Response:\n ECHO results pending, second set cardiac enzymes improved from previous\n set.\n Plan:\n Follow up ECHO results, third set to be drawn at 1600.\n Atrial fibrillation (Afib)\n Assessment:\n Pt with new AFIB, HR 80-120, occasional PVC.\n Action:\n On heparin gtt. PTT drawn at 1200\n Response:\n 1200 PTT results therapeutic at 93.\n Plan:\n Next PTT due at 1800. Will titrate heparin gtt according to order.\n" }, { "category": "Physician ", "chartdate": "2101-06-08 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 465754, "text": "Chief Complaint:\n 24 Hour Events:\n - Seen by ID for bcx growing coag positive staph. Thought endocarditis\n was concerning source. Enterococcus UTI may represent spill-over from\n bacteremia. Vegetation not seen on TTE. Also spine infection, empyema.\n Lower on differential would be likely line source, peritonitis. Also\n concern for influenza.\n - Received metoprolol 5mg IV x 1 for afib with with response in HR\n but drop in BP. Continued to require pressors. A-line planned but\n placement unsuccessful despite multiple attempts.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:34 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 97 (91 - 124) bpm\n BP: 109/66(77) {78/32(43) - 125/73(84)} mmHg\n RR: 17 (16 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 2,458 mL\n 326 mL\n PO:\n 190 mL\n 60 mL\n TF:\n IVF:\n 2,268 mL\n 266 mL\n Blood products:\n Total out:\n 1,765 mL\n 470 mL\n Urine:\n 1,765 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 693 mL\n -144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 335 K/uL\n 8.2 g/dL\n 95 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 102 mEq/L\n 135 mEq/L\n 24.2 %\n 7.2 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n 09:10 AM\n 05:22 PM\n 03:00 AM\n WBC\n 8.7\n 7.2\n Hct\n 26.0\n 24.2\n Plt\n 299\n 335\n Cr\n 0.5\n 0.5\n TropT\n 0.12\n 0.12\n 0.11\n 0.10\n Glucose\n 91\n 95\n Other labs: PT / PTT / INR:14.4/101.4/1.2, CK / CKMB /\n Troponin-T:25/5/0.10, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Albumin:2.2 g/dL, Ca++:7.1 mg/dL, Mg++:2.3 mg/dL,\n PO4:2.1 mg/dL\n Rapid resp viral screen: Ag screen not interpretable; viral cx pending.\n TTE: Normal systolic function (EF 65%). Moderate-severe tricuspid\n regurgitation. Mild aortic stenosis. Moderate mitral regurgitation.\n Moderate pulmonary hypertension.\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with .\n .\n # Fever: Bcx growing GPC in pairs/clusters; /spec pending. Urine\n now with >100,000 enterococcus; pending\n unclear if related\n source as could be spillover from Bcx (?source from recent surgery) or\n separate infection. Concern for endocarditis despite neg TTE. Also\n spine infection given tenderness and weakness and empyema given large\n pleural effusions. Lower on differential would be line source,\n peritonitis. Also concern for influenza.\n - Appreciate ID recs -> thought likely MRSA bacteremia. Consider MRI\n spine/TEE/. However, may be more likely enterococcus in blood and\n urine. Will d/w ID ?dapto/linezolid instead of vanco and d/c flagyl as\n cdiff neg.\n - F/u cx including viral resp culture\n - Pull femoral line when able\n - cte flagyl while on abx for C diff history\n # Hypotension: Likely from combination of rapid atrial fibrillation +\n sepsis; no longer on pressors\n - Tx infection as above\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - amio gtt for AF\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Holding home antihypertensive for now\n - given BP limitation w/ beta blocker and CCB, pharm conversion with\n amiodarone. Mod suggests decreased response to DCCV.\n - IV heparin gtt for now\n # Pleural effusions: be fluid overload in setting of atrial\n fibrillation with mod-severe TR (although nl EF) v. empyema.\n - Rate ctrl\n - Consider thoracentesis if other ID w/u negative as above\n - Consider diuresis when hemodynamically stable\n - home lasix on hold for hypotension\n # Demand ischemia: In setting of afib with and sepsis\n - Rate control with amio as above\n - Aspirin\n # H/o perforated ulcer: Stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n ICU Care\n Nutrition: Low sodium, heart healthy\n Glycemic Control:\n Lines: Try to place PICC today\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU until HR lower\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: F COPD, HTN, recent perf DU c/b abscess and\n c. diff. Was at rehab, developed 4d fevers and hypoxia. New AF c/b \n in ED c fevers to 102.8. BCx + GPCs, UCx enterococcus. Remains on\n low dose neo.\n Exam notable for Tm 96.9 BP 100/50 HR 110 RR 20-24 with sat 99 on 2LNC.\n Frail woman, NAD. Coarse BS B. RRR s1s2. Soft +BS, well healed scar.\n Labs notable for WBC 7K, HCT 30, K+ 3.4, Cr 0.5.\n Agree with plan to manage high-grade GPC bacteremia with IV vanco while\n awaiting speciation. If staph aureus, will need to consider spine MRI\n and TEE. Will continue zosyn and flagyl given ? polymicrobial urosepsis\n and recent c. diff. For AF , start amio and continue heparin\n IV for now. Surgery aware of admission, CT stable, tolerating POs and\n +BM. Will place PICC and d/c CVL. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 03:01 PM ------\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465842, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 110s-130s, BP 120s/. A&O x 3. UOP 50cc/hr.\n Action:\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. 500cc fluid bolus given.\n PTT drawn @ 1:30.\n Response:\n No significant change in HR and BP, UOP increased after fluid.\n Lopressor 5 mg IVP given with HR slowing to 80s-90s Afib. BP remained\n in 120s/. PTT 69.8, no change in heparin gtt.\n Plan:\n Amiodarone gtt, stop gtt today @ 13:15 PM. Heparin gtt per algorithm.\n Lopressor prn for RAF. Monitor VS in response to meds.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results (2^nd spec\n obtained.\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. Resp will obtain another spec this AM.\n Response:\n Afebrile. BP stable off of neo gtt.\n Plan:\n Contact and droplet precautions. Follow CX results. Obtain 3^rd DFA to\n r/o flu. Antibx.\n" }, { "category": "Nursing", "chartdate": "2101-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465551, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465626, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2101-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465741, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Sepsis without organ dysfunction\n Assessment:\n Pt with GPC bacteremia, +VRE, + MRSA. Unknown source at this time\n however team questioning urosepsis given WBC in urine, also questioning\n CDIFF. Pt remains afebrile. Received pt on low dose neo. SBP ranging\n 90-120s. OU >30cc/hr. Pt with documented back pain upon admission to\n unit.\n Action:\n Continues to receive broad spectrum ABX coverage, received 500cc bolus\n this AM in successful attempt to wean neo off. UO better with SBP\n >110. Taken for MR L spine this afternoon.\n Response:\n WBC WNL, neo weaned this AM remains off at this writing. Pt\n maintaining SBP >90. MRI results pending.\n Plan:\n Continue to trend temp and WBC, IV ABX as ordered, goal SBP >90,\n monitor UO. Follow up NR L spine results.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in AFIB 80-110s, up to 130s with stimulation.\n Action:\n On heparin gtt. Loaded and started on amiodarone gtt after pt having\n sustained HR in 130s.\n Response:\n PTT checked this AM, therapeutic at 74. Amiodarone gtt currently\n infusing at 1mg/min, started at 11:15am will be decreased to 0.5mg/min\n at 5:15pm, due to be shut off at 1:15pm .\n Plan:\n PTT to be rechecked at 1700, amio gtt due be shut off at 1:15pm .\n Continue to monitor rate and rhythm.\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465838, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 110s-130s, BP 120s/. A&O x 3. UOP 50cc/hr.\n Action:\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. 500cc fluid bolus given.\n PTT drawn @ 1:30.\n Response:\n No significant change in HR and BP, UOP increased after fluid.\n Lopressor 5 mg IVP given with HR slowing to 80s-90s Afib. BP remained\n in 120s/. PTT 69.8, no change in heparin gtt.\n Plan:\n Amiodarone gtt, stop gtt today @ 13:15 PM. Heparin gtt per algorithm.\n Lopressor prn for RAF. Monitor VS in response to meds.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results (2^nd spec\n obtained.\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. Resp will obtain another spec this AM.\n Response:\n Afebrile. BP stable off of neo gtt.\n Plan:\n Contact and droplet precautions. Follow CX results. Obtain 3^rd DFA to\n r/o flu. Antibx.\n" }, { "category": "Nursing", "chartdate": "2101-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 465844, "text": "F with PMH COPD, HTN recent ex-lap and omental patch for perforated\n duodenal ulcer (), percutaneous drainage of perihepatic abscess\n and recent C diff colitis. Referred to ED from rehab for fevers x 4\n days and hypoxia. Fevers noted to 102 on , started on vancomycin.\n Levofloxacin was added on for persistent fever and bilateral\n infiltrates on CXR. temp to 100.2 and hypoxic to 80% on 2L NC\n which improved with repositioning. Sent to ED from rehab.\n Hypotensive to 77/59, febrile to 102.8 and had AFIB to 110s noted in\n the ED. Numerous failed attempts at L-IJ CVL; eventually received L\n femoral line. Received 3L NS, vancomycin and zosyn. EKG showed rapid\n AFIB w/o ischemic changes however CE\ns positive. Started on levophed\n prior to transfer for sustained hypotension to 80's.\n In MICU pt c/o fatigue, chest pressure and mild dsypnea.\n - Seen by ID for bcx growing coag positive staph.? Enterococcus\n UTI may represent spill-over from bacteremia. Vegetation not seen on\n TTE. MRI spine done and pending to r/o abscess.\n Atrial fibrillation (Afib)\n Assessment:\n Continues in Afib 110s-130s, BP 110s-130s/. A&O x 3. UOP < 30cc/hr.\n Action:\n Amiodarone gtt @ 0.05 mg/min. Heparin gtt. 500cc fluid bolus given.\n PTT drawn @ 1:30.\n Response:\n No significant change in HR and BP, UOP increased after fluid.\n Lopressor 5 mg IVP given with HR slowing to 80s-90s Afib. BP remained\n in 120s/. PTT 69.8, no change in heparin gtt.\n Plan:\n Amiodarone gtt, stop gtt today @ 13:15 PM. Heparin gtt per algorithm.\n Lopressor prn for RAF. Monitor VS and UOP in response to meds.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile, T 96 Ax. Pt c/o feeling cold so Bair Hugger on pt O/N. + VRE\n and MRSA, ? urosepsis. MRI lower spine done\nper wet read no abscess on\n spine. DFA sent yesterday inadequate for test results (2^nd spec\n obtained).\n Action:\n Vanco changed to Linezolid per ID recs. 1^st dose given last night.\n Surveillance BC sent this AM. Remains on Droplet precautions until\n Influenza is r/o. Resp will obtain another spec this AM.\n Response:\n Afebrile. BP stable off of neo gtt.\n Plan:\n Contact and droplet precautions. Follow CX results. Obtain 3^rd DFA to\n r/o flu. Antibx. ? TEE to r/o vegetation. Need stool spec when\n available.\n" }, { "category": "Physician ", "chartdate": "2101-06-07 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 465537, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Remained in afib overnight but HR better controlled after bolus dose\n of diltiazem\n - Bcx growing out GPC in pairs and clusters in 4 of 4 bottles.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.7 mcg/Kg/min\n Heparin Sodium - 1,100 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 10:20 PM\n Heparin Sodium - 06:13 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.9\nC (96.7\n HR: 94 (89 - 136) bpm\n BP: 110/60(72) {77/44(34) - 119/81(89)} mmHg\n RR: 17 (11 - 33) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Mixed Venous O2% Sat: 46 - 46\n Total In:\n 4,001 mL\n 234 mL\n PO:\n TF:\n IVF:\n 601 mL\n 234 mL\n Blood products:\n Total out:\n 400 mL\n 540 mL\n Urine:\n 150 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,601 mL\n -306 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n GEN: NAD\n HEENT: NC/AT\n LUNGS: Decreased breath sounds bilaterally\n HEART: Tachycardic and irregular\n ABD: Soft. NT\n EXTREM: Edema bilaterally (per her report stable)\n NEURO: A+OX3\n Labs / Radiology\n 299 K/uL\n 8.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.1 mEq/L\n 12 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.0 %\n 8.7 K/uL\n [image002.jpg]\n 09:25 PM\n 03:38 AM\n WBC\n 8.7\n Hct\n 26.0\n Plt\n 299\n Cr\n 0.5\n TropT\n 0.12\n 0.12\n Glucose\n 91\n Other labs: PT / PTT / INR:14.8/53.6/1.3, CK / CKMB /\n Troponin-T:27//0.12, ALT / AST:13/40, Alk Phos / T Bili:107/0.3,\n Differential-Neuts:91.4 %, Lymph:5.0 %, Mono:1.9 %, Eos:1.6 %, Lactic\n Acid:1.5 mmol/L, Ca++:7.2 mg/dL, Mg++:1.6 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Ms. is a yo woman with recent surgery for perforated ulcer,\n complicated by perihepatic abscess & c diff colitis. She now presents\n with fevers, hypotension, and a fib with RVR.\n .\n # Fever: Bcx growing GPC in pairs/clusters; source unclear but may be\n from recent surgery in which case may be concern for VRE. also be\n from PNA. Could also have urosepsis as UA with WBCs. Continue\n vanc/flagyl.\n - Consider dapto for empiric treatment of VRE until sensitivities, d/c\n cipro and zosyn\n - F/u sputum culture & DFA for viral antigen\n - Consider TTE for endocarditis\n - F/u final CT chest\n - Consider thoracentesis if TTE negative\n - Consult ID re:enterococcal coverage with dapto/linezolid until\n sensitivities back.\n - C diff unlikely given nl WBC. Cte flagyl IV.\n - f/u culture data\n .\n # Hypotension: :Likely from combination of rapid atrial fibrillation +\n sepsis. See above for treatment of infection.\n - Rate control as below\n - Conservative fluid management as pt urinating & mentating.\n - consider amio/dig for rate control given hypotension with AF\n .\n # Pleural effusions: most likely related to CHF from atril\n fibrillation.\n - attempt to control a fib with rate or rhythm control\n - echo in morning\n - consider diuresis when hemodynamically stable.\n .\n # Demand ischemia: In setting of afib with RVR and sepsis\n - Rate control\n - Aspirin\n - Trend enzymes\n .\n # Atrial fibrillation: Patient hypotense in the setting of rapid a fib.\n - Wean off neosynephrine as tolerated\n - Holding home antihypertensive for now\n - Dilt IV boluses prn for RVR; holding po doses for now in setting of\n hypotension on pressors\n - Consider amiodarone or dig for persistent hypotension if rates\n uncontrolled\n - Consider cardiology consult and electrical cardioversion\n - IV heparin gtt\n .\n # H/o perforated ulcer: stable\n - Continue PPI \n - Appreciate surgical recs\n .\n # COPD: Continue home regimen; well-compensated.\n .\n # PPX: PPI , heparin gtt\n .\n # Code: full, confirmed with patient.\n ICU Care\n Nutrition: Low Na, Heart healthy\n Glycemic Control:\n Lines:\n Multi Lumen - 06:58 PM\n 18 Gauge - 07:00 PM\n Prophylaxis:\n DVT: Hep gtt\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code, confirmed with pt\n Disposition: ICU until BP stable off pressors\n" }, { "category": "ECG", "chartdate": "2101-06-12 00:00:00.000", "description": "Report", "row_id": 162126, "text": "Sinus rhythm. Left atrial abnormality. Low limb lead voltage. Compared to the\nprevious tracing of the rate has slowed. There is atrial ectopy.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 162127, "text": "Irregular narrow complex rhythm, probably atrial flutter. Since the previous\ntracing no significant change in previously noted abnormalities.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 162128, "text": "Irregular narrow complex rhythm, probably atrial fibrillation. Since the\nprevious tracing the rate has increased. Otherwise, as previously noted.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-06-06 00:00:00.000", "description": "Report", "row_id": 162129, "text": "Baseline artifact. Irregular narrow complex rhythm. Organized atrial\nactivity, only certain in lead V1, so the possibility of atrial fibrillation\nis present. Low voltage throughout. ST-T wave abnormalities. Since the\nprevious tracing of the rate is somewhat faster. Otherwise, no change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2101-06-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1084591, "text": " 10:08 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for pleural effusions and pulmonary edema.\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with h/o COPD/RAD who presents with 2L O2 requirement in the\n setting of MRSA bacteremia and AFIB with RVR.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pleural effusions and pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with history of COPD with increasing oxygen\n requirements in the setting of MRSA bacteremia and atrial fibrillation.\n Evaluate for pleural effusion and pulmonary edema.\n\n PA and lateral chest radiographs compared to shows no change in\n bilateral lower lobe collapse and large pleural effusions. The upper lungs\n are grossly clear. The heart remains moderately enlarged. There is no\n pneumothorax. A hiatal hernia is present.\n\n IMPRESSION: Persistent bilateral lower lobe collapse and large pleural\n effusions unchanged from .\n\n" }, { "category": "Radiology", "chartdate": "2101-06-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1085073, "text": " 12:24 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: picc tip 54 cm location right side\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with infection\n REASON FOR THIS EXAMINATION:\n picc tip 54 cm location right side\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with study of , the right subclavian PICC line\n extends to the mid portion of the SVC. The extensive bilateral lower lung\n opacifications may be slightly improved, though there is still consistent with\n bilateral effusions and volume loss involving the lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-09 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1084474, "text": " 3:04 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: EVAL FOR DVT\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with LUE swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with left upper extremity swelling.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of the left IJ, subclavian,\n axillary, brachial, basilic and cephalic veins are performed. The two\n brachial veins are small and echogenic and they do not compress on compression\n views. No venous flow can be detected in these veins on color Doppler or\n pulse wave Doppler imaging. The small caliber of the veins and their\n echogenic appearance suggest old chronic clot.\n\n The remainder of the veins demonstrates normal flow, compression and\n augmentation.\n\n IMPRESSION: Small echogenic brachial veins which do not compress and do not\n demonstrate venous flow. The small size and increased echogenicity of these\n veins is suggestive of chronic occlusive thrombus within them.\n\n These findings were conveyed to Dr. at 5:00 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083857, "text": " 1:58 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval chf/pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n eval chf/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever to 102.8 as well as hypoxia, to evaluate for infiltrate.\n\n COMPARISON: 2 hours prior.\n\n AP UPRIGHT CHEST: Multiple airspace opacities in the left upper lobe and\n right lower lung are unchanged since 2 hours prior. Loss of the right\n diaphragmatic contour again suggests effusion/atelectasis/consolidation. Left\n hiatal hernia is unchanged since . The cardiomediastinal silhouette is\n stable.\n\n IMPRESSION: No change since 2 hours prior. Bilateral airspace opacities\n remain concerning for aspiration pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1083868, "text": " 3:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for pneumonia, PE, intraabdominal source of infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fever to 102.8, shortness of breath, new hypoxia, also\n w/ recent () ex lap for perforated ulcer.\n REASON FOR THIS EXAMINATION:\n assess for pneumonia, PE, intraabdominal source of infection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc MON 5:57 PM\n Moderate hiatal hernia. Bilateral pleural effusions. No PE to subsegmental\n level. Intraabdominal ascites. Nondistended gallbladder, though with\n pericholecystic fluid, likely third spacing, though correlate with RUQ pain.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a -year-old female with fever 100 to 102.8,\n shortness of breath, hypoxia, also with recent known exploratory laparotomy\n for perforated ulcer performed . Evaluate for pneumonia, PE, or intra-\n abdominal source of infection.\n\n EXAMINATION: CT torso with contrast.\n\n COMPARISONS: Comparison to recent CT examination from , and CT abdomen\n and pelvis from .\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the mid abdomen initially using a low-dose non-contrast phase. Subsequently,\n contiguous axial images were obtained from the thoracic inlet to the mid\n abdomen using a CTA protocol after the administration of 130 cc of Optiray\n intravenous contrast. Then, contiguous axial images were obtained from the\n lung bases to the pubic symphysis after using a general CT abdomen and pelvis\n protocol.\n\n Coronal, sagittal, and oblique maximum intensity projection images were\n obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is no evidence of pulmonary\n embolism to the subsegmental levels. The thoracic aorta and its major\n branches are patent. There is no axillary, mediastinal, or hilar\n lymphadenopathy.\n\n There are bilateral moderate to large pleural effusions. There is bibasilar\n atelectasis with associated retained secretions in the bronchial tree. The\n trachea and bronchi are patent to the segmental levels.\n\n There is a large hiatal hernia with the herniated portion of stomach seen in\n an orientation that is compatible with an organoaxial volvulus. Posterior to\n the herniated portion of the stomach, there is a linear streak of air that can\n be correlated with air within the esophagus that is coursing posteriorly to\n the herniated stomach. Note is made of a pericardial effusion.\n (Over)\n\n 3:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for pneumonia, PE, intraabdominal source of infection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The right lobe of liver displays\n a small hyperenhancing focus, likely a flash hemangioma. There is no extra- or\n intra- hepatic biliary dilatation. The main portal vein and its major branches\n are patent. Noted within the spleen are multiple subcentimeter hypodensities\n that are nonspecific in nature and that most likely represent benign splenic\n cysts or hemangiomas. The gallbladder is nondistended; however, there is an\n extensive amount of pericholecystic free fluid and free fluid tracking\n throughout the abdomen, compatible with ascites. The pancreas, both adrenal\n glands, the visualized loops of intra-abdominal small and large bowel are\n unremarkable. Scattered throughout both kidneys are multiple subcentimeter\n hypodensities that are too small to accurately characterize, however,\n statistically, likely represent simple renal cysts. There is no mesenteric or\n retroperitoneal lymphadenopathy. The Cecum is mobile with a stable horizontal\n position, without twist or volvolus.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon, uterus\n and adnexa are unremarkable. The bladder is collapsed about a Foley catheter\n with multiple punctate foci of air. There is no pelvic or inguinal\n lymphadenopathy. Note is made of a fat-containing right-sided inguinal\n hernia.\n\n There is extensive subcutaneous edema diffusely throughout the entire\n subcutaneous tissues.\n\n BONE WINDOWS: There is grade 1 anterolisthesis of the L4 on L5 vertebral\n body. There are multilevel degenerative changes with marginal osteophyte\n formation and loss of intervertebral disc height. No suspicious lytic or\n sclerotic lesions.\n\n IMPRESSION:\n\n 1. Large hiatal hernia with organoaxial volvulus stable since .\n\n 2. Bilateral large left greater than right pleural effusions, pericardial\n effusions, and intra-abdominal ascites, most likely secondary to third\n spacing.\n\n 3. No evidence of pulmonary embolism.\n\n 4. Bibasilar atelectasis, no evidence of pneumonia.\n\n 5. No intra-abdominal source of infection identified.\n\n 6. Cecum is mobile with a stable horizontal position, without twist or\n volvolus.\n (Over)\n\n 3:22 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for pneumonia, PE, intraabdominal source of infection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-08 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 1084260, "text": " 5:42 PM\n MR W & W/O CONTRAST Clip # \n Reason: ?abscess->please image sacral spine as tenderness L-S spine\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n Contrast: MAGNEVIST Amt: 14CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with MRSA bacteremia and back pain\n REASON FOR THIS EXAMINATION:\n ?abscess->please image sacral spine as tenderness L-S spine on exam\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf WED 11:57 PM\n No epidural abscess. Multilevel degenerative changes in the lumbar spine most\n pronounced at L4-5 level with severe multifactorial spinal canal stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n MR LUMBAR SPINE WITH AND WITHOUT CONTRAST ON .\n\n COMPARISON: No prior MR examination\n\n INDICATION: A -year-old woman with MRSA bacteremia and back pain. Question\n abscess. Please image through sacral spine as patient experiences lumbosacral\n tenderness on exam.\n\n TECHNIQUE: Multiplanar and multisequence imaging was obtained through the\n lumbosacral spine with and without contrast.\n\n FINDINGS: There is no abnormal enhancement within the vertebral body,\n intervening disc spaces, epidural space or spinal canal to suggest underlying\n infection or abscess formation. There is no evidence of spondylodiscitis.\n\n The conus medullaris terminates at L1-L2 without signal abnormality.\n\n In the T12 vertebral body, there is a small hemangioma. The lateral recess is\n normal. At T12-L1, no significant canal or foraminal narrowing is identified,\n despite facet joint arthropathy and mild ligamentum flavum thickening.\n\n At L1-L2, the lateral recess is normal. A diffuse disc bulge as well as facet\n joint arthropathy is noted with a mild degree of ligamentum flavum thickening.\n No significant spinal canal narrowing is identified. There is mild bilateral\n foraminal narrowing. There may be a small annular tear associated with a disc\n bulge at this level.\n\n At L2-L3, there is disc desiccation as well as a diffuse disc bulge. Facet\n joint and uncovertebral osteophyte formation is noted without significant\n canal or foraminal narrowing.\n\n At L3-L4, there is grade 1 anterolisthesis, with uncovering of the posterior\n margin of the disc. There appears to be a small annular tear within the disc\n itself. Significant facet joint arthropathy is noted, causing narrowing of\n both the lateral recesses, right greater than left, as well as the right\n neural foramen. Ligamentum flavum thickening is also noted, causing narrowing\n (Over)\n\n 5:42 PM\n MR W & W/O CONTRAST Clip # \n Reason: ?abscess->please image sacral spine as tenderness L-S spine\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n Contrast: MAGNEVIST Amt: 14CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the lateral aspect of the thecal sac.\n\n At L4-L5, there is grade 1 anterolisthesis with uncovering of the posterior\n margin of the disc as well as a small annular tear. Significant ligamentum\n flavum thickening is noted causing severe canal narrowing. There is also\n narrowing of the lateral recesses. Severe bilateral foraminal narrowing is\n also noted.\n\n At L5-S1, there is disc desiccation as well as a diffuse disc bulge, more\n prominent on the right. Bilateral foraminal narrowing is noted, right greater\n than left. Facet joint arthropathy is also seen without significant canal\n narrowing.\n\n Of note, there is fluid within the uterus, abnormal for the patient's stated\n age.\n\n IMPRESSION:\n 1. No evidence of spondylodiscitis or abscess within the lumbosacral spine.\n 2. Significant spondylosis with severe canal narrowing, predominantly at L4-\n L5. The remainder of the lumbar spine as varying degrees of canal or\n foraminal narrowing as described above.\n 3. Fluid within the uterine canal, abnormal for the patient's stated age.\n Pelvic ultrasound can be obtained if clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083893, "text": " 6:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o PTX\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with attempted IJ placememnt\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n WET READ: CXWc MON 8:33 PM\n No PTX. Persistent bilateral pleural effusions and retrocardiac opacity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Attempted IJ placement, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there is no\n evidence of pneumothorax. Persistent bilateral pleural effusions persist,\n along with bibasilar opacifications consistent with atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-06-11 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 1084797, "text": " 2:25 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: evaluate for source of infection\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with MRSA bacteremia\n REASON FOR THIS EXAMINATION:\n evaluate for source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA bacteremia. Evaluate for source of infection. Correlation\n with the torso CT scan dated reveals that the patient had an\n exploratory laparotomy for perforated ulcer on .\n\n TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical\n and thoracic spine, with axial T1-weighted and gradient echo images of the\n cervical spine, and axial T1- and T2-weighted images of a portion of the\n thoracic spine. Following intravenous gadolinium administration, sagittal and\n axial T1-weighted images of the cervical and thoracic spine were repeated.\n\n CERVICAL SPINE MRI: There is no evidence of osteomyelitis, discitis, epidural\n collection, or paravertebral abscess. There is mild edema in the posterior\n subcutaneous soft tissues.\n\n Vertebral body height is preserved. There is a grade 1 anterolisthesis at\n C4-5. At C3-4, there are left uncovertebral and facet osteophytes resulting\n in moderate narrowing of the left neural foramen. There are also small\n posterior endplate osteophytes indenting the thecal sac, but not contacting\n the spinal cord. There is no significant spinal canal stenosis or neural\n foraminal narrowing at other cervical levels. There are no signal\n abnormalities in the spinal cord, allowing for mild artifact on the sagittal\n T2-weighted images.\n\n The imaged portion of the posterior fossa appears unremarkable. There is mild\n mucosal thickening in the left maxillary sinus.\n\n THORACIC SPINE MRI: There is no evidence of discitis, osteomyelitis, epidural\n collection, or paravertebral abscess. There is mild edema in the posterior\n subcutaneous soft tissues.\n\n Vertebral body height is preserved. There are multiple foci of high signal on\n all sequences in the imaged vertebral bodies, consistent with hemangiomas. A\n small focus of high signal on T2-weighted and STIR sequences in the vertebral\n body of T4 does not demonstrate high signal on the pre-contrast T1-weighted\n sequence, and it demonstrates contrast enhancement on the post-contrast T1-\n weighted sequence. This most likely represents a fat-poor hemangioma. There\n is no significant spinal canal stenosis. The spinal cord is normal in\n morphology and signal intensity, terminating at L1.\n\n There are bilateral pleural effusions, as seen on the torso CT scan.\n (Over)\n\n 2:25 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: evaluate for source of infection\n Admitting Diagnosis: UROSEPSIS;NSTEMI\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. No evidence of discitis, osteomyelitis, epidural collection, or\n paravertebral abscess.\n\n 2. Mild spondylosis.\n\n 3. Bilateral pleural effusions, as seen on .\n\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083838, "text": " 12:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension, hypoxia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever to 102.8 as well as hypoxia, to evaluate for infiltrate.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: Multiple airspace opacities in the left upper lobe and\n right lower are new since . Loss of the right diaphragmatic contour\n suggests effusion/atelectasis/consolidation. The right upper lung is grossly\n clear. Large left diaphragm hernia is unchanged since . The\n cardiomediastinal silhouette is stable.\n\n IMPRESSION: Increasing bilateral airspace opacities are concerning for\n aspiration pneumonia.\n\n Findings were discussed with Dr. by phone at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2101-06-06 00:00:00.000", "description": "P CHEST SGL VIEW/LINE PLACEMENT PORT", "row_id": 1083871, "text": " 3:37 PM\n CHEST SGL VIEW/LINE PLACEMENT PORT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for placement, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension, s/p L IJ\n REASON FOR THIS EXAMINATION:\n eval for placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old female with hypotension status post left internal\n jugular line placement, to assess for a pneumothorax.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with prior radiograph dated .\n\n FINDINGS:\n\n There is a curvilinear opacity traversing horizontally across the neck. There\n is a small area of lucency in the left lung apex which may represent a small\n pneumothorax. The cardiomediastinal silhouette is stable. Bibasal effusions\n are again noted. There may also be an infiltrate at the left lung base.\n\n CONCLUSION:\n\n There is a curvilinear opacity traversing horizontally across the neck, this\n does not have the appearance of a catheter. If a left central line is indeed\n in place, then this needs repositioning. There is a small lucency present at\n the left apex suggestive of a small apical pneumothorax. Basal effusions and a\n probable infiltrate at the left lung base.\n\n Please repeat the radiograph after repositioning of the left internal jugular\n line for confirmation of the position.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2138-11-21 00:00:00.000", "description": "Report", "row_id": 1504632, "text": "Nursing Progress Note:\n\nPt. is a 72yo Mandarin-speaking woman who came to with fever and mental status changes from NH where she was recovering from R hip replacement (6 wks ago). She was diagnosed with UTI and pneumonia and was on 3 being tx'd with abx. Today she became hypotensive to 60s-70s and was given 4L fluids with BP into 80s-90s. Pt. transferred to MICU for further monitoring. Son speaks and is HCP.\n\nNeuro: Pt. is alert and oriented per son with c/o pain only when moved. She MAE.\n\nCV: HR 80s-90s NSR with no ectopy noted, NBP now in 90s/50s (500cc NS bolus given here upon arrival). Pt. has 2 18g PIVs in R and L AC both of which are patent and WNL. PIV in R should be d/c'd as this is the side of pt's mastectomy. Hct ordered.\n\nResp: RR 20s, 02 sats 98-100% on 2L NC. Lungs are clear to all lobes.\n\nGI: Abdomen soft with BSX4. Per RN, no BM since admission.\n\nGU: 400cc pre-admission output, none since. Foley catheter draining cloudy urine. Urine cx ordered.\n\nSkin: Stage IV decubitus ulcer to coocyx, to bone, black,foul smelling. Wet-to-dry ressing changed. Per 3 RN, wound consult has been ordered.\n\nSocial: Son is and is at bedside, He is the HCP.\n\n" }, { "category": "Nursing/other", "chartdate": "2138-11-22 00:00:00.000", "description": "Report", "row_id": 1504633, "text": "Neuro alert frail looking woman, mae, fc, son stated she was ox3. c/o increased pain rt hip after being moved to an airbed given 1 oxycodone with good effect\ncvs Hct 22.3 given 1 uprbc repeat hct 32.1. HR 90-100's nsr to st without ectopy k+ 3.7 mag 1.9 phosph 1.8, calicium 7.9 skin w+d pp+\nResp lungs cta diminished rll cont azithromax 02 sat 99%\ngi coughes after taking fluids son stated does well with solids abd snt bs+ no stool\ngu u/o 0-320 given fb 500cc ns, irrigated foley with increase urine. Urine cloudy with sediment urine sent for culture\naccess 18/20 lt arm\nsacral decubitus dsg d+I\nID wbc 14.9 temp max 98.9 +1 bld cx bottle gm + cocci started on vanco IV also on ceftriaxone and azithromax, lactic acid 1.2\na. prob met ca, rll pna, uti\np. await bx results, cx results, antibx as ordered monitor temp, wbc, vigorous pulm toliet, echo today,? swallowing study, replace lytes, pt is a full code awaiting son's arrival from \n" }, { "category": "Nursing/other", "chartdate": "2138-11-22 00:00:00.000", "description": "Report", "row_id": 1504634, "text": "MICU Transfer note:\n\nReport given via phone to on 3 and has accepted pt at 17:00. Will be tx'ing w/i the hour monitor as pt. requires telementry bed.\n" }, { "category": "Echo", "chartdate": "2138-11-22 00:00:00.000", "description": "Report", "row_id": 82251, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nBP (mm Hg): 123/76\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:40\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural\neffusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nModerate tricuspid regurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2138-11-28 00:00:00.000", "description": "Report", "row_id": 207796, "text": "Sinus tachycardia. Otherwise, ECG findings are within normal limits. Compared\nto the previous tracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2138-11-28 00:00:00.000", "description": "Report", "row_id": 207797, "text": "Sinus rhythm. ECG findings are within normal limits. Compared to the previous\ntracing of no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2138-11-22 00:00:00.000", "description": "Report", "row_id": 207798, "text": "Sinus tachycardia. There is considerable motion artifact. Tracing is otherwise,\nunchanged compared to tracing #1\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-11-21 00:00:00.000", "description": "Report", "row_id": 207799, "text": "Normal sinus rhythm. Low limb lead voltage. Slight ST segment elevations noted\ndiffusely. No change compared to the previous tracing of .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2138-11-21 00:00:00.000", "description": "Report", "row_id": 207800, "text": "Normal sinus rhythm. No change compared to the previous tracing of .\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2138-11-21 00:00:00.000", "description": "Report", "row_id": 207801, "text": "Sinus rhythm. Low limb lead voltage. Diffuse slight ST segment elevation.\nCompared to the previous tracing of no diagnostic interim change and\nthe rate has slowed. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2138-11-20 00:00:00.000", "description": "Report", "row_id": 207802, "text": "Sinus rhythm. Low limb lead voltage. There is diffuse slight ST segment\nelevation. No previous tracing available for comparison. Clinical correlation\nis suggested.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2138-11-27 00:00:00.000", "description": "BONE SCAN", "row_id": 938079, "text": "BONE SCAN Clip # \n Reason: METASTATIC BREAST CA, C/O LEG PAIN ASSES FOR METS/CAUSE OF BONE PAIN\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 27.5 mCi Tc-m MDP ();\n HISTORY: 72 year old woman with metastatic breast cancer\n\n COMPARISON: CT torso \n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections along with static views of the pelvis.\n\n There is linear and patchy uptake involving the anterior 3rd-5th ribs as well as\n the sternum which corresponds to osseous involvement by a right chest wall soft\n tissue mass on CT scan. There is a focus of uptake in the right 2nd rib end\n which may correspond to the same process.\n\n There is a rotatory scoliosis. There is a photopenic defect in the right hip\n and femur corresponding to a hip prosthesis. There is patchy uptake around the\n intertrochanteric portion of the prosthesis which may simply represent\n post-surgical change. However, if the initial hip fracture was pathologic,\n osseous neoplastic involvement cannot be excluded.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: Patchy uptake involving the anterior right ribs and sternum\n correlates with right chest wall osseous tumor invasion on CT scan.\n\n Uptake around the trochanteric portion of the right hip prosthesis may relate to\n surgery, but if there had been a pathologic fracture initially, residual\n osseous tumor cannot be excluded.\n\n\n , M.D.\n , M.D. Approved: FRI 4:32 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2138-11-26 00:00:00.000", "description": "B FEMUR (AP & LAT) BILAT", "row_id": 938022, "text": " 5:21 PM\n FEMUR (AP & LAT) BILAT; KNEE (AP, LAT & OBLIQUE) BILAT Clip # \n Reason: need full length femur x-ray\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with metastatic breast cancer and leg pain\n REASON FOR THIS EXAMINATION:\n need full length femur x-ray\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Metastatic breast cancer and leg pain.\n\n PELVIS, SINGLE AP VW; RIGHT FEMUR, TWO VIEWS; LEFT FEMUR, 2 VWS\n\n Assessment of the pelvis on these views is limited. There is severe diffuse\n osteopenia.\n\n On the right, the patient is status post placement of a THR. No hardware\n loosening is identified. Some heterotopic ossification is seen adjacent to\n the greater trochanter. Tubing (question Foley catheter) overlies the distal\n femur. Allowing for this, no fracture, suspciious lytic or sclerotic lesion,\n or periosteal new bone formation is identified.\n\n On the left, there is severe diffuse osteopenia. There are moderately severe\n degenerative changes of the left knee joint, with medial compartment narrowing\n and spurring and medial and lateral compartment spurring and varus angulation\n as well as tibia vara configuration. No fracture, suspicious focal lytic or\n sclerotic lesion, or periosteal new bone formation is identified.\n\n\n Addendum -- Review of the bone scan report shows increased\n acitivity at the right greater trochanter. On the current xray, there\n is a scalloped appearance to the upper surface of the right greater\n trochanter, with immature edges and faint surruonding soft tissue\n calcification. While this may represent post-operative change, it would be\n unusual to see increased bone scan activity if the hip surgery were remote\n (e..g. > 18-24 months) and, if the THR surgery is old, then the possibility of\n an osteolytic process, such as a metastasis would then be considered. Review\n of the ct scan shows a similar defect in the greater trochanter, but\n is otherwise non-contributory.\n\n" }, { "category": "Radiology", "chartdate": "2138-11-25 00:00:00.000", "description": "BILAT HIPS (AP,LAT & AP PELVIS)", "row_id": 937884, "text": " 4:16 PM\n BILAT HIPS (AP,LAT & AP PELVIS) Clip # \n Reason: assess for fracture, dislocation\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right hip fx s/p ORIF 1 month ago now with increased\n pain and tenderness with significantly limited range of motion\n REASON FOR THIS EXAMINATION:\n assess for fracture, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, RIGHT HIP, TWO VIEWS, LEFT HIP, TWO VIEWS, AT\n 1548 HOURS\n\n HISTORY: Status post ORIF one month ago with increased pain and tenderness\n and significant limited range of motion.\n\n COMPARISON: .\n\n FINDINGS: As previously noted, there is profound baseline osteopenia, which\n reduces the sensitivity for detecting subtle non-displaced fracture. In\n addition, the sacrum and sacroiliac joints are obscured by bowel gas and\n retained oral contrast material within the colon. There is a right hip\n hemiarthroplasty in place similar in alignment to the prior examination. There\n is no radiographic evidence of loosening or periprosthetic fracture noted.\n Small curvilinear fragments are noted adjacent to the proximal femoral\n diaphysis and the lesser trochanter. These may be remnants of the surgery as\n it is relatively too soon a time course for heterotopic ossification to\n develop. The left hip is unremarkable. It is properly located with no signs\n of fracture.\n\n IMPRESSION: Again limited evaluation. No gross abnormality noted. There is\n no subcutaneous air or other finding to suggest infection of the new\n indwelling right hip hardware. Given persistence of symptoms, consider MRI\n for more sensitive and specific evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2138-11-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937456, "text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with fever to 102 w/o clear source. Rhonchi bilaterally.\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever to 102 without clear source.\n\n CHEST:\n\n The cardiac size is normal. Some tortuosity of the aorta is present. There\n is increased opacities in the right lower lobe consistent with a right-sided\n pneumonia. These appearances are present on the prior chest x-ray.\n\n IMPRESSION: Persistent right lower lobe pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937855, "text": " 1:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for ptx\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right sided pleural effusion, s/p thoracentesis r\n side.\n REASON FOR THIS EXAMINATION:\n Please eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right-sided pleural effusion, status post thoracocentesis on\n right side, evaluate for pneumothorax.\n\n FINDINGS: AP single view of the chest obtained with the patient in sitting\n upright position does not demonstrate any pneumothorax. The previously\n described density in the right superior mediastinum seen on AP single view\n examination remains unchanged. The previously shown diffuse density overlying\n the right mid and lower lung field has disappeared indicative that the pleural\n effusion better documented on the preceding CT examination () has\n been decreased. No new abnormalities identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-11-28 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 938213, "text": " 2:46 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstruction/ileus. Thank you\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with end-stage metastatic breast cancer on narcotics for\n pain control with worsening abdominal pain.\n REASON FOR THIS EXAMINATION:\n eval for obstruction/ileus. Thank you\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable abdomen.\n\n INDICATION: 72-year-old female with end-stage metastatic breast cancer.\n Worsening abdominal pain. Assess for obstruction/ileus.\n\n COMPARISONS: Comparison is made to the prior study dated ,\n of the pelvis.\n\n FINDINGS: A single portable abdomen supine film is submitted for review.\n There are no air-fluid levels identified. There are no dilated loops of small\n bowel identified. There is more air in the small bowel than would be normally\n expected, however. There appears to be residual contrast material within the\n colon, likely from a previous CT torso exam from . There is contrast\n material visualized within the sigmoid. There is no evidence of gross free air\n on this supine exam. The soft tissues and osseous structures are otherwise\n unremarkable.\n\n IMPRESSION: No direct evidence of obstruction or ileus.\n\n A preliminary report was submitted to CCC by Dr. and discussed with\n at 7:00 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2138-11-22 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 937426, "text": " 8:47 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: ? evidence of metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n Contrast: MAGNEVIST Amt: 10CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with metastatic breast cancer\n REASON FOR THIS EXAMINATION:\n ? evidence of metastatic disease\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with metastatic breast cancer, question\n evidence of metastasis.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion\n axial images were obtained before gadolinium. T1 sagittal, axial, and coronal\n images were obtained following gadolinium. There are no prior similar\n examinations for comparison.\n\n FINDINGS: The diffusion images demonstrate no evidence of slow diffusion to\n indicate acute infarct. There is moderate prominence of sulci indicating\n brain atrophy. There is no midline shift or hydrocephalus. Mild\n periventricular changes of small vessel disease are seen. Following\n gadolinium, no evidence of abnormal parenchymal, vascular, or meningeal\n enhancement identified.\n\n IMPRESSION: Moderate brain atrophy. No enhancing brain lesions to indicate\n metastatic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-11-23 00:00:00.000", "description": "PELVIS (AP & FROG HIPS)", "row_id": 937602, "text": " 6:38 PM\n PELVIS (AP & FROG HIPS) Clip # \n Reason: assess for fx or subluxed?\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right hip fx s/p ORIF 1 month ago now with increased\n pain and tenderness with significantly limited range of motion\n REASON FOR THIS EXAMINATION:\n assess for fx or subluxed?\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS, FOUR VIEWS, , AT 18:10 HOURS\n\n HISTORY: ORIF one month ago with increased pain and tenderness and\n significantly limited range of motion.\n\n COMPARISON: None.\n\n FINDINGS: The bones are diffusely osteopenic which reduces the sensitivity\n for detecting subtle nondisplaced fracture. A bipolar right hip\n hemiarthroplasty is in place although incompletely imaged as the distal tip is\n not included on any of the submitted radiographs. Alignment is anatomic.\n Curvilinear calcification parallels the lesser trochanter. Given the lack of\n a baseline postop examination, the acuity of this finding is unknown but is\n likely chronic and related to heterotopic ossification. No definite displaced\n fracture is seen although the severity of the osteopenia limits evaluation\n severely. The sacrum is completely obscured by overlying bowel gas and\n contrast within the bladder and distal ureters. An indwelling Foley catheter\n is evident.\n\n IMPRESSION: Severely limited examination due to severity of osteopenia and\n indwelling right hemiarthroplasty. A dedicated right hip radiograph series\n may be of benefit to fully evaluate for prosthesis and exclude a\n periprosthetic fracture in the proximal femoral diaphysis. Given the severity\n of osteopenia, cross-sectional imaging of the pelvis should be directed toward\n MRI for more sensitive evaluation.\n\n" }, { "category": "Radiology", "chartdate": "2138-11-23 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 937603, "text": " 6:09 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with known metastatic lung ca admitted for multiple\n infections\n REASON FOR THIS EXAMINATION:\n assess for metastatic disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old woman with known metastatic lung cancer, admitted for\n multiple infections, assess for metastatic disease.\n\n TECHNIQUE: Multidetector CT images of the chest, abdomen and pelvis were\n performed after the administration of 100 cc Optiray as well as oral contrast\n administration.\n\n Coronal and sagittal reformatted images were also obtained.\n\n COMPARISON: No prior examinations are available for direct comparison.\n\n FINDINGS:\n\n CT CHEST: A small amount of air is visualized within the left brachiocephalic\n vein. Multiple calcified lymph nodes are seen within the mediastinum and\n right hilum. No significantly enlarged mediastinal lymph nodes are\n visualized. The aorta and pulmonary artery are in normal proportion. The\n cardiac size is within normal limits.\n\n A large soft tissue mass is visualized along the right anterior chest wall,\n in the expected region of the right breast. This mass measures approximately\n 2.5 x 7.4 cm in maximal AP x transverse dimension. Additionally, several\n subcutaneous nodules in association with this mass are also seen. The\n adjacent sternum is eroded. A 1.2 cm necrotic right lateral thoracic wall\n subcutaneous mass is also seen (series 3, image 25).\n\n A 6 mm densely calcified nodule is visualized in the right lower lobe, likely\n representing a Ghon focus of healed tuberculosis.\n\n Within the apical segment of the right upper lobe, there is a 9 mm nodule.\n Within the lateral segment of the right middle lobe, there is a 3.5 mm nodule.\n Within the medial segment of the right middle lobe, there is a 3.5 mm nodule.\n There is dependent atelectasis at the lung bases bilaterally. There is a\n moderate-sized layering right pleural effusion and a small layering left\n pleural effusion.\n\n CT ABDOMEN: The liver demonstrates intrahepatic biliary dilatation with\n pneumobilia. There is also extrahepatic biliary dilatation with the common\n (Over)\n\n 6:09 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bile duct measuring 1.8 cm in maximal dimension. There is diffuse perfusion\n abnormality within the liver, without evidence for focal mass. Fatty sparing\n is visualized adjacent to the gallbladder fossa in segment . A simple\n hepatic cyst is seen in the liver dome. The pancreatic duct is at the upper\n limits of normal in size. The adrenal glands, kidneys and spleen are\n unremarkable except for a simple left midpole renal cyst. Oral contrast is\n visualized progressing as far as the distal colon. There is no significant\n abdominal or retroperitoneal lymphadenopathy.\n\n CT PELVIS: The patient is status post right hip replacement, which limits\n evaluation of some of the pelvic structures. The patient has an atrophic\n uterus. A small amount of pelvic ascites is visualized surrounding the\n uterus. A large amount of air is visualized within the bladder, likely\n secondary to Foley catheter placement. There is no significant pelvic\n adenopathy.\n\n CT BONES: There is a large right gluteal sacral decubitus ulcer that measures\n approximately 7 cm wide and 1.3 cm deep. This extends to the sacral bone and\n coccyx and chronic osteomyelitis cannot be excluded. The patient is status\n post right total hip replacement. The femoral component appears well seated\n within the acetabular component. Aside from the infiltrative right anterior\n chest wall soft tissue mass, with associated sternal erosion and infiltration,\n there is no additional evidence for osseous metastatic disease.\n\n IMPRESSION:\n\n 1. Large right breast/anterior chest wall soft tissue mass, measuring\n approximately 7.4 cm in size, eroded the adjacent sternum. Associated right\n lateral chest wall 1.2 cm subcutaneous deposit. Moderate-sized layering right\n pleural effusion with three right upper lobe/right middle lobe nodules. No\n primary lung mass identified. No additional osseous metastatic lesions seen.\n\n 2. Calcified lung nodule with associated multiple calcified mediastinal nodes\n suggest prior tuberculosis exposure.\n\n 3. Pneumobilia with distended intra- and extra-hepatic biliary ducts. No\n hepatic metastases visualized.\n\n 4. Large right sacral decubitus ulcer extending to the sacrum/coccyx, chronic\n osteomyelitis cannot be excluded.\n\n 5. Right total hip replacement without evidence for loosening. No acute\n fracture or dislocation.\n (Over)\n\n 6:09 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2138-11-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937255, "text": " 8:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? effusion?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with fever to 102 w/o clear source. Rhonchi bilaterally. No\n focality.\n REASON FOR THIS EXAMINATION:\n infiltrate? effusion?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever to 102.\n\n FINDINGS: Upright portable AP radiograph of the chest was reviewed without\n comparison. There is an ill-defined opacity at the right lower lobe that\n obscures the right diaphragmatic border. There is a small right pleural\n effusion. Pulmonary vasculature is within normal limits. The heart and\n mediastinal contours are within normal limits.\n\n IMPRESSION: Right lower lobe pneumonia with a small parapneumonic effusion.\n\n" }, { "category": "Radiology", "chartdate": "2138-11-23 00:00:00.000", "description": "MR L SPINE W/O CONTRAST", "row_id": 937578, "text": " 12:04 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: assess for spinal mets\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with known metastatic lung ca admitted for multiple\n infections, now with incontinence and LE weakness\n REASON FOR THIS EXAMINATION:\n assess for spinal mets\n ______________________________________________________________________________\n WET READ: AEBc SUN 5:28 PM\n T2-hyperintense foci in L1 and L2 are more consistent with hemangiomas than\n metastases. No evidence of lower cord or cauda equina compression. \n MD pager \n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE LUMBAR SPINE.\n\n CLINICAL HISTORY: Metastatic lung carcinoma, incontinence, and lower\n extremity weakness.\n\n TECHNIQUE: Sagittal and axial T1- and T2-weighted images and sagittal STIR\n images were obtained. Dr. gave a preliminary report describing\n hemangiomas.\n\n FINDINGS:\n\n There are small areas of T1- and T2 hyperintensity in L1 and L2 consistent\n with hemangiomas. No lesions are seen that suggests a metastasis. At L4-5,\n there is grade-1 spondylolisthesis with considerable facet hypertrophy and\n overall moderate spinal stenosis. The neural foramina are mildly distorted,\n but not significantly stenotic. There is no clear spondylolysis. A disc\n bulge is seen at L3-4 where there is also facet hypertrophy, but no\n significant stenosis. Free fluid is noted in the pelvis.\n\n IMPRESSION:\n 1. No lesion is seen that suggests a lumbar spine metastasis.\n 2. There is moderate degenerative stenosis at L4-5 where there is grade 1\n spondylolisthesis and posterior element hypertrophy.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-11-23 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 937579, "text": " 12:04 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: assess for metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with known metastatic lung ca admitted for multiple\n infections, now with incontinence and LE weakness\n REASON FOR THIS EXAMINATION:\n assess for metastatic disease\n ______________________________________________________________________________\n WET READ: AEBc SUN 5:34 PM\n Multiple T2-hyperintense lesions likely to represent hemangiomas. Moderately\n large right pleural effusion. No cord compression. MD pager\n .\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL SPINE\n\n CLINICAL HISTORY: Known metastatic lung carcinoma. Infections and\n incontinence.\n\n TECHNIQUE: Sagittal T1-weighted, T2-weighted and STIR images and axial T2-\n weighted and gradient echo images were obtained.\n\n FINDINGS:\n There are areas of T2 hyperintensity in C7 and T2 which are essentially\n isointense to fatty marrow on the T1-weighted images most consistent with\n hemangiomas. Lesions are also STIR hyperintense. The vertebral bodies are\n well maintained and normally aligned. At C4/5 minimal bulging of the disc is\n seen. Subarachnoid space is well maintained and the spinal cord appears\n normal. A moderate-to-large sized right pleural effusion is noted.\n\n IMPRESSION:\n 1. There is no spinal cord compression.\n 2. There are STIR and T1 hyperintense lesions in C7 and T2 most consistent\n with hemangiomas.\n\n MRI OF THE THORACIC SPINE.\n\n TECHNIQUE: Sagittal T1-weighted, T2-weighted and STIR images were obtained.\n\n FINDINGS:\n T2 hyperintense lesions are seen in the T2 vertebral body and the T9 vertebral\n body. They are isointense to fatty marrow consistent with hemangiomas. The\n subarachnoid space is well maintained. The thoracic spinal cord is normal.\n There is scoliosis.\n\n IMPRESSION: There is no evidence of metastatic disease to the thoracic spine\n or thoracic spinal cord compression.\n\n (Over)\n\n 12:04 PM\n MR CERVICAL SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: assess for metastatic disease\n Admitting Diagnosis: MI-UTI-PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2178-07-21 00:00:00.000", "description": "Report", "row_id": 1328247, "text": "MICU NURSING PROGRESS NOTE 0700-1900\nNEURO--INITIALLY AGITATED AND HAVING TO URINATE CONSTANTLY BUT HAVING RETENTION AND ONLY VOIDING 50 CC AT A TIME. FINALLY VOIDED 650 CC AND FELT MUCH BETTER. RECEIVED 10 MG IV VALIUM X3 IN ADDITION TO 10 MG PO. SLEPT ALOT OF THE SHIFT AND IS NOW MORE ORIENTED, ALERT AND PLEASANT. SPEECH IS CLEAR. FOLLOWS COMMANDS CONSISTENTLY. PT SPOKE WITH PSYCH AND IS STATING THAT HE WANTS HELP AND WANTS TO GET SOBER. CASE MANAGER IN TO SEE PT. EARLIER IN SHIFT, PT WAS HAVING VISUAL HALLUCINATIONS. THEY HAVE SINCE STOPPED.\n\nCARDIAC--HR 90-120'S SR/ST WITHOUT OBSERVED VEA. SBP 110-130. NO ADDITIONAL LABS DRAWN TODAY SO FAR.\n\nRESP--WEARING O2 AT 3L NC. WHEN SLEEPING RR DECREASED TO THIS AM AND SAO2 WOULD DECREASE TO FROM 99% TO 93%. PRESENTLY PT IS ON 3L NC WITH SAO2 99% AND RR 12-20. LUNGS CLEAR BILATERALLY.\n\nGI--TOLERATING SOFT SOLIDS AS PT HAS INFECTED TEETH AND IT HURTS TO EAT COLD OR HOT THINGS. DRANK BOOST,GINGER ALE AND IS ATTEMPTING TO EAT SUPPER. NO STOOL.\n\nGU--AS ABOVE. PT IS VOIDING ON OWN IN AMTS >600CC AT A TIME.\n\nENDO--UNREMARKABLE AT PRESENT. BANANA BAG FINISHED.\n\nSKIN--OLD TRACK MARKS ON BILAT ARMS. BUTTOCKS WITHOUT BREAKDOWN.\n\nID--AFEBRILE. NO ABX.\n\nPAIN--DENIES H/A, ABD PAIN OR ANY OTHER DISCOMFORTS. PT IS VALIUM Q2 HRS.\n\nCOPING--PT DOES NOT HAVE ANY FAMILY THAT HE KEEPS IN TOUCH WITH. HE DOES HAVE A FATHER WHO LIVES LOCALLY BUT HAS NOT SPOKEN WITH HIM IN \"A LONG TIME\". HE STATES THAT HE HAS NO FRIENDS AND THAT HE DOESN'T KNOW WHERE TO GO. HE WOULD LIKE TO GET INTO A HALFWAY HOUSE. CASE MANAGER IN TO SEE PT.\n\nA--ETOH WITHDRAWAL IS CLEARING AND PT IS MORE ALERT AND ORIENTED. SPEECH IS CLEAR.\n\nP--CON'T TO MONITOR. CON'T TO GIVE VALIUM Q1-2 HRS AS NEEDED. OFFER SUPPORT AND SET LIMITS.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-22 00:00:00.000", "description": "Report", "row_id": 1328248, "text": "PT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT. PT. DOES C/O SHAKING, RESTLESSNESS. PT. HAS BEEN TREATED WITH 20MG PO ROUTINE VALIUM AND 30MG OF IV PRN VALIUM. WITH DESIRED EFFECTS REACHED EACH TIME. PT. HAS REMAINED NSR 70-90'S WITH NO NOTED ECTOPY. B/P HAS BEEN STABLE AND 98-136/60-70'S PULSES ARE UNCHANGED AND STRONG WITH NO NOTED EDEMA. LUNGS REMAIN CLEAR IN ALL FIELDS AND RESP RESP RATE IS REGULAR WITH O2 SATS >99% ON R/A. PT. IS TOLERATING HIS DIET, WITH BOWEL SOUNDS EASILY AUDIBLE, AND NO STOOL NOTED. PT. HAS BEEN VOIDING AMPLE OF CLEAR YELLOW URINE. I.V. SITE CONTNIUE TO HAVE BLOOD RETURN, BUT PAINS PT. UPON FLUSHING. PT. REFUSES TO HAVE NEW SITE PLACED. NO SKIN BREAKDOWN NOTED, PT. REMAINS A FULL CODE. HE IS FOR SOCIAL SERVICES EVALUATION TODAY FOR POSSIBLE GROUP HOME PLACEMENT FOLLOWING DISCHARGE. PT. EXPRESSES DESIRE FOR HELP REGARDING HIS ADDICTIONS. AM LABS ARE PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-21 00:00:00.000", "description": "Report", "row_id": 1328246, "text": "NURSING MICU NOTE 7P-7A\n\nPT IS A 33 Y/O MALE 16YEARS HOMELESS, PMH POLYSUBSTANCE ABUSE AND HEP C. PT ARRIVED TO ER VIA EMS FOR OVERDOSE OF KLONAPIN ~90TABS AND TYLENOL #3 ~30 TABS WITH AND ALCOHOL LEVEL 309. PT GIVEN 2MG IV NARCAN X2 W/ GOOD EFFECT. PT AWAKE, CONFUSED, RESTLESS. PT GIVEN , 20MG IV VALIUM AND BANANA BAG STARTED. PT TO MICU FOR Q1HR CIWA SCALE AND 1:1 SITTER ON SUICIDE PERCAUTIONS.\n\nNEURO: PT RESTLESS ON ADMISSION, CONFUSED, ATTEMPTING TO GET OOB, CIWA SCALE 21. PT GIVEN 2MG IV ATIVAN. PT FOLLOWS COMMANDS, NONCOMBATIVE. PT NOW AROUSES TO VOICE, CONFUSED. PT C/O HEADACHE, N/V, VISUAL DISTERBENCES, AT THE SAME TIME WILL FALL RIGHT BACK ASLEEP. PT HAS HISTORY OF SEIZURES W/ WITHDRAWL FROM ETOH, NO SEIZURE ACTIVITY NOTED. PT IS ON 1:1 SITTER FOR SUCIDE PERCAUTIONS.\n\nRESP: LS CLEAR. PT IS AT TIMES AFTER DOSES OF ATIVAN. PT PLACED ON 3LNC, SATS 90-99%.\n\nCV: HR 60-80'S NSR, NO ECTOPY. SBP 100-110. PT AFEBRILE. PT ARRIVED AND CONT TO HAVE INFUSSING NS W/ THIAMINE, MAG, MVI AND FOLATE AT 125CC/HR.\n\nGI/GU: ABD SOFT, +BS, NO BM. PT HAS NOT URINATED IN MICU, PER ER NURSE PT DID VOID IN ED. PT IS NO EXCEPT MEDS.\n\nACCESS: PT HAS A #20 PIV IN LEFT ARM.\n\nDISPO: 1:1 SITTERS UNITL PSYCH CONSULT THIS AM. CIWA SCALE Q1HR. FOLLOW TYLENOL LEVELS. MONITOR RESP STAUTS. PT IS A FULL CODE IN MICU.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-22 00:00:00.000", "description": "Report", "row_id": 1328249, "text": "MICU NURSING PROGRESS NOTE 0700-1700\nVSS THROUGHOUT THE DAY. PT RECEIVED TOTAL OF 40MG IV VALIUM AND 10 MG PO VALIUM FOR CIWA SCALE >10. PT PACING AROUND ROOM MOST OF DAY. INSOMNIA PERSISTS.\n\nPT D/CED TO AT 1700 VIA AMBULANCE.\n" }, { "category": "ECG", "chartdate": "2178-07-21 00:00:00.000", "description": "Report", "row_id": 212824, "text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2178-07-20 00:00:00.000", "description": "Report", "row_id": 212825, "text": "Sinus tachycardia. Since the previous tracing of the rate has slowed\nbut no other changes have occurred.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-10-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 984979, "text": " 11:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with DM, h/o DKA, here w/ hyperglycemia, CP and cough\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Diabetes and cough.\n\n FINDINGS: The cardiomediastinal and hilar contours are normal. The pulmonary\n vasculature is unremarkable. There are no consolidations or effusions. There\n is no pneumothorax. Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Normal chest radiograph.\n\n\n" }, { "category": "ECG", "chartdate": "2128-10-01 00:00:00.000", "description": "Report", "row_id": 183190, "text": "Sinus tachycardia. Compared to prior tracing of no change.\n\n" }, { "category": "Nursing/other", "chartdate": "2128-10-01 00:00:00.000", "description": "Report", "row_id": 1417609, "text": " 4 nursing progress note/admit note cont..\n Given IV and started on gtt. Back pain treated with 2mgm Dialuded. Sent to ICU for further management of her bs.\n Systems Review:\n Diabetes: Continues on gtt..5-3u/hr..following bs q1hr..Lytes sent..IVF= .45ns at 100hr.. 40meq po k given\n Cardiac: hr 115-120st (tachy in EW)..bp115-120's/\n Respiratory: Room air..sats 90's\n GI: No n/v..pt wanting to eat the minute she got here. On diabetic diet.\n GU: Refused foley in EW..has not voided since admit to ICU\n ID: Afebrile..though WBC up to 21.\n Social: Has 4yr old child..says he is with her mother.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2128-10-02 00:00:00.000", "description": "Report", "row_id": 1417610, "text": "Nsg notes 1900-0700hrs\n\nAllergies:Morphine.\n\nKC/O DM with multiple admissions for high BS,admitted yesterday afternoon with high BS,started on drip.\n\nNeuro:alert and oriented x3.c/o constant pain on back and itching all whole body. she said its her chronic pain from an accident .pain treated with inj.dilaudid img PRN with good effect as she stated oxycodone not gives her good relief .applied pt's own cream on body for icthing .per pt no itching when at home ,she had same problem with last hospitalization also.slept well during the shift.\n\nResp:LS clear,sats 100% on RA.\n\ncvs:HR 90-120,NSR-ST.no ectopics noted.BP 95-110 sys.ivf D5 0.45 W 20MEQ K 100CC/hr .\n\nGU/GI:Abdomen soft,BS present.had BM this shift.using toilet.voided x2-4 times,yellow clear urine.on diet.\n\nEndo:BS done and titrated q1h on early shift,then changed to sliding scale when BS reached 90's.PM dose glargine 31 units given.\n\nSocial:calm and co operative.independant.walks with steady gait.full code .no family contact during the shift.\n\nPlan:continue monitor BS and chemistry.\npain management.treat her itching.? call out.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2128-10-02 00:00:00.000", "description": "Report", "row_id": 1417611, "text": "neuro: alert and oriented, afebrile. c/o chronic back pain, dilaudidx2 given w/ good effect. c/o itching benadrylx2 given w/ good effect.\n\nresp: LSC, O2 sat 100% on RA.\n\nCV: BP stable 100-115, NSR-ST no ectopy noted. 20meq PO KCl given, 1L NS given.\n\ngi/gu: voiding clear yellow urine. no stool this shift. +BS, tolerating diet. no N/V. sliding scale and fixed dose.\n\nplan: called out to floor, self care ambulates to commode. monitor blood sugars. full code.\n" }, { "category": "Nursing/other", "chartdate": "2128-10-01 00:00:00.000", "description": "Report", "row_id": 1417608, "text": " 4 ICU nursing admit/progress note:\n 23 y/o woman with hx of DM1..multiple admissions for DKA. Last DC for 2 day admit.\n Pt had woken up with back pain this am and could not take her am (?)..came to EW with back pain and bs was above 500 and +anion gap\u0013.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2132-10-23 00:00:00.000", "description": "Report", "row_id": 1312206, "text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains alert and x 3. MAE. Assists with care. Denies any pain.\n\nResp - LS clear. RR 16-20. 02 sat > 98% RA. No cough.\n\nC-V - HR 70 -90 NSR, no ectopy noted. ABP 100-120/40-60. Remains off dopamine. Hct dropping to 30.2 from 37.7 - MD notified, no further interventions ordered at this time.\n\nGI - Abd soft. No pain on palp. Tolerating renal diet well. No n/v. Passing flatus, no stool.\n\nF/E - Pt voiding occasionally in sm amts with urinal. K 6.5 at onset of shift. Rx with one amp d50, 10 units regular insulin iv and 30 gms kayexelate po, K dropped to 4.8. Labs this am BUN 47 Cr 9.4 K 5.2 - plan is for dialysis via cath today.\n\nID - Afeb. WBC 7.1, previously 16.2. + MRSA precautions. Being rx with linezolid and levoflox as well as itraconazole for pulm aspergillis.\n\nSocial - No phone calls or visitors. Pt spoke with girlfriend on phone.\n\nA+P - Pt hemodynamically stable off pressors. Dialysis today. Continue antibiotic regime and follow up on cx results. ? dulcolax for constipation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-10-23 00:00:00.000", "description": "Report", "row_id": 1312207, "text": "Nursing note (0700-1900) 16:15\n\n\nROS.\nPt with essentialy unchanged exam, stable CVS during and post dialysis today, Temp 97-98F, cultures have grown gram +ve cocci, on Vanco post HD.\nPt has had bowels open for brown loose, guiacc -ve stool.\nPt eating and drinking within limits of diet, RISS in place, last FSG 256.\n\nPt is called out to floor, transfer note done, awaiting bed.\n\nIf no bed overnight, ? discharge to home in am.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-24 00:00:00.000", "description": "Report", "row_id": 1312208, "text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt remains AAO X 3, MAEE, turning self STS in bed. He denies discomfort, although freq grunting. Slept for 2-3hrs overnight.\n\nResp: RR 14-20 and regular, with O2 sat 100% on RA. Lungs clear throughout.\n\nCV: HR 65-88SR with rare PVC's. Pt had brief period of ventric trigeminy. BP 105/48-133/65.\n\nGI: Pt with good appetite. No BM this shift. FSG 319 @ MN, pt given Regular Insulin 8units per sliding scale.\n\nGU: Pt voided 70ml yellow urine X 1.\n\nPlan: Transfer to floor vs D/C to home. No beds available @ this time for pt with MRSA.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-24 00:00:00.000", "description": "Report", "row_id": 1312209, "text": "NPN:7a-7p\nStable day. Called out to floor for greater than 24h, no bed available. Vanco dose given, D/C'd to home. Discharge instructions and Prednisone prescription given. Sent home with girlfriend. follow up tomorrow at Dialysis Center.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-22 00:00:00.000", "description": "Report", "row_id": 1312203, "text": "Micu Acceptance Note\n\n48 yo male with lengthy pmhx including ESRD, failed transplant on and recent admit for MRSA line sepsis. Of note, per pts girlfriend he has been on prednisone 5 mg qd for a failed cortisol stim test during previous admit but has forgotten to take this for the last few days.Pt presented from dialysis to ER with fever, chills, tachycardia and hypotension. Rx with vanco at dialysis and after bld cxs sent in ER, given levaquin. BP 75/53 with HR 130 ST and temp 101.1 po. Received a total of 1750 ccs NS and then BP supported with dopamine. Pt also given tylenol for temp and 1 mg morphine iv for headache. WBC 13.9 and lactate 2.7. Could not be placed on sepsis protocol due to lack of access sites for central line. Sent to MICU with peripheral dopamine infusing.\n\nReview of Systems\n\nNeuro - Alert and x 3. MAE. PERL. Moans at times but denies pain.\n\nResp - LS clear, occas dry cough. RR 14-20. 02 sat > 97% on 2 L NC.\n\nC-V - HR 90-130 ST, no ectopy noted. ABP and NBp vary significantly. Aline dampened and positional at times. Dopamine being titrated down to maintain MAP >60, currently infusing at 6mcgs/kg/min. + dop pulses. EKG in ER reportedly unchanged from previous one. PTT > 150 on admit - being repeated, INR wnl. Coumadin on hold for ? line placement. NSR on EKG. Antihypertensives held in lieu of hypotension.\n\nGI - Abd soft. +BS. No abd pain on palp. Pt with 2 episodes of vomiting ~ 50ccs bilious fluid. Resolved without intervention, pt declined antiemetic. NPO except for ice chips. Protonix ppx.\n\nF/E - Anuric. One 500cc NS fluid bolus given to help support BP and aid in weaning of dopamine. Am lytes pend.\n\nID/ Endo- Max temp 100.1 po. + MRSA precautions. Lactate decreasing from 2.7 to 1.5. AM CBC pend. Rx with linezolid x 1, to receive levaquin q 48hrs for gm neg coverage. stim test results pend. Hydrocortisone 50 mg iv q 6hrs initiated. FS q6hrs. Bactrim ppx. Itraconazole ordered for pulm aspergillus. BC sent from catheter - plan is to instill vanco and let it dwell and then ? d/c in am .\n\nAccess - 2 peripheral # 20 , catheter.\n\nSocial - Girlfriend called, spoke to pt and RN.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-10-22 00:00:00.000", "description": "Report", "row_id": 1312204, "text": "Addendum - Vanco instilled into blue port of catheter to dwell, not flushed with saline or heparin. Unable to aspirate fluid from red port, vanco not injected - MD aware. K 5.7 this am - EKG taken, no peaked t waves noted. Pt premedicated with reglan prior to receiving 30gms kayexelate po.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-22 00:00:00.000", "description": "Report", "row_id": 1312205, "text": "Nursing note (0700-1900) 16:40\n\nNeuro.\nPt A+Ox3, no complaints of pain this shift, seems a little withdrawn and frustrated at being in the ICU at times, though improving. MAE with problem.\n\nRESP.\nPt now on room air as unable to keep NC on pt, 2 97-100%, LS clear to all fields.\n\nCVS.\nHR 80's NSR with no ectopy seen.\nNow off dopamine, given bolus of NS 500cc with minimal effect this am. BP 100-130's/60's-70's. Repeat K level due at 17:00. Last lactate 1.1.\n\nGI/GU.\nPt remains NPO except meds, +BS, no result from kayexalate yet.\nPt passing some urine to bottle this shift. For dialysis tomorrow.\n\nAccess.\n cath with TPA instilled by dialysis nurse this am, to be left insitu until dialysis.\n\nID.\nT-current 98.4F oral. On linazolid 600mg PO, Levoquin and itrraconazole.\n\nSocial.\nPt has recieved calls to his phone this am, no contact to hospital from friends or relatives.\n\nPlan.\ncontinue antibiotics.\nMonitor fever curve.\n" }, { "category": "ECG", "chartdate": "2132-10-22 00:00:00.000", "description": "Report", "row_id": 275659, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , ST-T wave changes decreased\n\n" }, { "category": "ECG", "chartdate": "2132-10-21 00:00:00.000", "description": "Report", "row_id": 275660, "text": "Sinus rhythm\nModest nonspecific inferolateral ST-T wave changes\nSince previous tracing of , sinus tachycardia rate slower and T wave\namplitude improved\n\n" } ]

[ { "category": "Radiology", "chartdate": "2167-12-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 944949, "text": " 6:49 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia or CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with COPD and multiple myeloma now with cough and dyspnea.\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old man with COPD and multiple myeloma with cough and\n dyspnea.\n\n Comparison is made to prior study on .\n\n Portable semi upright view.\n\n FINDINGS: Mildly enlarged heart is unchanged in appearance. Mediastinal\n countour is unremarkable. Hilar contours look prominent with slight upper\n zone redistribution. Poor inspiratory effort with low lung volumes is\n unchanged. The opacity in the right lung base is unchanged. This might be due\n to pesistent effusion/infiltrate. Multiple bilateral healing rib fractures are\n unchanged. Incidental note is made of severe osteoarthritic changes of the\n left glenohumeral joint and right acromioclavicular joint.\n\n IMPRESSION:\n\n 1. Slight prominence of pulmonary hila and upper zone redistribution suggests\n mild heart failure.\n\n 2.The opacity at right lung base is stable and might suggest persistent\n pleural thickening.\n\n 2. Unchanged appearance of multiple healing rib fractures.\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2167-12-14 00:00:00.000", "description": "Report", "row_id": 125983, "text": "Sinus rhythm with atrial premature beat. Short P-R interval. Left ventricular\nhypertrophy. Non-specific T wave changes in leads I and aVL. Compared to the\nprevious tracing of atrial premature beats is new and bradycardia is\nabsent.\n\n" }, { "category": "ECG", "chartdate": "2167-12-13 00:00:00.000", "description": "Report", "row_id": 125984, "text": "Sinus bradycardia\nSeptal and lateral ST-T changes are nonspecific\nCompared to previous tracing, rate slower\n\n" }, { "category": "Radiology", "chartdate": "2167-12-13 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 944994, "text": " 2:36 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Eval for RLL effusion/atelectasis, whether airspace or pleur\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with multiple myeloma, restrictive and obstructive lung\n disease, COPD who was recently admitted for dyspnea, CXR shows chronic RLL\n effusion/atelectasis.\n REASON FOR THIS EXAMINATION:\n Eval for RLL effusion/atelectasis, whether airspace or pleural\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of multiple myeloma. Evaluate for right lower lobe\n effusion/atelectasis.\n\n COMPARISON: CT dated .\n\n TECHNIQUE: Non-contrast chest CT.\n\n FINDINGS: Images are very limited by motion. There is stable scarring versus\n atelectasis at the right lung base. There is a stable area of plate-like\n opacity in the lateral portion of the lingula anterior to the major fissure\n that may represent atelectasis or scarring. There is new linear atelectasis\n at the left lung base. There is no pleural effusion or pneumothorax. There\n are stable small mediastinal lymph nodes, notably a 6 mm prevascular node and\n a 9 mm right peritracheal node. There are coronary artery calcifications.\n There is no pericardial effusion.\n\n Limited images of the upper abdomen are unremarkable.\n\n Bone windows again demonstrate diffuse osseous abnormality consistent with the\n patient's history of multiple myeloma.\n\n IMPRESSION: Stable scarring/atelectasis at the right lung base with no pleural\n effusion. Stable scarring or atelectasis in the lingula anterior to the major\n fissure.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2167-12-13 00:00:00.000", "description": "Report", "row_id": 1464421, "text": "71 yr pt with muptiple myeloma, restrictive lung disease{non smoker}, htn , admitted for difficulty breathing and unable to sleep. called emts and to ew early this am. no fever, lactate 1.5, no resp distress and congested upper air way with poor clearing effort. see more extensive PMH, pt is DNR/DNI.\n\nsocial: pt lives at home with 3x wk services for adls and sister visits often and prepares meals. pt was in NH post last admit and became very paranoid there and agitated. readmitted and then lives at home. pt is incontinent of urine. is followed colsly by heme onc and comes to heme onc for ?neupogen injections. sister is contact person. team discussed with pt need for more closly monitored care in facility today and pt was not aggressive or upset but asked md to discuss with his sister.\n\nneuro: pt A&O but a bit confused when discusing care and activieties at home. ho poor historian, has had psy w/u in recent past for agressive behavior and is on ziprasisdone. hx subdural hematoma and is on depakote, hx diabetis insipitus on desmopressin. able to communicate all needs.\n\ncard: nsr rate 70's no ectopy. bp 110-132 sys on dilt and metoprolol, on lasix qd . fluid balance is neg thus far and skin turgor is poor pt seems dry.\n\nresp: cxr has unresolved rt LL opacity, not clear since 06.non contrast ct scan done to eval for fluid or atelectisis. was somulent in ew due to prob use of nonrebreather in ambulance and improved with short tx BIPAP and now on ra with sat 95-97% RA. ls course upper airway cong with poor cough effort. neb and mucomist ih ordered. pt finished prednisone taper and ?? if is to be on prednisone 20 mg qd,\n\ngi: last bm 1/20 per pt ? if reliable. taking po well good swallow no cough with eating. last admit had swallow study and passed. hypoactive bs. pt is on oxyconton sustained release .\n\ngu: pt voids freq small amts. leaving urinal in place at all times to avoid inc. clear urine\n\nskin: very dry and covered with and aloe lotion no breakdown noted\n\nID: afeb and wbc 5.6. pt covered with levoquin and vancomycin.\n\nplan: poss call out if not going to tx rt lung after ct scan evaluated, monitor resp status and use bipap if needed, chest PT\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2180-06-21 00:00:00.000", "description": "Report", "row_id": 279578, "text": "Sinus bradycardia\nLong QTc interval- clinical correlation is suggested\nSince previous tracing of , atrial ectopy absent\n\n" }, { "category": "ECG", "chartdate": "2180-06-20 00:00:00.000", "description": "Report", "row_id": 279579, "text": "Sinus bradycardia with atrial premature complexes\nST-T wave changes with prolonged QT interval\nProbable left ventricular hypertrophy\nSince previous tracing of same date, bradycardia rate faster and left bundle\nbranch block absent\n\n" }, { "category": "ECG", "chartdate": "2180-06-20 00:00:00.000", "description": "Report", "row_id": 279580, "text": "Probable sinus bradycardia with unconducted atrial premature complexes and\njunctional escape beats\nLeft bundle branch block\nSince previous tracing of same date, rhythm as described and left bundle branch\nblock now present\n\n" }, { "category": "ECG", "chartdate": "2180-06-20 00:00:00.000", "description": "Report", "row_id": 279581, "text": "Sinus tachycardia\nST-T wave changes with long QTc interval - clinical correlation is suggested\nLeft ventricular hypertrophy by voltage\nSince previous tracing of same date, left bundle branch block absent\n\n" }, { "category": "ECG", "chartdate": "2180-06-20 00:00:00.000", "description": "Report", "row_id": 279582, "text": "Sinus rhythm. Left bundle-branch block. No previous tracing available for\ncomparison.\n\n" }, { "category": "Radiology", "chartdate": "2180-06-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 911172, "text": " 5:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Rule out bleed.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with mental status change, hypertensive. Also status post\n meningioma resection remotely.\n REASON FOR THIS EXAMINATION:\n Rule out bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd TUE 6:33 AM\n no ich\n postoperative changes in right frontal lobe\n lumbar puncture would be necessary to exclude microscopic blood\n WET READ VERSION #1 KCLd TUE 6:32 AM\n no ich\n postoperative changes in right frontal lobe\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Hypertensive, mental status change, status post meningioma\n resection remotely. Evaluate for bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: The ventricles appear prominent, and there is a lobulated mass in\n the atrium of the left lateral ventricle, roughly 2.5 cm in transverse\n dimension and surrounding the choroid plexus. The mass is of density equal to\n or slightly greater than that of cortex. There is also blunting of the\n occipital of this ventricle, which suggests there may be intraventricular\n debris or blood products. No other signs of hemorrhage, and no acute blood is\n identified in the intracranial space.\n There is no shift of the normally midline structures and the basal cisternal\n spaces are well visualized.\n Encephalomalacia of the right frontal lobe, and adjacent osseous irregularity\n and hyperostosis, is consistent with prior surgery in the area. Without old\n exams for comparison, the possibility of residual memigioma (as stated by\n history) cannot be excluded.\n\n Due to motion artifact, some portions of the brain are poorly evaluated.\n\n There is dolichoctasia of the vertebrobasilar system\n\n There is irregular granular density of the skull base which may be related to\n an infiltrative process or Pagets.\n\n There is no sinusitis.\n\n IMPRESSION: Lobulated mass in the left ventricular atrium. Further\n characterization with MR imaging is advised. No clear evidence of acute\n hemorrhage or territorial infarction. Findings and changes to this report, as\n (Over)\n\n 5:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Rule out bleed.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n well as recommendation for MR imaging, were discussed with Dr. at 7:34 am\n on .\n\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2180-06-21 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 911328, "text": " 8:01 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please do with gad and with stroke protocol\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with chg in mental status, periventricular mass seen on CT\n and RLE weakness\n REASON FOR THIS EXAMINATION:\n please do with gad and with stroke protocol\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with change in mental status and ventricular\n mass observed on CT, right lower extremity weakness also.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was\n performed. Diffusion-weighted scans and post-gadolinium T1-weighted images\n are provided.\n\n Comparison is made to the CT scan of .\n\n FINDINGS:\n\n As noted on the previous study, there is a lobulated mass within the atrium of\n the left lateral ventricle, measuring up to 3.7 cm in maximal transverse\n dimension. This mass has smooth margins and is roughly isointense to \n matter on T1- and T2-weighted images. The mass homogeneously enhances\n following contrast administration. The left ventricular choroid plexus\n appears surrounded by the mass, and it is unclear if it is involved. There is\n indentation of the ependymal surface of the atrium of the left lateral\n ventricle, and there is no well-defined margin between the outer edge of the\n mass and the ventricle. A mild degree of increased T2 signal is present in\n the adjacent temporal lobe white matter, likely representing edema.\n\n There is also a roughly 5 mm T2 hypointense and enhancing nodule along the\n lateral surface of the right cerebellum, near the junction of the transverse\n and sigmoid sinuses. This too could represent a meningioma. It is not well\n seen on a number of the sequences due to motion artifact.\n\n Within the brain, there are encephalomalacic changes of the right frontal lobe\n and areas of increased T2 signal throughout the white matter, which probably\n reflect chronic microvascular ischemia and infarction. No signs of diffusion\n abnormality are present to indicate acute ischemia or infarction.\n\n The inner table of the right frontal bone is thickened, as seen on the CT\n exam, but there isno abnoraml enhancement in this location to suggest\n recurrent meningioma.\n\n Gradient-echo images reveal three tiny foci of parenchymal susceptibility\n artifact, two in the left putamen and one in the right occipital lobe, perhaps\n related to old microhemorrhages.\n (Over)\n\n 8:01 AM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please do with gad and with stroke protocol\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is no hydrocephalus or shift of normally midline structures. There is\n preservation of flow voids in the proximal branches of the circle of .\n\n Mild mucosal thickening or fluid is identified in some of the inferior left\n mastoid air cells, and to a very mild degree in the maxillary and sphenoid\n sinuses.\n\n IMPRESSION: There is a lobulated mass in the left ventricular atrium, which\n could represent an intraventricular meningioma. There are no signs of\n recurrent meningioma in the right frontal postoperative region.\n An additional tiny focus of enhancement and signal abnormality is noted along\n the right side of the cerebellum. This is difficult to characterize due to\n its small size and the limited visualization of this finding.\n\n\n DFDgf\n\n" }, { "category": "Radiology", "chartdate": "2180-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 911184, "text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Rule out infiltrate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with mental status change, leukocytosis.\n REASON FOR THIS EXAMINATION:\n Rule out infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:43 A.M. \n\n HISTORY: Mental status changes and high white count.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lungs are low in volume but clear. Pleural effusion, if any, is on the left\n and minimal. Mild cardiomegaly. Atherosclerotic calcification above the\n aortic knob suggests aberrant right subclavian artery.\n\n Tips of a dual channel right supraclavicular central venous catheter project\n over the SVC and superior cavoatrial junction respectively. No pneumothorax.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-06-20 00:00:00.000", "description": "Report", "row_id": 1416613, "text": "Nursing note (1000-1900) 17:30\n\nPt admit from ED with hx of siezures due to meningioma in past (removed) in 's. HD for renal failure for many years, IDDM, hypertension, hyperlipidaemia.\nPt presented with K+ of 7.5 and Dilantin level of 1.4, severe altered MS noted by RN at where pt resides this am, no siezure activity noted at that time.\n\nSee careview for details.\n\nNeuro.\nPt lethargic, opens eyes to verbal stimuli, not following commands, moving self in bed at times. Pt seemed to be improving until 17:00 when had a siezure of about 1 minute duration witnessed by Neurology team. Loading dose of Dilantin ordered (awaiting dose). Pt now in post ictal phase.\nCT head showed small area of ?? blood to ventricles on the left, to have repeat CT in am and probable MRI to confirm.\nTeam to perform LP also.\n\nResp.\nLS clear to all fields, SpO2 100% on 4l nc, impaired cough and gag, so on aspiration precautions, team may place NG tube later.\n\nCVS.\nPt hypertensive in ED to 230/70, now in 130-170/90's, labetolol gtt hanging, but not needed as yet (goal to keep SBP below 180mmHg)\nHR initially 50's SB with rare ectopy due to high K+, pt also into heart block ? due to rapid infusion of Dilantin in ED (inifusion stopped about half way through). Currently NSR 60's with no ectopy noted.\n\nGI/GU.\nPt NPO, +BS with no BM as yet.\nPt dialysed at bedside, 1500cc removed, repeat lytes pending.\n\nEndo.\nStarted on RISS, no coverage as yet needed.\n\nSkin.\nIntact, no issues at this time.\n\nSocial.\nDaughter called for update, will be in to visit later (needs to fill in MRI check list).\n\n" }, { "category": "Nursing/other", "chartdate": "2180-06-21 00:00:00.000", "description": "Report", "row_id": 1416614, "text": "NPN 1900-0700:\nNeuro: Pt is lethargic, nonresponsive, unarousable except for once when I asked her name answered properly the first name but not oriented to place and date, opens eyes to verbal stimuli, localizes pain, PERLA, moving all extremities in bed, today for MRI, checklist filled by daughter and placed in pt's chart.\n\nResp: Breathing regularly on O2 NC 4 L/min, RR14-25, SPO2 95-100%, LS clear to diminished at bases, not coughing not expectorating, no gag.\n\nCV: SB-SR HR 50-67, BP 121-175/52-91, started on Labetelol drip, then weaned and stopped, pulses weak peripherally, with a femoral central line and a dialysis central line, rceived vancomycin and Ampicillin, on Dilantin.\n\nGI/GU: NPO, PO meds not given, MD informed, abdomen soft, BS present, blood glucose was 255, given 3 units insulin as per sliding scale, at 0400, pt'd bld sugar decreased to 54, given ampule Dextrose 50%, anuric, on dialysis (done yesterday).\n\nInteg: Skin is warm and dry, integrity is intact, afebrile.\n\nSocial: visited by daughters in the evening and updated about POC.\n\nPlan: Monitor bld glucose level and use sliding scale of insulin, Monitor BP and start Labetolol accordingly, continue antibiotics, MRI today.\n" }, { "category": "Nursing/other", "chartdate": "2180-06-21 00:00:00.000", "description": "Report", "row_id": 1416615, "text": "altered neuro status:\nd: neuro: pupils briskly and equally reactive to light. pt unarousable and some withdrawal of lower extremities with painful stimulation. pt transported to rdiology for mri and final results re pending .eeg done at bedside as well and await final . no seizure activity noted and pt continues to receive dilantin as ordered.pain/anesthesia md x2 at the bedside without success and plan is to transport pt in am at 1030 to pain clinic for lp. by 1130 pt became more awake when asked who was pt stated it was her daughter. pt times with garbled speech and inconsistent in when she responds verbal stimulation. neuro consult team continues to follw pt on daily basis.\n\nresp: pt has not required any o2 and her sats have been > 96%. coarse bs on auscultation but diminished at the bases. pt with cough and intact gag but will maintain pt on spiration precautions.\n\ncv: pt 's hr ranges from 40's -low 60's without ectopy. her sbp has run form 153-170's although she did have 1 episode of her sbp being 185. she was medicated with 10 mg iv hydralazine with good effect and can receive this med q 6 hrs prn to keep sbp < 180. gaol for her bp is 140-180. electrolytes wnr and will continue to follow as ordered and replete as needed. pt now started on heparin 5000 u sc tid.\n\ngi: pt remains npo b/cause of her altered ms and may need to conside inserting ngt if her ms improve. will maintain aspiration precautions. abd soft and nontender with pos bowel sounds on auscultation. no stool output this shift. hct stable at 32.9\n\ngu: pt is dialyzed on tues,thurs and saturday via r subclavian quintan cath. pt now orderd to receive 1 gm ceftriaxone q 12 hrs on days of dialysis. bun=46 and creat=6.8.\n\niv access: pt has r fem triple lumen in place. unsuccessful attempt to place ej cath so will need to consider having new cl placed tomorrow while in clinic.\n\nsocial: pt is a full code. her daughter plans to visit this evening. will continue with present medical management and keep fmaily well informed on a daily basis\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2180-06-22 00:00:00.000", "description": "Report", "row_id": 1416616, "text": "NPN 1900-0700\n\nNEURO: GARBLED SPEECH, UNINTELLIGABLE, CANNOT ASSESS ORIENTATION. OCCASIONALLY WILL BE ABLE TO ANSWER YES OR NO QUESTIONS, BUT CANNOT ASCERTAIN HOW MUCH SHE KNOWS.\n\nRESP: ON 2 L NC, MAINTAINING SATS 97-100%. LUNGS CLEARBUT DIM AT BASES.\n\nC/V: SR ,HYPERTENSIVE INTO 180'S. RECIEVED ONE DOSE OF HYDRALAZINE 10MG, AS WELL AS 5 MG LOPRESSOR W/ FAIR RESULTS.\n\nF/E/N: HNV, NO STOOL OVER NOC. NPO FOR NOW , NO PO ACCESS.\n\nPLAN: LP AT PAIN CLINIC, POSSIBLE LINE PLACEMENT, DIALYSIS . MONITOR HEMODYNAMICS, EMOTIONAL SUPPORT FOR FAMILY\n" }, { "category": "Nursing/other", "chartdate": "2180-06-22 00:00:00.000", "description": "Report", "row_id": 1416617, "text": "pt had lp done under fluoro and results revealed high protein level and plan is to continue acyclovir and d/c all other antibiotics. pt transfered by ambulance to 7 for hd and will be assigned medical bed on . see transfer note for additional occurunces of today.\n" } ]

[ { "category": "Radiology", "chartdate": "2145-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952613, "text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: LEFT TIBIAL PLATEAU FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe scoliosis who presents with tibial fracture\n now with increasing shortness of breath, increasing O2 requirement from\n baseline home O2.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 3:54 A.M.\n\n INDICATION: Tibial fracture. Increasing shortness of breath.\n\n FINDINGS: Compared with 3/11, there has been considerable clearing and\n re-aeration of the right lung. There appears to be mild edema.\n\n The left lung base also appears better aerated, but there is some persistent\n infrahilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-12 00:00:00.000", "description": "PELVIS (AP ONLY)", "row_id": 952004, "text": " 12:02 AM\n PELVIS (AP ONLY); FEMUR (AP & LAT) LEFT Clip # \n TIB/FIB (AP & LAT) LEFT; ANKLE 1 VIEW LEFT\n Reason: please eval hip for evidence of trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with knee fracture\n REASON FOR THIS EXAMINATION:\n please eval hip for evidence of trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with knee fracture. Evaluate hip for evidence\n of trauma.\n\n COMPARISON: CT lower extremity from .\n\n FINDINGS: Eleven images of the left hip and leg demonstrate a healed\n intertrochanteric fracture of the proximal left femur which is fixated by an\n intramedullary rod with single interlocking distal screw and wide proximal\n screw extending into the left femoral head. No acute fracture lines are\n identified. The bones are diffusely demineralized and gracile.\n\n Again identified is a fracture of the tibial plateau, better characterized on\n the concurrent CT. A large lipohemarthrosis is noted. There is deformity and\n bowing of the mid tibia and fibula. Hardware is seen transversing the\n syndesmosis of the distal tibia and fibula. There is valgus angulation of the\n foot in relationship to the distal tibia. There is significant atrophy of the\n musculature throughout the extremity.\n\n IMPRESSION: Tibial plateau fracture, better characterized on the CT of , . No evidence of acute bony injury within the hip or femur. Chronic\n changes as above.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-12 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 952005, "text": " 12:08 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: FX ANKLE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old female with trauma.\n\n COMPARISON: .\n\n AP SUPINE CHEST: There is moderate cardiomegaly. A large hiatus hernia is\n redemonstrated. Significant distortion is appreciated at the thoracic cavity\n secondary to marked scoliotic change. Patchy air space opacities are present\n in the left upper and right mid lung concerning for aspiration or multifocal\n pneumonia. Asymmetric edema is also a consideration. There is no pleural\n effusion or pneumothorax. No fractures are identified.\n\n IMPRESSION: Study limited by distortion from severe S-shaped thoracic\n scoliosis. Cardiomegaly with alveolar opacity in the right mid and left upper\n lung concerning for aspiration or multifocal pneumonia. Evolving asymmetric\n edema cannot entirely excluded and follow up radiographs are recommended.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-11 00:00:00.000", "description": "L CT LOW EXT W/O C LEFT", "row_id": 952000, "text": " 8:56 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: OSTEO., H/O TIBIAL FX, PAIN AFTER TWISTING.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with osteoporisis, hx of superior tibial fracture, now\n presents with severe pain after twisting injury, concerning for new fracture.\n REASON FOR THIS EXAMINATION:\n ?fracture vs soft tissue injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:39 PM\n Acute minimally drepressed bicondylar left tibial plateau fracture with large\n lipohemarthrosis. Fracture lines extend to the articular surface of the\n lateral tibial plateau. Likely minimally displaced fracture through the head\n of the left fibula.\n WET READ VERSION #1 10:44 PM\n Acute left tibial plateau fracture with large lipohemarthrosis.\n Fracture lines extend to the articular surface of the lateral tibial plateau\n which is mildly depressed. Likely minimally displaced fracture through the\n head of the left fibula.\n ______________________________________________________________________________\n FINAL REPORT\n CT LEFT KNEE\n\n HISTORY: 85-year-old woman with osteoporosis and pain after a twisting\n injury.\n\n TECHNIQUE: Axial CT images are obtained through the proximal left tibia.\n Sagittal and coronal reconstructions were performed.\n\n COMPARISON FILMS: Left knee radiographs .\n\n FINDINGS: There is a tibial plateau fracture. The complex predominantly Y-\n shaped fracture line extends through the posterior lateral articular surface.\n The fracture extends from the posterior aspect of the lateral tibial spine\n inferiorly through the proximal medial cortex of the tibia; the fracture does\n not involve the medial articular surface. There is no significant\n displacement, depression, or extraction of the acute fracture.\n\n There is a small nondisplaced acute fracture through the fibula head. An old\n healed slightly more distal tibial shaft fracture has resulted in the distal\n tibia being angulated medially. The bones are severely osteoporotic. There is\n high density within the proximal tibial shaft, some of which is the result of\n hemorrhage from the acute fracture. Other relatively high- attenuation\n intramedullary regions in the more distal tibial diaphysis may represent\n hematopoietic foci surrounded by fatty marrow.\n\n There is a large knee lipohemarthrosis containing a fat fluid level.\n\n IMPRESSION:\n 1. Acute, impacted tibial plateau fracture, Y-shaped and intra-\n articular (Schatzker Type V), but without significant depression.\n (Over)\n\n 8:56 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: OSTEO., H/O TIBIAL FX, PAIN AFTER TWISTING.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Associated large lipohemarthrosis of the knee.\n 3. Small nondisplaced acute fibular head fracture\n 4. Old healed proximal tibial shaft fracture.\n 5. Severe osteoporosis, gracile bones of the left lower extremity with bowing\n deformity, and fatty atrophy of the regional musculature raise the possibility\n of remote poliomyelitis or other underlying neuromuscular disorder.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952158, "text": " 7:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for worsening infiltrate/edema.\n Admitting Diagnosis: LEFT TIBIAL PLATEAU FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe scoliosis who presents with tibial fracture now\n with increasing shortness of breath, increasing O2 requirement from baseline\n home O2.\n REASON FOR THIS EXAMINATION:\n eval for worsening infiltrate/edema.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Increasing dyspnea, tibial fracture, severe scoliosis.\n\n Frontal views of the chest are compared to the examination.\n\n The cardiac silhouette is enlarged, though this may be in part due to a large\n hiatal hernia evidenced on prior CT. There are increased bilateral\n predominantly bibasilar airspace disease and vascular congestion attributed\n to worsening CHF. Note is made of severe thoracolumbar S-shaped scoliosis.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952106, "text": " 4:33 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for worsening infiltrate\n Admitting Diagnosis: LEFT TIBIAL PLATEAU FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe scoliosis who presents with tibial fracture now\n with increasing shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for worsening infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH OF \n\n COMPARISON: at 12:38 a.m.\n\n INDICATION: Increasing shortness of breath.\n\n Cardiac silhouette remains enlarged. There is vascular engorgement and\n worsening bilateral perihilar haziness. Additional more confluent area of\n opacification in the right middle and retrocardiac portion of the right lower\n lobe are noted. Left retrocardiac area is difficult to assess to large hiatal\n hernia.\n\n IMPRESSION:\n 1. Worsening perihilar edema.\n\n 2. Worsening right middle and lower lobe opacity which may be due to\n asymmetrical edema or superimposed aspiration or pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952766, "text": " 5:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: LEFT TIBIAL PLATEAU FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe scoliosis who presents with tibial fracture\n now with increasing shortness of breath, increasing O2 requirement from\n baseline home O2.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe scoliosis and tibial fracture, now with increasing\n shortness of breath.\n\n COMPARISON: .\n\n SINGLE AP SUPINE CHEST RADIOGRAPH: There is moderate diffuse air space\n disease, likely pulmonary edema. Severe scoliosis leading to tortuosity of\n the aorta and right-sided shift of the trachea is unchanged. Large hiatal\n hernia is not as clearly seen on today's exam, though is still present.\n\n IMPRESSION:\n 1. Moderate CHF, increased compared to one day prior.\n 2. Large hiatal hernia.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2145-03-11 00:00:00.000", "description": "L KNEE (AP, LAT & OBLIQUE) LEFT", "row_id": 951984, "text": " 5:40 PM\n KNEE (AP, LAT & OBLIQUE) LEFT; TIB/FIB (AP & LAT) LEFT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with knee pain s/p twisting it today\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n WET READ: 6:30 PM\n Corical irregularity along the proximal tibia concerning for fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old woman with knee pain after twisting injury today.\n\n COMPARISON: Left femur from .\n\n THREE VIEWS OF THE LEFT KNEE AND TWO VIEWS OF THE LEFT TIBIA AND FIBULA: There\n is diffuse bony demineralization. Intramedullary nail with a traversing screw\n is seen within the distal femur. There is a deformity of the proximal tibia\n consistent with a healed fracture as well as chronic remodelling. Just\n superiorly to this region, however, there is cortical irregularity\n involving both the medial and lateral cortex of the proximal tibia, with the\n suggestion of increased density which raises the possibility of an impacted\n proximal tibial fracture. There is an accompanying moderately large\n lipohemarthrosis. There is a small calcific density just anterior to the\n patellar tendon. There is soft tissue edema in the lower leg. Hardware is\n seen traversing the distal tibia and fibula.\n\n IMPRESSION:\n 1. Lipohemarthrosis, with cortical discontinuity and step-off involving both\n the medial and lateral tibial plateau, and sclerosis in the proximal tibia,\n indicative of underlying impacted tibial plateau fracture.\n 2. Acute non-displaced fracture of the fibular head.\n 3. Abnormal gracile appearance of the bones of the entire left lower\n extremity, with diffuse demineralization and bowing deformity, as well as\n diffuse fatty muscle atrophy, suggestive of remote poliomyelitis or other\n neuromuscular disorder. This may have placed the patient at risk for\n pathologic fracture, currently (and in the past).\n\n COMMENT: As discussed with covering Orthopedics Resident, suggest dedicated\n lower extremity CT (or MR) examination, to further characterize this\n fracture; a wet was posted to the ED dashboard.\n\n" }, { "category": "Radiology", "chartdate": "2145-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 952238, "text": " 9:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: repeat CXR\n Admitting Diagnosis: LEFT TIBIAL PLATEAU FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe scoliosis who presents with tibial fracture\n now with increasing shortness of breath, increasing O2 requirement from\n baseline home O2.\n REASON FOR THIS EXAMINATION:\n repeat CXR\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:32 A.M., .\n\n HISTORY: Severe scoliosis. Tibial fractures and increasing shortness of\n breath.\n\n IMPRESSION: AP chest compared to and and 10, .\n\n Moderate-to-severe pulmonary edema has worsened. More pronounced\n consolidation in the right lower lung could be due to coexistent pneumonia.\n Large hiatus hernia projects over the midline heart. Severe thoracolumbar\n scoliosis noted.\n\n Dr. was paged to report these findings at the time of dictation.\n\n\n" }, { "category": "Echo", "chartdate": "2145-03-17 00:00:00.000", "description": "Report", "row_id": 64923, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 58\nWeight (lb): 115\nBSA (m2): 1.44 m2\nBP (mm Hg): 117/69\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 11:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the interatrial\nseptum at rest.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial flutter.\n\nConclusions:\nThe left atrium is elongated. A left-to-right shunt across the interatrial\nseptum is seen at rest consistent with the presence of small secundum type\natrial septal defect. There is mild symmetric left ventricular hypertrophy.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , small atrial\nseptal defect is now detected.\n\n\n" }, { "category": "ECG", "chartdate": "2145-03-13 00:00:00.000", "description": "Report", "row_id": 129238, "text": "Atrial fibrillation\nPoor R wave progression\nST-T changes are nonspecific\nSince previous tracing of , slower ventricular rate, ST segment\ndepression less pronounced\n\n" }, { "category": "ECG", "chartdate": "2145-03-13 00:00:00.000", "description": "Report", "row_id": 129239, "text": "Atrial fibrillation with rapid ventricular response with ventricular premature\ncomplexes\nExtensive nonspecific ST-T changes\nSince previous tracing of , atrial fibrillation and ST-T wave changes\nare noted\n\n" }, { "category": "ECG", "chartdate": "2145-03-12 00:00:00.000", "description": "Report", "row_id": 129240, "text": "Sinus rhythm\nPoor R wave progression\nSince previous tracing of , sinus tachycardia absent, QRS changes in\nlead V3 - ? lead placement\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-14 00:00:00.000", "description": "Report", "row_id": 1269664, "text": "Respiratory Care:\nPatient remained off NIV on a NRB mask all night long. Last abg results determined a partially compensated metabolic alkalemia with good oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-14 00:00:00.000", "description": "Report", "row_id": 1269665, "text": "MICU NPN 0700-1900\n\nEvents: Heparin gtt initiated today for a-fib. Fentanyl patch placed for pt comfort. Please see carevue for all objective data.\n\nNeuro: AA&Ox3. Pleasnt and cooperative. Pt continues to c/o pain in left leg. Fentanyl patch placed. Pain scale less since fentnayl patch placed. she is also receiving tylenol for pain.\n\nResp: Pt has remained on NRB mask all day. Sats 89-94%. Pt denies feeling SOB with mask on, but will drop sats quickly to the low 80's with mask off. RR 21-34. CXR shows worsening pulmonary edema and RLL PNA. Pt started on levofloxacin. Pt able to cough up thick yellow sputum. No further lasix given for pulmonary edema.\n\nCV: HR 88-101, afib with occasional PACs. Pt remains on PO diltizem. Heparin gtt initiated for a-fib. PTT checks q 6 hours. Next due @ 1700. BP 111--68. 2 PIVs remain patent.\n\nGI: Cardiac diet ordered. Difficulty with eating due to her resp. status (sats dropping). Abdomen soft, non-tender. Pt on colace. Last BM reported . She states she takes metamucil each night at home. Pt did have small stool smear today. need to increase bowel regime.\n\nGU: u/o 10-20cc/hr. Dr. aware. Plan to leave pt even today therefore no lasix given.\n\nID: afebrile. Levofloxacin started for RLL PNA.\n\nSkin: intact. Left leg remains in brace. Ortho following\n\nSocial: Pt has 2 , (who works in PACU) and , who are HCPs. Please contact for next 24 hours for any issues. Discussion had with , and Pt with Dr. about code status. Decision for Pt to be DNR/DNI but can use \"chemical rescusitation.\" No shocks or chest compressions wanted by pt.\n\nDispo: Remain in MICU. DNR/DNI\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-13 00:00:00.000", "description": "Report", "row_id": 1269662, "text": "MICU NPN 1500-1900\n\nEvents: a-line placed. Pt able to tolerate BIPAP x 1hour. Second lasix dose given. Resp. status improving. Please see carevue for all objective data.\n\nNeuro: AA&Ox3. Pleasant and cooperative. Pt c/o Left leg pain. Tylenol given. Pt refused ativan when offered for comfort.\n\nResp: Baseline ABG 7.47/47/65/35. Pt then placed on BiPAP for one hour which she tolerated well. Repeat ABG: 7.49/53/97/41. Pt placed back on non-rebreather. RR 38 but now pt is breathing mid 20's. LS diminished with crackles. Pt will need repeat CXR in am. Pt is a DNI. Will need clarification on DNR status. Dr. aware.\n\nCV: HR, afib, with rates now in 90's-100's. Diltizem gtt remains at 10mg/hr. BP 96-117/53-61. Plan is to increase PO dilitizem and attempt to wean drip off tonight. K level check due for 20:00pm\n\nGI: NPO except meds. Abdomen soft. non-tender. No BM this shift\n\nGU: Pt has been given lasix x2 since arrival to MICU. Goal -1 Liter today. Pt is currently negative 586cc thus far.\n\nID: Tmax 99.6\n\nSkin: left leg in brace. NO breakdown noted.\n\nDispo: remain in MICU. DNI. Clarification of DNR needed.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-18 00:00:00.000", "description": "Report", "row_id": 1269681, "text": "Nursing progress notes 0700-1900\nCode: DNR/DNI\n\nEvents:Husband visited from rehab, cont on BIPAP.\n\nNeuro: Pt lethargic, difficuilt to wake up, unable to assess for orientation, able to speak one or two words inappropriately, unable to obey commands, responds to painful stimuli, flex and withdraws the extremities. Pt was able to open the eyes and respond on stimulation during visit by the husband. Fentanyl patch d/c'd due to increased sedation.\n\nResp: Received on BIPAP Fio2 70%/15/+5, RR irregular with short periods of apnea, shallow breathing, ABG pH 7.28/84/120/9/41, o2 sat 94%, PEEP increased to +8, initially LS clear upper lobes, diminished bases, later on exp wheezes with coarse with low urine output, 15ml/hr and no urine for two hrs, HO notified. Furosemide 80mg IVP given with good effect. LS improved. ABG at noon,pH 7.25/101/134/46, HO notified,\ncontinued the same management.\n\nCV: HR 74-100,Afib with occasional PVC's and atrial flutter. BP 94/56- 127/68, no CP or discomfort noted. Heparin gtt contd 650 units/hr, decreased to 550 units with PTT 102.1, for PTT after 6hrs. Left A line\nwith good waveform.\n\nGI: Abd soft,+BS,unable to swallow ,Pt kept NPO, no BM this shift.\n\nGU: Foley catheter draining clear yellow urine, output improved after Furosemide IV.\n\nID: Cont on Levofloxacin, Vancomycin d/c'd for today due to trough level 18.1, afebrile, Tmax 96.8\n\nEndo: BS Q 6hrs, on Insulin s/s, cont on IV steroids.\n\nSocial:Family visited, husband from rehab came in to visit, are at the bedside. ICU team discussed with the about the Pt's deterioration, no final decision made until now.\n\nPlan: Cont on BIPAP now, monitor resp status, neuro status,PTT monitoring, ABG PRN, blood sugar, emotional support to the family, ? for comfort measures after discussing to the family. To keep on BIPAP during night, Pt was using BIPAP machine at home.\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-18 00:00:00.000", "description": "Report", "row_id": 1269682, "text": "Resp Care\nPt spent most of the day on NIV 15/8 70%, paco2 continued to climb regardless of bipap. BLBS wheezey and very diminished pt only taking very shallow breaths. Pt given xopenex Q4 with some improvement. Family in all day, and at 5pm HCP asked for the ventilation to be stopped permenently MDs aware, pt taken off bipap and placed on NRB with sats slowly trending down, currently 93%. Plan to continue to follow pt for neb treatments\n" }, { "category": "Nursing/other", "chartdate": "2145-03-19 00:00:00.000", "description": "Report", "row_id": 1269683, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: DNR/DNI, pt also comfort measures only\nAlleriges: morphine, amoxicillin\n\nEvents: Pt made comfort measures only by who are HCPs.\n\nNeuro: Pt arousable to voice/stimuli, noted to be becoming increasingly lethargic. Oriented to self. Pt inconsistently following commands, calling out occasionally for husband. Pt given dilaudid 0.5mg x 2 for pain to left leg and general discomfort.\n\nCV: HR a-fib 103-140 with rare PVC, a-line d/c'd and per family's request NIBP left off. Heparin gtt d/c'd.\n\nResp: Pt remains on non-rebreather with slowly falling 02 sat. Lung sounds clear in upper lobes, diminished in bases. RR 20's.\n\nGI: BS x 4, no stool this shift. Pt remains NPO.\n\nGU: Foley patent and draining small amounts clear, yellow urine. UO 5-70cc/hr. No AM labs drawn.\n\nID: Tmax 98.9 AX, all ABX d/c'd.\n\nSocial: Two , both nurses, (one here in ) sleeping on cot at bedside.\n\nPlan:\nPRN medication for comfort\nc/o to floor?\nemotional support to family and pt\n" }, { "category": "Nursing/other", "chartdate": "2145-03-14 00:00:00.000", "description": "Report", "row_id": 1269663, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: DNI, per Dr. pt unsure whether she wants to be DNR, will discuss with HCP in AM.\nAllergies: Morphine, Amoxicillin\n\nEvents: Weaned off dilt drip, IV lasix given, maintaining acceptable sat on NRB mask.\n\nNeuro: Pt A&O x 3, pleasant, follows commands, able to make needs known. Complaining of pain to left foot, received PRN percocet with good effect, pt did complain of brief period of nausea. Pt slept most of night.\n\nCV: HR a-fib 78-103 with occasional PAC/PVC, successfully weaned of dilt gtt. Received additional PO dilt dose at 0500 for HR increasing into 110's. ABP 98-124/45-63. Please see carevue for AM labs. Pt afebrile, tmax 98.3 AX. PIV x 2, left radial a-line.\n\nResp: Pt remains on NRB mask @ 10LMP, RR 17-29, sats >90%, per Dr. goal sat >90% is acceptable. Pt noted to desat to 88% when mask removed. Desatted to mid 80's x 1, improved to >90% with MDIs. Lung sounds coarse to diminished throughout with occasional crackles. Weak non-productive cough.\n\nGI: BS x 4, no stool this shift. Able to take meds with water. Remains NPO in case of BIPAP/CPAP.\n\nGU: Foley patent, draining clear amounts of light yellow urine. Pt given 80mg lasix IVP with minimal effect, Dr. aware. AM K 4.0 after 40mEq PO potassium at MN.\n\nSkin: left leg in knee immobilizer, otherwise skin intact.\n\nPlan:\nmonitor HR, UO\nclarify DNR status\npain management\ngoal sats >90%\nroutine ICU care and monitoring\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-17 00:00:00.000", "description": "Report", "row_id": 1269677, "text": "7pm to 7am:\n\nPt has had an uneventful night.\n\nROS:\n\nNeuro) Pt is alert and O X3 w/A. Pt found to be sl disoriented at 4am , but was easy to reorient. Pt found to be sl anxious and feeling \"doom\" after her left. Emotional support given with good effect.\n\nCV) Pt remains in Afib (80-90's) with rare PVC's. VSS and WNL's. Pt on heparin gtt protocol, now at 750 units/hr. Next PTT due at 10 am. A-line with good wave form. No CP or any other cardiac complaints. Pt has some swelling to bil lower legs. BS found to be elevated steroids, ? RISS. ECHO today.\n\nResp) Pt remains on CPAP+PS as noted throughout the night. Pt will desat within seconds when off. ABG this am: 7.28/90/152. Neb tx done and PS decreased to 15. Will F/U with ABG. TV's 250->360's. Goal to wean off CPAP. LS CTA with decreased bases. No resp distress noted.\n\nGI) Abd soft with + BS. NO N/V/BM. NPO with IVF at KVO. ? advance diet when off CPAP.\n\nGU) Low U/O via foley catheter (25-40 cc/hr). IVF bolus given with minimal effect. Needs F/U.\n\nPain) Pt only reports some discomfort when turned side to side. Pt has fentanyl patch on.\n\nAct) immobilizer on Lt leg fx. PT to see pt today for ROM.\n\nsoc) SS following pt and pt's family re plans after discharge.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-17 00:00:00.000", "description": "Report", "row_id": 1269678, "text": "\nNPN: ros see carevue for details\n\nNEURO: patient alert & oriented this morning, anxious as to when family was going to visit, c/o inpending doom \"I don't know why I take these meds they aren't going to help\". recieved 0.25 mg ativan this morning for anxiety/tachypnea. since recieving dose patient has been lethargic, although wakes up easily to stimulation/voice and is oriented when awake. denies pain\n\nCV: remains in afib, hr 80-90s, rare PVCs, ABP 100-120s/50-60s, +pp. + edema to extremities\n\nRESP: remains on nonrebreather with O2 sats 92-96%. LS clear, diminished t/o. hypercapnea cont. team aware. treatments per RT\n\nGI: tolerating clears > abd s/nt/nd > +bs. taking pills without difficulty\n\nGU: marginal urine output t/o day. team aware\n\nENDO: RISS started today to maintain BS control\n\nID: afebrile. ABX as ordered\nskin: grossly intact.\n\nsocial: at bedside t/o day\n\nPLAN: cont. to monitor & support as indicated. wean O2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-18 00:00:00.000", "description": "Report", "row_id": 1269679, "text": "Resp: pt on NRB. HHN administered of xopenex 0.63 as ordered with no adverse reactions. Pt placed back on NIV @ 4:00 Psv 15/5/60%. Fio2 ^ to 60% due to 02 sats in low 80's. ABG pending. Will continue to monitor progress to wean.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-18 00:00:00.000", "description": "Report", "row_id": 1269680, "text": "MICU Nursing Note 1900-0700\nEvents: Pt tachypneic with good Sats on 100%NRB during evening---40 mg. Lasix x1 with fair effect but increased Sats and RR normalized, Pt with increasing lethargy during early morning hours and Sats down to 87-88%---ABG 7.28-89-67 on 100% NRB---placed back on BIPAP via vent 15/5 at 60% with Sats up to 93-94%.\n\nNeuro: A+Ox3 with periods of anxiety, pt verbalizing feeling of impending doom---asking \"how long until she dies\", responds well to calm approach and reassurance, moving all extremities, following all commands, c/o pain with turning and repositioning and then settles, has fentanyl patch in place, increased lethargy this am---but easily arouseable, placed back on bipap\n\nCardiac: HR= 90-100 Afib, no ectopy noted, BP= 90-128/50-60, left radial Aline with good waveform and correlation, Continues on IV Heparin gtt at 750 units/hr with am PTT pending.\n\nResp: Lungs initially clear upper lobes and rales at bilat bases and RR= 30's on 100% NRB during evening, 40 mg. IV Lasix as ordered with RR= 14-20 and diminished at bases, Sats 90-96% on 100% NRB until 3-4am with pt's Sats dipping to 87-88%---ABG= 7.28-89-67-44-8 ; pt placed back on BIPAP at 15/5 and 60% with Sats up to 93-94% and new ABG to be sent. Prod cough of thick creamy colored sputum--using tissues and yankaur.\n\nGI: Abd soft with + hypoactive bowel sounds all quads, no BM, Taking clears with assist.\n\nGU: Foley to CD draining clear yellow urine, minimal effect from Lasix after first 2 hours of drug administration, urine output borderline 20-30ml/hr---MICU team advised.\n\nSkin: grossly intact\n\nID: Afebrile, vanco trough sent this am and pending\n\nEndo: 12 am fingerstick = 187---covered with sliding scale as ordered. Continues on IV steroids.\n\nSocial: called during evening hours and was updated on pt's care\n\nPlan: Obtain ABG in 1 hour and adjust BIPAP settings accordingly, monitor I+O and pt may need gently fluid bolus for decreased urine output and trending BP to 90's, Aggressive pulmonary toiletting, Reassure pt, hold ativan for anxiety, Support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2145-03-13 00:00:00.000", "description": "Report", "row_id": 1269660, "text": "Nursing progress note (10am-1400):\n\nPt admitted to MICU from 7 for resp distress (pt refused bipap on floor), rapid AFIB (new afib) into the 130s-150s...pt on Diltiazem gtt.\n\nPt on 7 w/ left tibial plateau fx. Pt twisted leg at home getting up from sofa. Pt did not fall, no LOC.\n\nPt w/ restrictive lung disease (on home O2...pt notes she is in the mid-80s when off O2), pulmonary htn, HTN, osteo, scoliosis, spinal fusions.\n\nROS:\n\nNeuro: Pt A&O x 3. Pleasant and cooperative. Pt able to move BUE and RLL. LLL...+ sensation and +PP. Pt unable to Move RLE d/t pain. RLE in knee immobilizer (followed by ortho..not candidate for surgery). C/O pain . Pt refused narcotic for pain med, given 650mg po tyelenol w/ fair effect.\n\nResp: LS crackles R>L. Rec'd on NB w/ sats 92-94%. RR 20s-40s. No cough. Bipap to be applied at home ( pt states she is normally on Bipap at night but has not been on it recently since husband being in hospital).\n\nCV: Rapid AFIB. HR 120s-150s. Given 15mg Dilt x 1, started on dilt gtt @ 5mg/h..since increased to 10mg/h. Given 15mg bolus x 1. SBP 100s-130s. SBP dropped to 87...dilt. stopped briefly and BP increase. (goal SBP >100, goal HR low 100s-110). + edema to LLE. K 3.4- given 40mg po K. Pt denies CP, but c/o increased SOB. Cardiac enzymes pending.\n\nGI/GU: abd obese, soft, BS hypoactive. Tolerating po's. No c/o N/V. Last BM . Urine yellow/clear, UOP dropping down..team aware. Pt was given lasix on far 7 and put out 500cc since.\n\nCode status: DNI.\n\nSocial: at bedside. HCP is , , who works in the PACU.\n\nAllergies: morphine, amoxicillin.\n\nPlan: cont w/ dilt gtt, wean O2 as tolerated, BIPAP, monitor UOP, monitor labs.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-13 00:00:00.000", "description": "Report", "row_id": 1269661, "text": "85yr female s/p tibial fx who enters from floors in marked respiratory distress and rapid Afib. On NRB satting 95. Placed on NIV but pt very resistant to face mask. Eventually (with 0.5mg Ativan on board), settled in on vent for approximately two hours. Will try again later. BS rhonchi. ? asp PNA. DNI.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-16 00:00:00.000", "description": "Report", "row_id": 1269673, "text": "NPN 7pm-7am\nReview carevue for all other objective data\n\nNeuro: Alert, oriented x3, following commands. Patient is anxious at times, calm down with reassurance, no meds. lt knee immobilizer in place, denies pain except changing position, fentanyl patch continued.\n\nCV: a fib, with occasional PAc/PVC's, continued on po dilt/metoprolol. Also continued on heparin gtt titerated as per SS, SBP 110-120's monitoring via a line.\n\nResp: Continued on mask ventilation, tolerating the mask well, tried NRB for 2 hrs and blood gas 7.35/75/73, 30 min after NRB. Bilateral lung sounds clear and diminished at the base. O2 sats 93-95% on BIPAP and desats to 86% soon mask is off for care.\n\nGu/Gi: NPO, tolerating po meds, abd soft, bs present, no BM this shift, continued bowel regimen. UO 5-80cc, catheter flushed, lasix 40mg iv given with effect, MD aware.\n\nSkin:Intact\nId: a febrile continued on levo and vanco\nSocial: Call from updated by RN, she would like to be called when her pulmonologist come to visit her tomorrow.\n\nPlan: Watch for resp status and continue on BIPAP as tolerated\n PTT q 6hrs and continue as per ss\n close monitoring of UO and lasix as tolerated\n emotional support to patient\n Social servise consult\n" }, { "category": "Nursing/other", "chartdate": "2145-03-16 00:00:00.000", "description": "Report", "row_id": 1269674, "text": "Resp Care,\nPt. remains on NIV overnoc IPS 15/5 70%. VT 200's RR 20's. Taken off NIV for 2 hours, placed on 100% mask. After 2 hours O2 Sat dropped to 88%, placed back on NIV. Tol well. Desaturates quickly when off O2. Attempt to wean off NIV as tol. MDI's x 1. See carevue.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-16 00:00:00.000", "description": "Report", "row_id": 1269675, "text": "NPN 0700-1900\nEvents: cont to be NPO, desatt on NRB , cont on BIPAP, seen by\npulmon physician, cardiac ECHO.\nNeuro: Pt is alert, oriented x 3, good range of motion to the upper extremities, lt leg with knee immobilizer on able to wiggle toes, rt leg moves at the baseline, able to wiggle toes.\n\nResp: Recieved on BIPAP, Fio2 70%,PS 15/+5, o2 sat 93-95%, tried on NRB , unable to tolerate, Pt desat to 85%, put back to BIPAP on prev settings. O2 sat 93-98%, ABG ph 7.33/90/95, PS increased to 18/+5, sat improved 95-98%, cont the same. ABG repeated pH 7.33/68/70\n\nCV: HR 85-103, BP 107/62-130/68, cont on metoprolol and diltiazem po. Heparin gtt contd, PTT WNL.\n\nGI/GU: Abd soft, NPO except meds, no BM this shift, bowel meds contd.Foley cath patent,low urine output,NS 250 ml bolus given with fair effect.\n\nID: afebrile, cont abt Levoflooxacin and Vancomycin.\n\nSocial: Husband from the rehab and the visited. POC updated by the HO.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-16 00:00:00.000", "description": "Report", "row_id": 1269676, "text": "BS fine crackles. Pt on NIV most of shift except for a short trial on NRB where she immediately desatted to high ''s. PaCO2 95 so PSV increased to 18. PaCO2 now 68.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-14 00:00:00.000", "description": "Report", "row_id": 1269666, "text": "MICU NPN addendum\nOxygen saturation dropping 88-89%. ABG:7.44/55/50/39. Pt given 100mg lasix. Pt placed on BIPAP 15/5 @ 70%. Ativan given for increase anxiety level. Antibx coverage broadened by starting vancomycin.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-14 00:00:00.000", "description": "Report", "row_id": 1269667, "text": "MICU NPN addendum\n\nPTT supertherapeutic @ >150. Gtt stopped. To restart @ 1900 @ 800u/hr. Next PTT check @ midnoc.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-15 00:00:00.000", "description": "Report", "row_id": 1269668, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: DNR/DNI\nAllergies: Morphine, amoxicillin\n\nPt is 85 year old woman who was transferred from 7 where she was admitted for a tibial plateau fracture. Brought to MICU for hypoxia, tachypnea, tachycardia, new afib.\n\nEvents: Pt restarted on dilt gtt, able to maintain good sat on NRB. Please see carevue for labs.\n\nNeuro: Pt A&O x 3, pleasant, cooperative with care. Full ROM to upper extremities, able to move right toes, left leg in knee immobilizer for fracture. Pt getting much better pain control with fentanyl patch, received PRN tylenol x 1 for pain to left leg () after turning.\n\nCV: HR 86-111 a-fib with occasional PAC/PVC, ABP 103-128/58-71. Pt restarted on dilt gtt (10mg/hr) for rate control after receiving lopressor x 1 with no response. Heparin gtt started for new a-fib, most recent PTT 150, gtt stopped for one hour and restarted at 550 units/hour. Next PTT due at 0900. Mild edema noted to bilateral lower extremities. Peripheral pulses palpable.\n\nResp: Received pt on BIPAP, able to be switched to NRB around midnight. Pt able to maintain sats >90%, pt noted to desat when mask removed. Per team goal sat >90%. RR 91-30 with sats >91% on NRB 13LPM at 70%. Pt has weak cough. Lung sounds clear in apices, diminished in bases. CXR shos RLL PNA.\n\nGI: BS x 4, no stool this shift. Ordered for heart healthy diet.\n\nGU: Foley patent and draining clear, yellow urine. Received lasix last evening with good response, however UO now diminishing.\n\nID: Tmax 98.0 PO. Receiving ABX therapy, Levofloxacin and Vanco, for RLL PNA.\n\nSkin: Intact, prefers to be on left side for comfort.\n\nSocial: Pt's two are , (works in ) and (lives in ). called last night, updated on pt's condition and plan of care, she asked that she be called with any issues that come up for now as other has Virus.\n\nPlan:\ntransition dilt gtt to PO dilt\nwean oxygen requirements as tolerated by pt\npain management\nnext PTT due at 0900, titrate heparin according to protocol\nmonitor UO\ncontinue ABX therapy\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-15 00:00:00.000", "description": "Report", "row_id": 1269669, "text": "Respiratory Care:\nPatient switched to nrb mask, with NIV left in room. Received xopenex neb RX at 0100 and 0500. SPO2 stabile between 90-91%.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-15 00:00:00.000", "description": "Report", "row_id": 1269670, "text": "RT SHIFT NOTE 7A-7P\n\nBS few fine crackles. On NRB mask most of day sift with sats 89-92. Placed back on NIV at end of shift due to sustained sat<90.\n" }, { "category": "Nursing/other", "chartdate": "2145-03-15 00:00:00.000", "description": "Report", "row_id": 1269671, "text": "NPN 0700-1900\nEvents- Diltiazem IV gtt stopped and started PO meds, Furosemide 40 mg IVx2 for low urine output, NPO and on BIPAP for low O2 sat.\n\nNeuro: Pt is alert, oriented x3,pleasant,cooperative with care, full ROM to upper exremities, able to wiggle toes BLE, lt leg with knee immobilizer on, +CSM, +PP and warm, and denied pain. Fentanyl patch on for the pain relief.\n\nResp: Received on NRB mask was able to tolerate 20-30 min, pt started to desat to 86-87%, ABG pH 7.38/63/53/39 so put back to BIPAP , Fio2 70%, PS 15/+5, O2 sat improved to 93-95% and contd on same settings. ABG repeated pH 7.38/69/84/11,with sat 95%. LS coarse upper lobes and diminished bases.\n\nCV: Recieved on Diltiazem gtt 10mg/hr for atrial fibrillation. HR 86-103 with occasional PAC's, BP 108/58- 132/71, no chest pain, no SOB. On Heparin gtt 550 units/hr, PTT monitored WNL. Metoprolol 50mg PO started. Diltiazem 60mg PO started and Dilt gtt stopped in the afternoon, maintaining stable vital signs now.\n\nGI: Abdomen soft,+BS, only had ice chips, kept NPO except meds. No BM\nthis shift, contd bowel regimen, Lactulose 30ml po given.\n\nGU: Foley draining yellow clear urine, low urine output, 15-20ml/hr,\nLasix 40mg IV given x2, urine output improved.\n\nID: Afebrile, temp 96.2-97.2 axillary. Cont on abt Levofloxacin and Vancomycin/PNA.\n\nSkin: Intact, warm and dry.\n\nSocial: Pt is concerned about her husband, called x 2, updated with POC. Social worker with the pt and the about the social issues.\n\nPlan: Cont to monitor PTT, ABG, urine output, resp status, to wean as tolerated, keep NPO now, emotional support to the Pt and family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2145-03-15 00:00:00.000", "description": "Report", "row_id": 1269672, "text": "BS medium crackles; no change with MDI Combivent. Other nebs dc'd since pt desats very quickly when off NIV. On NRB for about 20 min until desat to ''s. On NIV most of shift. Tolerating somewhat better than previously.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2180-08-02 00:00:00.000", "description": "Report", "row_id": 1410681, "text": "NEURO: PT. LETHARGIC, ORIENT X3, MAE AND OBEYS COMMANDS.\n\nCV: PT. NSR, SBP 95-120, NO ECTOPY NOTED. PALPABLE PULSES.\n\nRESP: PT. LUNG SOUNDS CLEAR THROUGHOUT, +PRODUCTIVE COUGH, EXPECTORATES THICK, TAN SPUTUM INDEPENDENTLY. IS ACHIEVEMENT: 1000. CT DRAINING SEROSANG DRAINAGE, CT TO WATERSEAL AT 0500 , MD. PT. DRAIN X2 TO BULB SUCTION- BULB SUCTION LOST AFTER TIME OR WHEN PT. COUGHS- TEAM AWARE. SEE CAREVUE FOR OUTPUT MEASUREMENTS.\n\nGI/GU/ENDO: PT. ABD SOFT, NONDISTENDED, HYPOACTIVE BOWEL SOUNDS, GAG REFLEX CHECKED- WEAK. PT. GIVEN SIPS OF WATER AND TOLERATED FINE. PT. FOLEY DRAINING CLEAR YELLOW URINE. U/ MD . 250CC NS BOLUS X2 GIVEN FOR LOW URINE OUTPUT. PT. BLOOD SUGARS TREATED PER CSRU RISS.\n\nPAIN: PT. PCA- SEE CAREVUE FOR SETTINGS. 15MG KETOROLAC GIVEN WITH GOOD EFFECT PER PT.\n\nA/P: CONTINUE TO MONITOR PULMONARY STATUS, FLUID STATUS, PAIN MANAGEMENT, ? 2, ADVANCE DIET (ASSESS SWALLOWING ABILITY) AND ACTIVITY AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2180-08-02 00:00:00.000", "description": "Report", "row_id": 1410682, "text": "Addendum\nLast hour u/o 5cc. MD at bedside. New order for Lasix 10mg ivp, given as ordered. still transfer MD .\n" }, { "category": "Nursing/other", "chartdate": "2180-08-01 00:00:00.000", "description": "Report", "row_id": 1410679, "text": "12-7p\nPt is a 75 year old female admitted to CSRU s/p resection of anterior chest wall mass, wedge resection to left upper lobe, reconstruction w/ gortex mesh. Uneventful intra-op. Extubated in OR. To CSRU w/ nasal trumpet in for airway protection, nasal trumpet dc'd at 1400, pt alert and able to protect own airway at that time. HOB 30-45 degrees.\n\nNeuro: Pt alert and oriented, though sleepy, weak voice. + cough, weak gag. MAE. Follows all commands. Dilaudid PCA for pain, dose adjusted to 0.25mg per injection w/ better relief of pain. Toradol prn.\n\nCV: HR 50-60s SR/SB, no ectopy. SBP 110-130s. Received w/ SBP >150, hydralazine given w/ good effect. + palpable pedal pulses.\n\nResp: LS coarse- clear but diminished. Received on 8L mask weaned to 5Lnc sats >95%. RR WNL. Received w/ nasal trumpet to left nare, dc'd at 1400, pt alert and able to protect own airway. Pt coughing up dark bloody sputum NP at bedside and aware, no new orders. Left chest tube to suction, no air leak, no crepitus. Pt has 2 JPs, 1 right and 1 left, JPs unable to hold to bulb suction, and MD aware, CT and JPs dsgs changed to more occlusive dsg, though continues to stay to bulb suction. NP aware, no new orders.\n\nGI/GU: Abd soft, hypoactive BS. Foley draining adequate amts of clear yellow urine.\n\nEndo: RISS\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pulmonary toilet. Follow labs and treat as appropriate. Increase diet w/ improved gag.\n" }, { "category": "Nursing/other", "chartdate": "2180-08-01 00:00:00.000", "description": "Report", "row_id": 1410680, "text": "Addendum\nMD at bedside assessing JPs. Continue to put to bulb suction. After pt coughs, noted JPs unable to continue bulb suction. Watch JPs and if bulb not to suction, put to back to bulb suction MD -thoracic.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2107-07-09 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1194549, "text": " 11:21 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 30 year old man with metastatic lesion s/p crani & resection\n Admitting Diagnosis: BRAIN MASS/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n REASON FOR THIS EXAMINATION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 5:12 PM\n PFI: Status post resection of right temporal lobe lesion. Expected\n post-surgical changes are identified. No acute infarcts or hydrocephalus.\n Subtle enhancement of the posterior margins of the surgical cavity noted.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient is status post resection of right temporal lobe\n lesion.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility, and diffusion\n axial images obtained before gadolinium. T1 axial and MP-RAGE sagittal images\n acquired following gadolinium. Comparison was made with the MRI of .\n\n FINDINGS: Since the previous study, the patient has undergone resection of\n right temporal lobe lesion. Blood products are seen in the surgical cavity.\n Subtle enhancement at the posterior margin of the surgical cavity is\n identified. Otherwise, no other areas of abnormal enhancement are seen. Mass\n effect on the right lateral ventricle is unchanged. There are expected\n post-surgical changes seen. No acute infarcts or hydrocephalus noted.\n\n IMPRESSION: Status post resection of right temporal lobe lesion. Expected\n post-surgical changes are identified. No acute infarcts or hydrocephalus.\n Subtle enhancement of the posterior margins of the surgical cavity noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-09 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1194550, "text": ", M. NSURG SICU-B 11:21 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 30 year old man with metastatic lesion s/p crani & resection\n Admitting Diagnosis: BRAIN MASS/SDA\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n REASON FOR THIS EXAMINATION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Status post resection of right temporal lobe lesion. Expected\n post-surgical changes are identified. No acute infarcts or hydrocephalus.\n Subtle enhancement of the posterior margins of the surgical cavity noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-07-08 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1194386, "text": " 4:45 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-surgical mapping\n Contrast: MAGNEVIST Amt: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with brain mets\n REASON FOR THIS EXAMINATION:\n pre-surgical mapping\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Brain mets. Presurgical mapping.\n\n COMPARISON: Multiple head CTs and brain MRIs dating back to and\n most recent from .\n\n TECHNIQUE: Postcontrast axial, coronal and sagittal MP-RAGE as well as spin\n echo images of the brain were obtained.\n\n FINDINGS: A 3.7 x 2.5 x 3.1 cm mass along the medial right temporal lobe with\n heterogeneous enhancement is stable. This mass is in close proximity to the\n right superior cerebellar artery and posterior cerebral artery. This mass is\n at the location of the right hippocampus. Previously described lesion in the\n left choroid plexus, likely represents normal choroid plexus with attention to\n the current appearance. Intracranial major vasculature is patent. There is\n no invasion of the adjacent vasculature by this mass. There is minimal\n extension of the mass into the right side of the suprasellar cistern. There\n is no intracranial hemorrhage or herniation. Imaged soft tissues are grossly\n unremarkable.\n\n IMPRESSION: Stable 3.7 cm right medial temporal lobe mass with heterogeneous\n enhancement. Given the well circumscribed appearance and history of\n underlyying malignancy metastatic etiology is most likely, and primary glioma\n is a secondary consideration.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1194466, "text": " 2:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 30 year old man with metastatic lesion s/p crani & resection\n Admitting Diagnosis: BRAIN MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n REASON FOR THIS EXAMINATION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EHAb FRI 3:29 PM\n 1. Postoperative changes in the right temporal lobe with edema and\n parenchymal air.\n\n 2. 3-mm leftward shift of normally midline structures.\n\n 3. Large pneumocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old male with metastatic melanoma to the brain status\n post resection of right temporal lobe lesion.\n\n COMPARISON: MR dated at approximately 5 a.m. and CT dated\n .\n\n TECHNIQUE: Axial CT images through the head were acquired without intravenous\n contrast.\n\n FINDINGS: There has been interval right craniotomy. Within the right\n temporal lobe, there is a large territory of hypodensity, which likely\n represents post-operative edema; however, in this setting we cannot assess for\n residual neoplasm or ischemia. Foci of parenchymal air and air tracking along\n the tentorium are consistent with recent intervention. There is a large\n amount of frontal pneumocephalus. There is 3-mm leftward shift of normally\n midline structures. The basal cisterns appear patent. There is no\n hydrocephalus. There is no evidence for acute intracranial hemorrhage.\n\n Visualized bones demonstrate right craniotomy changes. No other bony\n abnormality is seen. The visualized portions of the paranasal sinuses and\n mastoid air cells demonstrate anterior ethmoid mucosal thickening which was\n seen on prior CT in and is grossly unchanged. A mucus-retention\n cyst is seen in the left maxillary sinus. Overlying the right craniotomy\n site, there is subgaleal air and hematoma, consistent with postoperative\n changes.\n\n IMPRESSION:\n\n 1. Right temporal lobe hypodensity, which likely represents post-operative\n edema; however, in this setting we cannot assess for residual neoplasm or\n ischemia. MR would be more sensitive for these entities if clinically\n concerned.\n\n (Over)\n\n 2:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 30 year old man with metastatic lesion s/p crani & resection\n Admitting Diagnosis: BRAIN MASS/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. 3-mm leftward shift of normally midline structures.\n\n 3. Post-operative pneumocephalus and superficial changes, as above.\n\n" }, { "category": "Radiology", "chartdate": "2107-07-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1194467, "text": ", M. NSURG CC1A 2:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 30 year old man with metastatic lesion s/p crani & resection\n Admitting Diagnosis: BRAIN MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n REASON FOR THIS EXAMINATION:\n 30 year old man with metastatic lesion s/p crani & resection. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Postoperative changes in the right temporal lobe with edema and\n parenchymal air.\n\n 2. 3-mm leftward shift of normally midline structures.\n\n 3. Large pneumocephalus.\n\n" }, { "category": "ECG", "chartdate": "2107-07-06 00:00:00.000", "description": "Report", "row_id": 215133, "text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 1261123, "text": "CCU Nursing Admission Note 1900-0700:\nHPI: In brief 45 yo male who p/w chest heaviness and diaphoresis to OSH and found to be ruling in for acute inferolateral MI, then started on IVNTG, Heparin and recieving TnK, post TnK infusion pt going into VFIB arrest requiring cardioversion times three and restroring to NSR with frequent runs of AIVR vs VT, then started on Lidocaine and transfered to for emergent cath.\n\nSEE FHP FOR DETAILED HPI, PMH, AND, ALLERGIES\n\nCATH:Upon arrival to cath, Nitro and Heparin stopped, Lidocaine found not to be running so discontinued. Pt pain free with stable VSs. RHC opening pressures RA 9, RV 38/14, PA 38/20 and PCWP 24. LHC: LMCA, LAD, and RCA normal. LCx with 90% disease mid and stented with Taxol stent without complication with good flow and no residual. No LV gram performed. Recieved 125mcgs of Fent, 3mg of Versed, 300mg of Plavix and 2500u of Heparin. No Integrillin started secondary to lytics. RFA and RFV sheath dc'd in holding area. VSS throughout procedure and denying chest heaviness or pain.\n\nS-\"I feel like I could go back to work tommorow!\"\n\nO-MS:A/O/X/3. Very pleasant and cooperative with care. Sleeping in naps overnight with some effect. Denies discomfort while on bedrest. Repositioned to make comfortable. Refusing sleep aids. Despite h/o drinking, smoking and coccaine, no visible effects of detox.\nCV:HR 50-80s, SB/NSR with no noted runs of ectopy. K and Mg stable. Denies CP. SBPs 100-130s. Recieving Lopressor 12.5mg PO with good effect, holding off on starting ACE till AM. Remaining pain free throughout night. Arriving from cath lab with right groin site free of hematoma/ecchymosis, post turning, developed walnut size hematoma with some ecchymosis, pressure dsg applied and left in place throughout night, pulses palpable distal, BLEs warm and with good color. Post cath IVFs,(1/2 NS at 75cc/hr) times 1L. No documented CKs and Troponin from OSH, CK/MBs tonight 894 with no MB done, later 2528 with MB 98 and (+) Troponin both draws. AM CKMBs pending.\nRESP:Breath sounds clear with small crackles at left base. O2Sats WA > 95% on 3L, later when falling asleep down to 89% pt not noted to be apenic but laying flat and is dose have large torso and neck, increased to 6Ls and sating > 95%.\nGU/GI:Voiding in condom catheter without difficulty in adeqaute amounts, clear and yellow in appearance. Tolerating cardiac diet, denies nausea.\nID:Afebrile. No issues.\nHEME: HCT stable. Clot in BB.\nSOC:Owns own construction buisness and married to wife and have 7 year-old son. and friend into visit last night updated by MDs in regards to condition and plans. Wife and child to be into visit today between mid-day to mid-afternoon.\nA/P: s/p inferolateral MI with stent to LCx, doing well post procedure.\nCardiac echo today\nMonitor for sign/symtpoms of DTs\nIf groin remains stable, OOB to chair/ambulate as tolerated\nContinue to follow CKs till begin to fall.\nContinue cardiac teaching and smoking cessation\nAnticipate call out to floor if stable day.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 1261124, "text": "CCU Nursing Admission Note 1900-0700:\n(Continued)\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 1261125, "text": "Addedum to CCU Nursing Note 1900-0700:\nSKIN:Pt calling stating itchy, noted face to be flushed and groin area with rash appearance, red-pathces around pressure dsg, in addition to upper chest, stomach, back, and coccyx area. Denies SOB but states \"came on all of a sudden.\" Bendadry 25mg PO given and rubbed with Sarna with releif.Continue to monitor\nMS:Pt noted to be sleeping off and on all night, monitoring CIWA towards early morning, denying symptoms so far and none observed. Last CIWA at 430AM 5 prior to O.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 1261126, "text": "NPN-CCU\nMr. to be pain free.\nCV:pt on captopril, tol 6.25mg with min drop in BP. He to be w/o c/o CP or SOB. Listening to peolple talk of life style changes but not to receptive as yet.\nA/P: to be pain free.Will wit hmed teaching and need for lifestyle changes.\n" }, { "category": "Nursing/other", "chartdate": "2170-03-22 00:00:00.000", "description": "Report", "row_id": 1261127, "text": "7p-7a\ns:\"my nicotine craving is really kicking in this am\"\no/a: pt a/o, sleeping most of shift after receiving ativan 1mg at 8p\nawoke this am around 0400 and pt given ativan 1mg at 0500 after above statement made regarding his craving. pt moving all extremeties w/o difficulty.\nresp: pt's lungs clear/ little decreased in the bases, 100% on ra, no c/o of sob\ncv: pt in sr/sb, hr 50-60, bp 94-112/40-50, pt's lopressor increased to 25mg and pt also on captopril, no c/o cp\ngi: abd softly distended, pos bs nontender, tol po's fine,\ngu: pt voiding in urinal dk yellow urine, no bm this shift\nid: afebrile,\nskin: intact, groin dsg intact, pos pulses\nplan: pt's transfer note done, pt wanting to go home, needs lifestyle changes, reinforcement/teaching, titrating med doses watch vs\n" }, { "category": "Echo", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 76249, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 73\nWeight (lb): 265\nBSA (m2): 2.43 m2\nBP (mm Hg): 108/50\nHR (bpm): 56\nStatus: Inpatient\nDate/Time: at 12:11\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferolateral - hypokinetic; mid inferolateral -\nhypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nthickening of the mitral valve chordae. Trivial mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include inferolateral hypokinesis/akinesis. Right ventricular\nchamber size and free wall motion are normal. The aortic root is mildly\ndilated. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2170-03-23 00:00:00.000", "description": "Report", "row_id": 185635, "text": "Sinus bradycardia\nInferior T wave inversion may be due to myocardial ischemia\nPeaked T waves\nSince previous tracing, T wave changes in leads V5-V6 improved\n\n" }, { "category": "ECG", "chartdate": "2170-03-22 00:00:00.000", "description": "Report", "row_id": 185636, "text": "Sinus bradycardia. Since the previous tracing of T waves are inverted\nor terminally inverted in leads II, III, aVF and V5-V6. The abnormalities are\nconsistent with an acute inferolateral process.\n\n" }, { "category": "ECG", "chartdate": "2170-03-21 00:00:00.000", "description": "Report", "row_id": 185637, "text": "Sinus rhythm, rate 57. Since the previous tracing the heart rate has slowed. No\nother changes are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2170-03-20 00:00:00.000", "description": "Report", "row_id": 185638, "text": "Sinus rhythm, rate 73. Left axis deviation. The tracing is otherwise normal.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2182-05-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 461334, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient was a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had 8 admissions since .\n Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated, but trending down. bld. cx\ns with GPC in pairs\n in clusters.\n Action:\n MRCP completed today, to eval. Pneumobilia. On Cipro/Flagyl/Vanco.\n Transplant consulted and following patient.\n Response:\n Pt afebrile. Cont to c/o pain. LFTs/Tbili trending down.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U on MRCP results.\n Pain control (acute pain, chronic pain)\n Assessment:\n Reports continued moderate to severe RUQ abdominal pain that she states\n is constant, at rest.\n Action:\n Dilautid iv changed to PO dilautid, given 4mg PO Q4hrs.\n Response:\n Sleeping most of day, awaking periodically, c/o pain and need for pain\n meds, but then would quickly fall back to sleep, most of the time with\n out pain med intervention.\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n Please note: Patient placed on Neutropenic precautions today in setting\n of wbc count of 2.0. Down from 2.6 yesterday. Likely chronic ETOH\n and pancreatitis.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PANCREATITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 74.1 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Precautions:\n PMH: Anemia, Asthma, ETOH, Hepatitis, Liver Failure, Pancreatitis,\n Smoker\n CV-PMH:\n Additional history: *alcoholic cirrhosis dx c/b varicies, ascites,\n encephalopathy\n *chronic pancreatitis dx on pancrease\n *EtOH abuse with h/o DTs\n *substance abuse including heroin\n *low back pain since with degenerating L4-6 discs\n *asthma with h/o needing intubation in past\n *uterine and cervical CA s/p TAH \n *anemia\n *thrombocytopenia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:108\n D:66\n Temperature:\n 97\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 7 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,278 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:33 AM\n Potassium:\n 3.7 mEq/L\n 03:33 AM\n Chloride:\n 105 mEq/L\n 03:33 AM\n CO2:\n 25 mEq/L\n 03:33 AM\n BUN:\n 8 mg/dL\n 03:33 AM\n Creatinine:\n 0.5 mg/dL\n 03:33 AM\n Glucose:\n 85 mg/dL\n 03:33 AM\n Hematocrit:\n 24.5 %\n 03:33 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: Two gold colored hoop like earrings in with valuables on\n patients person.\n Transferred from: MICU-7 Rm. 788\n Transferred to: Rarr 1021\n Date & time of Transfer: 17:00\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 461338, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo woman w/ EtOH cirrhosis admitted w/ sepsis of unclear source.\n 24 Hour Events:\n Yest notable events include blood cx ( sets) w/ GPCs in pairs and\n clusters.\n Allergies:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Pantoprazole (Protonix) - 08:06 AM\n Other medications:\n folate, thiamine, MVI, nicotine patch, Atrovent nebs,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 85/48(57) {85/46(56) - 108/63(74)} mmHg\n RR: 13 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 714 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 514 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -616 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n possible murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Wheezes :\n scattered)\n Abdominal: Soft, Bowel sounds present, Tender: RUQ , LLQ tenderness\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.2 g/dL\n 33 K/uL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: MRCP ()- pending\n Microbiology: Blood- sets GPCs in pairs and clusters\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)- sepsis w/ GPC bacteremia, resolving -->\n hemodyn stable since yesterday\n -probable underlying chronic hypotension related to chronic liver\n disease\n -probable source gut translocation given extensive GI disease\n -will check echo given murmur to r/o endovascular source, though low\n suspicion\n BORDERLINE NEUTROPENIA- presumably due to sepsis plus underlying\n liver dz/ EtOH\n -will need to follow closely for frank neutropenia\n \n - unclear if ERCP at OSH prior to this hospitalization, also\n considering emphysematous cholecystitis though not as toxic as one\n would expect. no imaging evidence of eroded GB wall\n -cont broad ABX coverage w/ vanco + ciproflox + metronidazole\n -Surgery and Hepatology following --> MRCP today read pending\n -attempting to obtain OSH records re: poss ERCP or other intervention\n ETOH CIRRHOSIS\n - c/b coagulopathy, chronic thrombopenia, varices, possible ascites,\n and now portal v thrombosis\n -Hepatology consult\n -no evidence of encephalopathy\n -cont lactulose\n -on PPI\n PANCREATITIS, ACUTE ON CHRONIC\n - related to EtOH\n -supportive care, npo, prn antiemetics\n NEW PORTAL V THROMBOSIS\n - deferring anticoagulation for now given prior variceal bleed\n -will await Hepatology recommendations re: further mgmt\n ETOH INTOXICATION/ WITHDRAWAL\n -CIWA protocol\n -thiamine, folate\n -Social services involvement\n SCATTERED GROUND GLASS ON CT- poss aspiration or pneumonia\n -covered w/ broad ABX as above. will attempt to obtain sputum culture\n COPD\n -nicotine patch\n -prn ipratropium and albuterol\n ICU Care\n Nutrition:\n Comments: npo for now given pancreatitis\n Glycemic Control:\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Comments: dc triple lumen\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n" }, { "category": "Nursing", "chartdate": "2182-05-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 461328, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient was a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had 8 admissions since .\n Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated, but trending down. bld. cx\ns with GPC in pairs\n in clusters.\n Action:\n MRCP completed today, to eval. Pneumobilia. On Cipro/Flagyl/Vanco.\n Transplant consulted and following patient.\n Response:\n Pt afebrile. Cont to c/o pain. LFTs/Tbili trending down.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U on MRCP results.\n Pain control (acute pain, chronic pain)\n Assessment:\n Reports continued moderate to severe RUQ abdominal pain that she states\n is constant, at rest.\n Action:\n Dilautid iv changed to PO dilautid, given 4mg PO Q4hrs.\n Response:\n Sleeping most of day, awaking periodically, c/o pain and need for pain\n meds, but then would quickly fall back to sleep, most of the time with\n out pain med intervention.\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n Please note: Patient placed on Neutropenic precautions today in setting\n of wbc count of 2.0. Down from 2.6 yesterday. Likely chronic ETOH\n and pancreatitis.\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 461303, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo woman w/ EtOH cirrhosis admitted w/ sepsis of unclear source.\n 24 Hour Events:\n Yest notable events include blood cx ( sets) w/ GPCs in pairs and\n clusters.\n Allergies:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Pantoprazole (Protonix) - 08:06 AM\n Other medications:\n folate, thiamine, MVI, nicotine patch, Atrovent nebs,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 85/48(57) {85/46(56) - 108/63(74)} mmHg\n RR: 13 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 714 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 514 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -616 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n possible murmur\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: No(t) Clear : , Wheezes :\n scattered)\n Abdominal: Soft, Bowel sounds present, Tender: RUQ , LLQ tenderness\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.2 g/dL\n 33 K/uL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: MRCP ()- pending\n Microbiology: Blood- sets GPCs in pairs and clusters\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)- sepsis w/ GPC bacteremia, resolving -->\n hemodyn stable since yesterday\n -probable underlying chronic hypotension related to chronic liver\n disease\n -probable source gut translocation given extensive GI disease\n -will check echo given murmur to r/o endovascular source, though low\n suspicion\n BORDERLINE NEUTROPENIA- presumably due to sepsis plus underlying\n liver dz/ EtOH\n -will need to follow closely for frank neutropenia\n \n - unclear if ERCP at OSH prior to this hospitalization, also\n considering emphysematous cholecystitis though not as toxic as one\n would expect. no imaging evidence of eroded GB wall\n -cont broad ABX coverage w/ vanco + ciproflox + metronidazole\n -Surgery and Hepatology following --> MRCP today read pending\n -attempting to obtain OSH records re: poss ERCP or other intervention\n ETOH CIRRHOSIS\n - c/b coagulopathy, chronic thrombopenia, varices, possible ascites,\n and now portal v thrombosis\n -Hepatology consult\n -no evidence of encephalopathy\n -cont lactulose\n -on PPI\n PANCREATITIS, ACUTE ON CHRONIC\n - related to EtOH\n -supportive care, npo, prn antiemetics\n NEW PORTAL V THROMBOSIS\n - deferring anticoagulation for now given prior variceal bleed\n -will await Hepatology recommendations re: further mgmt\n ETOH INTOXICATION/ WITHDRAWAL\n -CIWA protocol\n -thiamine, folate\n -Social services involvement\n SCATTERED GROUND GLASS ON CT- poss aspiration or pneumonia\n -covered w/ broad ABX as above. will attempt to obtain sputum culture\n COPD\n -nicotine patch\n -prn ipratropium and albuterol\n ICU Care\n Nutrition:\n Comments: npo for now given pancreatitis\n Glycemic Control:\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Comments: dc triple lumen\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 461304, "text": "Chief Complaint: Bacteremia\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 AM\n from TLC.\n - increase dilaudid strength and frequency for abdominal pain\n - Blood cx w/ GPC in pairs and clusters from \n - MRCP ordered\n - Hepatology did not recommend starting heparin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 90/55(64) {87/46(56) - 108/63(74)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 636 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 436 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -694 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Gen: no acute distress, resting comfortably in bed\n HEENT: Clear OP, dry mucus membranes\n NECK: Supple, No LAD, No JVD, RIJ in place\n CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops\n LUNGS: decreased breath sounds at the bases bilaterally with no\n wheezes, rales, or rhonchi\n ABD: + BS, Soft, diffusely tender to palpation with no rebound or\n guarding\n EXT: trace lower extremity edema. 2+ DP pulses BL\n SKIN: No rashes\n Labs / Radiology\n 33 K/uL\n 8.2 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR\n Lung volumes are lower, mediastinal vasculature is appreciably more\n distended\n and pulmonary vessels are mildly dilated, all suggesting volume\n overload and\n borderline cardiac decompensation. Heart size is normal but increased\n since\n yesterday. Right jugular line ends centrally. Findings were discussed\n by\n telephone with Dr. at the time of dictation.\n Microbiology: 5/23 2/4 bottles + for GPC in pairs and clusters\n Assessment and Plan\n 51yo female with history of alcoholic cirrhosis, alcohol abuse, and\n chronic pancreatitis was admitted from the ED with septic shock.\n 1. Septic Shock\n Etiology of her septic shock is likely GPC bacteremia. Source is not\n clear. No obvious skin source. ? IVDU. Relatively immunocompromised.\n She was hypotensive in the Emergency Department on arrival, although\n her blood pressure has improved with IVF boluses. Now off pressors.\n Plan is the following:\n - follow-up final read of CT scan and RUQ US -> findings c/w\n pancreatitis, PV thrombosis, a few ground glass opacities\n - follow-up blood and urine cultures\n - continue broad spectrum antibiotics with vancomycin and cipro/flagyl,\n - pain control with IV morphine for now\n - IVF resuscitation with NS to aim for MAP > 60, goal UOP 30mL/hour\n 2. Pancreatitis\n Patient has findings consistent of pancreatitis on CT scan, most likely\n related to alcoholism. Additional possibilities include gallstone\n pancreatitis, although no significant findings of gallstones on RUQ US.\n Although we don't have clear records from her recent hospitalization,\n she may have had an ERCP which would also explain pancreatitis.\n Triglycerides and calcium have been normal in the past.\n - appreciate surgery input\n - follow-up CT Abd/Pelvis and RUQ scan\n - aggressive IVF resuscitation\n - pain control -> switch to orals\n 3. \n Patient has findings of on CT scan of unclear etiology.\n Differential diagnosis includes a recent ERCP if she had one, infection\n with gas-forming organism, cholangitis, or emphysematous cholecystitis.\n - MRCP ordered -> f/u read\n - appreciate surgery input\n - liver consult, appreciate recs\n 4. Alcohol Intoxication\n Patient has evidence of alcohol intoxication on exam and also with\n serum alcohol of 162. Patient has had multiple admissions in the past\n with alcohol intoxication. Plan is the following:\n - CIWA scale\n - thiamine, multivitamins, and folate\n - social work consult\n 5. Acute Renal Failure\n Patient's creatinine is 1.1, which is increased from baseline of .5-.7.\n Etiology is most likely prerenal in the setting of infection, although\n she is still at risk for ATN given hypotension in the ED. No new\n medications to suggest AIN. No evidence of urinary obstruction on CT\n Abd/Pelvis.\n - urine lytes\n - monitor close I/Os\n - follow-up final read of CT Abd/Pelvis\n - avoid nephrotoxic agents\n - renally dose medications\n 8. Thrombocytopenia\n Etiology is most likely related to cirrhosis and consistent with prior\n values.\n - continue to trend daily\n -xfuse for <10\n 9. Coagulopathy\n Patient has an elevated INR, most likely consistent with liver\n cirrhosis. DIC is possible, although fibrinogen will be difficult to\n interpret in this patient with acute infection and liver disease\n - continue to trend\n 10. Cirrhosis\n Patient has known alcoholic cirrhosis with associated complications of\n varices, portal gastropathy. Plan is the following:\n - continue PPI\n - continue lactulose\n - liver consult\n 11. Portal Vein Thrombosis\n Patient has findings on RUQ US with new portal vein thrombosis; however\n given her history of variceal bleed in the past, will hold off on\n anticoagulation.\n - will follow-up with radiology regarding time course\n - will follow-up with liver in the morning regarding risk / benefit of\n anticoagulation\n 12. ? Pneumonia\n Patient's CT scan has findings concerning for pneumonia given patchy\n ground glass opacities, although she has minimal O2 requirement and\n minimal findings on physical exam.\n - check urine legionella -> f/u\n - sputum gram stain and culture if able\n - wean O2 as tolerated\n - follow-up final read of CT scan\n - AM CXR\n - Cont vanco, cipro, flagyl\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2182-05-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 461323, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient is a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had 8 admissions since .\n Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated.\n Action:\n MRCP ordered. On Cipro/Flagyl/Vanco. Transplant consulted and\n following patient.\n Response:\n Pt afebrile. Cont to c/o pain. LFTs/Tbili trending down.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U transplant \n recs. MRCP to eval. Pneumobilia.\n Pain control (acute pain, chronic pain)\n Assessment:\n Reports continued moderate to severe RUQ abdominal pain that she states\n is constant, at rest.\n Action:\n Pt given dilaudid 0.5mg IV dilaudid Q4-5hrs.\n Response:\n Sleeping most of day, awaking periodically, c/o pain and need for pain\n meds, but then would quickly fall back to sleep, with out pain med\n intervention. Pt remains somnolent with low RR and BP on low side.\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 461279, "text": "Chief Complaint: Bacteremia\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 AM\n from TLC.\n - increase dilaudid strength and frequency for abdominal pain\n - Blood cx w/ GPC in pairs and clusters from \n - MRCP ordered\n - Hepatology did not recommend starting heparin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 90/55(64) {87/46(56) - 108/63(74)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 636 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 436 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -694 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 33 K/uL\n 8.2 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR\n Lung volumes are lower, mediastinal vasculature is appreciably more\n distended\n and pulmonary vessels are mildly dilated, all suggesting volume\n overload and\n borderline cardiac decompensation. Heart size is normal but increased\n since\n yesterday. Right jugular line ends centrally. Findings were discussed\n by\n telephone with Dr. at the time of dictation.\n Microbiology: 5/23 2/4 bottles + for GPC in pairs and clusters\n Assessment and Plan\n PANCREATITIS, ACUTE\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 461280, "text": "Chief Complaint: Bacteremia\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 AM\n from TLC.\n - increase dilaudid strength and frequency for abdominal pain\n - Blood cx w/ GPC in pairs and clusters from \n - MRCP ordered\n - Hepatology did not recommend starting heparin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 90/55(64) {87/46(56) - 108/63(74)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 636 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 436 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -694 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 33 K/uL\n 8.2 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR\n Lung volumes are lower, mediastinal vasculature is appreciably more\n distended\n and pulmonary vessels are mildly dilated, all suggesting volume\n overload and\n borderline cardiac decompensation. Heart size is normal but increased\n since\n yesterday. Right jugular line ends centrally. Findings were discussed\n by\n telephone with Dr. at the time of dictation.\n Microbiology: 5/23 2/4 bottles + for GPC in pairs and clusters\n Assessment and Plan\n 51yo female with history of alcoholic cirrhosis, alcohol abuse, and\n chronic pancreatitis was admitted from the ED with septic shock.\n 1. Septic Shock\n Etiology of her septic shock is unclear. Differential diagnosis\n includes likely GI / biliary source given CT scan findings of\n pancreatitis and pneumobilia. Additional possibilities include\n pneumonia given findings of ground glass opacities on CT Chest,\n although her respiratory exam is unremarkable and she has minimal O2\n requirement. Patient has no urinary symptoms. She was hypotensive in\n the Emergency Department on arrival, although her blood pressure has\n improved with IVF boluses. Plan is the following:\n - follow-up final read of CT scan and RUQ US\n - follow-up blood and urine cultures\n - continue broad spectrum antibiotics with vancomycin and levo/flagyl,\n will taper off vancomycin within 48 hours if no positive culture data\n for gram positive infection\n - pain control with IV morphine for now\n - place Foley\n - aggressive IVF resuscitation with NS to aim for MAP > 60, goal UOP\n 30mL/hour\n - add levophed prn to achieve MAP goals if not responding to IVF\n 2. Pancreatitis\n Patient has findings consistent of pancreatitis on CT scan, most likely\n related to alcoholism. Additional possibilities include gallstone\n pancreatitis, although no significant findings of gallstones on RUQ US.\n Although we don't have clear records from her recent hospitalization,\n she may have had an ERCP which would also explain pancreatitis.\n Triglycerides and calcium have been normal in the past.\n - appreciate surgery input\n - follow-up CT Abd/Pelvis and RUQ scan\n - aggressive IVF resuscitation\n - pain control\n 3. Pneumobilia\n Patient has findings of pneumobilia on CT scan of unclear etiology.\n Differential diagnosis includes a recent ERCP if she had one, infection\n with gas-forming organism, cholangitis, or emphysematous cholecystitis.\n - follow-up final read of CT Abd/Pelvis and RUQ scan\n - appreciate surgery input\n - liver consult\n 4. Alcohol Intoxication\n Patient has evidence of alcohol intoxication on exam and also with\n serum alcohol of 162. Patient has had multiple admissions in the past\n with alcohol intoxication. Plan is the following:\n - CIWA scale\n - thiamine, multivitamins, and folate\n - social work consult\n 5. Acute Renal Failure\n Patient's creatinine is 1.1, which is increased from baseline of .5-.7.\n Etiology is most likely prerenal in the setting of infection, although\n she is still at risk for ATN given hypotension in the ED. No new\n medications to suggest AIN. No evidence of urinary obstruction on CT\n Abd/Pelvis.\n - urine lytes\n - monitor close I/Os\n - follow-up final read of CT Abd/Pelvis\n - avoid nephrotoxic agents\n - renally dose medications\n 8. Thrombocytopenia\n Etiology is most likely related to cirrhosis and consistent with prior\n values.\n - continue to trend daily\n 9. Coagulopathy\n Patient has an elevated INR, most likely consistent with liver\n cirrhosis. DIC is possible, although fibrinogen will be difficult to\n interpret in this patient with acute infection and liver disease\n - continue to trend\n 10. Cirrhosis\n Patient has known alcoholic cirrhosis with associated complications of\n varices, portal gastropathy. Plan is the following:\n - continue PPI\n - continue lactulose\n - liver consult\n 11. Portal Vein Thrombosis\n Patient has findings on RUQ US with new portal vein thrombosis; however\n given her history of variceal bleed in the past, will hold off on\n anticoagulation.\n - will follow-up with radiology regarding time course\n - will follow-up with liver in the morning regarding risk / benefit of\n anticoagulation\n 12. ? eumonia\n Patient's CT scan has findings concerning for pneumonia given patchy\n ground glass opacities, although she has minimal O2 requirement and\n minimal findings on physical exam.\n - check urine legionella\n - sputum gram stain and culture if able\n - wean O2 as tolerated\n - follow-up final read of CT scan\n - AM CXR\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2182-05-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 461281, "text": "Chief Complaint: Bacteremia\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 AM\n from TLC.\n - increase dilaudid strength and frequency for abdominal pain\n - Blood cx w/ GPC in pairs and clusters from \n - MRCP ordered\n - Hepatology did not recommend starting heparin\n History obtained from Patient\n Allergies:\n History obtained from PatientPenicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 02:00 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.6\nC (97.9\n HR: 74 (70 - 83) bpm\n BP: 90/55(64) {87/46(56) - 108/63(74)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,540 mL\n 636 mL\n PO:\n 200 mL\n TF:\n IVF:\n 4,540 mL\n 436 mL\n Blood products:\n Total out:\n 2,450 mL\n 1,330 mL\n Urine:\n 2,450 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,090 mL\n -694 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///25/\n Physical Examination\n Gen: no acute distress, resting comfortably in bed\n HEENT: Clear OP, dry mucus membranes\n NECK: Supple, No LAD, No JVD, RIJ in place\n CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops\n LUNGS: decreased breath sounds at the bases bilaterally with no\n wheezes, rales, or rhonchi\n ABD: + BS, Soft, diffusely tender to palpation with no rebound or\n guarding\n EXT: trace lower extremity edema. 2+ DP pulses BL\n SKIN: No rashes\n Labs / Radiology\n 33 K/uL\n 8.2 g/dL\n 85 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 136 mEq/L\n 24.5 %\n 2.0 K/uL\n [image002.jpg]\n 05:08 AM\n 03:33 AM\n WBC\n 2.6\n 2.0\n Hct\n 24.1\n 24.5\n Plt\n 35\n 33\n Cr\n 0.6\n 0.5\n Glucose\n 102\n 85\n Other labs: PT / PTT / INR:19.5/38.6/1.8, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:8.0 mg/dL, Mg++:1.7 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR\n Lung volumes are lower, mediastinal vasculature is appreciably more\n distended\n and pulmonary vessels are mildly dilated, all suggesting volume\n overload and\n borderline cardiac decompensation. Heart size is normal but increased\n since\n yesterday. Right jugular line ends centrally. Findings were discussed\n by\n telephone with Dr. at the time of dictation.\n Microbiology: 5/23 2/4 bottles + for GPC in pairs and clusters\n Assessment and Plan\n 51yo female with history of alcoholic cirrhosis, alcohol abuse, and\n chronic pancreatitis was admitted from the ED with septic shock.\n 1. Septic Shock\n Etiology of her septic shock is unclear. Differential diagnosis\n includes likely GI / biliary source given CT scan findings of\n pancreatitis and pneumobilia. Additional possibilities include\n pneumonia given findings of ground glass opacities on CT Chest,\n although her respiratory exam is unremarkable and she has minimal O2\n requirement. Patient has no urinary symptoms. She was hypotensive in\n the Emergency Department on arrival, although her blood pressure has\n improved with IVF boluses. Plan is the following:\n - follow-up final read of CT scan and RUQ US\n - follow-up blood and urine cultures\n - continue broad spectrum antibiotics with vancomycin and levo/flagyl,\n will taper off vancomycin within 48 hours if no positive culture data\n for gram positive infection\n - pain control with IV morphine for now\n - place Foley\n - aggressive IVF resuscitation with NS to aim for MAP > 60, goal UOP\n 30mL/hour\n - add levophed prn to achieve MAP goals if not responding to IVF\n 2. Pancreatitis\n Patient has findings consistent of pancreatitis on CT scan, most likely\n related to alcoholism. Additional possibilities include gallstone\n pancreatitis, although no significant findings of gallstones on RUQ US.\n Although we don't have clear records from her recent hospitalization,\n she may have had an ERCP which would also explain pancreatitis.\n Triglycerides and calcium have been normal in the past.\n - appreciate surgery input\n - follow-up CT Abd/Pelvis and RUQ scan\n - aggressive IVF resuscitation\n - pain control\n 3. Pneumobilia\n Patient has findings of pneumobilia on CT scan of unclear etiology.\n Differential diagnosis includes a recent ERCP if she had one, infection\n with gas-forming organism, cholangitis, or emphysematous cholecystitis.\n - follow-up final read of CT Abd/Pelvis and RUQ scan\n - appreciate surgery input\n - liver consult\n 4. Alcohol Intoxication\n Patient has evidence of alcohol intoxication on exam and also with\n serum alcohol of 162. Patient has had multiple admissions in the past\n with alcohol intoxication. Plan is the following:\n - CIWA scale\n - thiamine, multivitamins, and folate\n - social work consult\n 5. Acute Renal Failure\n Patient's creatinine is 1.1, which is increased from baseline of .5-.7.\n Etiology is most likely prerenal in the setting of infection, although\n she is still at risk for ATN given hypotension in the ED. No new\n medications to suggest AIN. No evidence of urinary obstruction on CT\n Abd/Pelvis.\n - urine lytes\n - monitor close I/Os\n - follow-up final read of CT Abd/Pelvis\n - avoid nephrotoxic agents\n - renally dose medications\n 8. Thrombocytopenia\n Etiology is most likely related to cirrhosis and consistent with prior\n values.\n - continue to trend daily\n 9. Coagulopathy\n Patient has an elevated INR, most likely consistent with liver\n cirrhosis. DIC is possible, although fibrinogen will be difficult to\n interpret in this patient with acute infection and liver disease\n - continue to trend\n 10. Cirrhosis\n Patient has known alcoholic cirrhosis with associated complications of\n varices, portal gastropathy. Plan is the following:\n - continue PPI\n - continue lactulose\n - liver consult\n 11. Portal Vein Thrombosis\n Patient has findings on RUQ US with new portal vein thrombosis; however\n given her history of variceal bleed in the past, will hold off on\n anticoagulation.\n - will follow-up with radiology regarding time course\n - will follow-up with liver in the morning regarding risk / benefit of\n anticoagulation\n 12. ? eumonia\n Patient's CT scan has findings concerning for pneumonia given patchy\n ground glass opacities, although she has minimal O2 requirement and\n minimal findings on physical exam.\n - check urine legionella\n - sputum gram stain and culture if able\n - wean O2 as tolerated\n - follow-up final read of CT scan\n - AM CXR\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "General", "chartdate": "2182-05-12 00:00:00.000", "description": "micu staff admission note", "row_id": 461067, "text": "TITLE:\n Critical care note\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 51 yo F , etoh abuse, cirrhosis, multiple\n admissions (8 since ) for etoh/pancreatitis/hematemesis, presents\n after fall complaining of R flank pain. Was recently at \n --d/c'd on . In ED hypotensive 79/47 , with generalized abd pain.\n Af and not hypoxic or tachy. Work up revealed transaminitis (ast/alt\n 138/45). t bili 3, tylenol level 10 and etoh 266. CT head and spine\n neg. CT torso with patchy ggo in lungs, evidence of pancreatitis,\n cirrhosis and pneumobilia, new c/t . Given levo, vanco, ctx, and\n dilaudid. RIJ placed. Surgery c/s'd felt ct findings most c/w recent\n procedure. Admitted to for further manaegment.\n PMH: cirrhosis from etoh, ( to 1 pint vodka daily) c/b esoph\n varices, ascities, HE, pancreatitis, h/o DTs, asthma with prior\n intubation, uterine/cervical cx post tah\n SH, FH, MEDS, ALL reviewed as in resident h and p\n PE: 97.8 77 95/65 15 100% 2L\n WD F, NAD, intoxicated but cooperative, flat JVP, CTA, RR, + BS, soft,\n mild diffuse tenderness, no r/g, trace edema\n Labs: WBC 5.3K, HCT 27 , plt 46 K+ 3.7 , Cr 1.1 ,t bili 3 ast/alt\n 138/45 lactate 2.7 inr 1.8\n CT torso reviewed: chest with few small areas of ggo\n ruq usg new main portal v thrombosis, pneumobilia, no stones\n ecg: NSR, no acute sttwc\n Hypotension with lab and imaging evidence of pancreatitis and new\n pneumobilia. Hypotension concerning for infection, early sepsis vs\n dehydration/hypovolemia from etoh intoxication. The abd findings on CT\n with pneumobilia are concerning for emphasematous cholecystitis or\n infection but could also be from a recent procedure such as ercp.\n Hypotension has responded well to IVF with no need for pressors and she\n remains AF with stable O2 sats without leukocytosis or elevated\n lactate which are reasuringThe lung quite unimpressive and\n may represent resolving asd noting no hypoxia.\n Agree with plan to cover empirically for possible biliary infection\n with levo/flagy and vanco following cs results. Surgery is following\n regarding the pneumobilia and we contact ercp for other input. Will\n obtain records from recent OSH hospitalization to assess whether pt had\n a recent ercp which might explain both pancreatitis and the\n pneumobilia. Trend LFTs. IVFs for cvp 10-12, maps > 65. Pain\n control. Mild arf is likely prerenal though atn is on ddx. Check\n urine lytes and follow u/o. Monitor for etoh withdrawal, ciwa, thimaine\n folate MVI. New portal v thrombos seen on ruq usg. Will hold on\n anticoagulating given h/o recurrent variceal bleeding. ICU: rij,\n PPI,boots. Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "General", "chartdate": "2182-05-12 00:00:00.000", "description": "micu staff PN", "row_id": 461063, "text": "TITLE:\n Critical care note\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 51 yo F , etoh abuse, cirrhosis, multiple\n admissions (8 since ) for etoh/pancreatitis/hematemesis, presents\n after fall complaining of R flank pain. Was recently at \n --d/c'd on . In ED hypotensive 79/47 , with generalized abd pain.\n Af and not hypoxic or tachy. Work up revealed transaminitis (ast/alt\n 138/45). t bili 3, tylenol level 10 and etoh 266. CT head and spine\n neg. CT torso with patchy ggo in lungs, evidence of pancreatitis,\n cirrhosis and pneumobilia, new c/t . Given levo, vanco, ctx, and\n dilaudid. RIJ placed. Surgery c/s'd felt ct findings most c/w recent\n procedure. Admitted to for further manaegment.\n PMH: cirrhosis from etoh, ( to 1 pint vodka daily) c/b esoph\n varices, ascities, HE, pancreatitis, h/o DTs, asthma with prior\n intubation, uterine/cervical cx post tah\n SH, FH, MEDS, ALL reviewed as in resident h and p\n PE: 97.8 77 95/65 15 100% 2L\n WD F, NAD, intoxicated but cooperative, flat JVP, CTA, RR, + BS, soft,\n mild diffuse tenderness, no r/g, trace edema\n Labs: WBC 5.3K, HCT 27 , plt 46 K+ 3.7 , Cr 1.1 ,t bili 3 ast/alt\n 138/45 lactate 2.7 inr 1.8\n CT torso reviewed: chest with few small areas of ggo\n ruq usg new main portal v thrombosis, pneumobilia, no stones\n ecg: NSR, no acute sttwc\n Hypotension with lab and imaging evidence of pancreatitis and new\n pneumobilia. Hypotension concerning for infection, early sepsis vs\n dehydration/hypovolemia from etoh intoxication. The abd findings on CT\n with pneumobilia are concerning for emphasematous cholecystitis or\n infection but could also be from a recent procedure such as ercp.\n Hypotension has responded well to IVF with no need for pressors and she\n remains AF with stable O2 sats without leukocytosis or elevated\n lactate which are reasuringThe lung quite unimpressive and\n may represent resolving asd noting no hypoxia.\n Agree with plan to cover empirically for possible biliary infection\n with levo/flagy and vanco following cs results. Surgery is following\n regarding the pneumobilia and we contact ercp for other input. Will\n obtain records from recent OSH hospitalization to assess whether pt had\n a recent ercp which might explain both pancreatitis and the\n pneumobilia. Trend LFTs. IVFs for cvp 10-12, maps > 65. Pain\n control. Mild arf is likely prerenal though atn is on ddx. Check\n urine lytes and follow u/o. Monitor for etoh withdrawal, ciwa, thimaine\n folate MVI. New portal v thrombos seen on ruq usg. Will hold on\n anticoagulating given h/o recurrent variceal bleeding. ICU: rij, PPI,\n sq hep. Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 50 min\n" }, { "category": "Physician ", "chartdate": "2182-05-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 461160, "text": "Chief Complaint: Abd pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo F w/ etoh cirrhosis, multiple admissions (8 since ) for\n etoh/pancreatitis/hematemesis, admitted after fall w/ complaint of R\n flank pain. Recent hosp at OSH for similar symptoms. In ED hypotensive\n 79/47 , with generalized abd pain. Afebrile but not hypoxic or tachy.\n Work up revealed transaminitis (ast/alt 138/45). t bili 3, tylenol\n level 10 and etoh 266. CT head and spine neg. CT torso with patchy\n ggo in lungs, evidence of pancreatitis, cirrhosis and , new\n c/t . Given levo, vanco, ctx, and dilaudid. RIJ placed. Surgery\n c/s'd felt ct findings most c/w recent procedure.\n 24 Hour Events:\n PMH: cirrhosis from etoh, ( to 1 pint vodka daily) c/b esoph\n varices, ascities, HE, pancreatitis, h/o DTs, asthma with prior\n intubation, uterine/cervical cx post tah\n Overnight, broadly covered w/ ABX and treated w/ CIWA scale withdrawal\n protocol.\n This AM, continues to note abd pain but sleeping.\n Allergies:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Ciprofloxacin - 02:30 AM\n Metronidazole - 04:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n folate, MVI, thiamine, pantoprazole,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 74 (72 - 82) bpm\n BP: 91/53(61) {87/49(59) - 96/64(72)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,204 mL\n 3,618 mL\n PO:\n TF:\n IVF:\n 204 mL\n 3,618 mL\n Blood products:\n Total out:\n 150 mL\n 465 mL\n Urine:\n 465 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,054 mL\n 3,153 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), no murmurs\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Wheezes : scattered exp wheezes)\n Abdominal: Soft, Tender: diffusely, no rebound or guarding, Obese, ?\n fluid wave and shifting dullness,\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): name, place, time, Movement: Not assessed,\n Tone: Not assessed, not asterixic\n Labs / Radiology\n 7.7 g/dL\n 35 K/uL\n 102 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 111 mEq/L\n 138 mEq/L\n 24.1 %\n 2.6 K/uL\n [image002.jpg]\n 05:08 AM\n WBC\n 2.6\n Hct\n 24.1\n Plt\n 35\n Cr\n 0.6\n Glucose\n 102\n Other labs: PT / PTT / INR:19.9/40.2/1.9, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.8 mg/dL\n Imaging: CT c/a/p ()- patchy ggo in lungs, findings c/w\n pancreatitis (stranding), , and findings c/w cirrhosis\n RUQ U/S ()- new portal v thrombosis and \n Microbiology: Blood, Urine- pending\n Assessment and Plan\n PANCREATITIS, ACUTE ON CHRONIC\n - related to EtOH\n -supportive care, npo, prn antiemetics\n \n - unclear if ERCP at OSH prior to this hospitalization, also\n considering emphysematous cholecystitis though not as toxic as one\n would expect. no imaging evidence of eroded GB wall\n -cont broad ABX coverage w/ vanco + ciproflox + metronidazole\n -Surgery following\n -attempting to obtain OSH records re: poss ERCP or other intervention\n ETOH CIRRHOSIS\n - c/b coagulopathy, chronic thrombopenia, varices, possible ascites,\n and now portal v thrombosis\n -Hepatology consult\n -no evidence of encephalopathy\n -cont lactulose\n -on PPI\n -? if she should be on SBP prophylaxis if there is ascites, given hx of\n variceal bleed\n NEW PORTAL V THROMBOSIS\n - deferring anticoagulation for now given prior variceal bleed\n -will await Hepatology recommendations re: further mgmt\n ETOH INTOXICATION/ WITHDRAWAL\n -CIWA protocol\n -thiamine, folate\n -Social services involvement\n HYPOTENSION (NOT SHOCK)\n - possible fluid-responsive sepsis vs hypovolemia\n -cont monitoring and prn boluses to support\n -probable chronic hypotension related to chornic liver disease\n SCATTERED GROUND GLASS ON CT- poss aspiration or pneumonia\n -covered w/ broad ABX as above. will attempt to obtain sputum culture\n COPD\n -nicotine patch\n -prn ipratropium and albuterol\n ICU Care\n Nutrition:\n Comments: npo for bowel resting and pending GI workup for \n Glycemic Control:\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2182-05-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 461154, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient is a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had 8 admissions since .\n Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated.\n Action:\n MRCP ordered. On Cipro/Flagyl/Vanco. Transplant consulted and\n following patient.\n Response:\n Pt afebrile. Cont to c/o pain. LFTs/Tbili trending down.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U transplant \n recs. MRCP to eval. Pneumobilia.\n Pain control (acute pain, chronic pain)\n Assessment:\n Reports continued moderate to severe RUQ abdominal pain that she states\n is constant, at rest.\n Action:\n Pt given dilaudid 0.5mg IV dilaudid Q4-5hrs.\n Response:\n Sleeping most of day, awaking periodically, c/o pain and need for pain\n meds, but then would quickly fall back to sleep, with out pain med\n intervention. Pt remains somnolent with low RR and BP on low side.\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n Hypotension (not Shock)\n Assessment:\n MAP 59-60\ns. BP ranging 80s-90s. Adequate u/o.\n Action:\n Pt given 1L LR bolus for low BP this am.\n Response:\n SBP now in 90s with MAP ~ 60 or greater. Patient appears to be\n autodiuresing this afternoon.\n Plan:\n Goal MAP 60. need additional boluses if BP drops.\n Additional Data:\n Repleted lytes, now has prn lyte sliding scale.\n Nicotene patch and nebs ordered for COPD.\n" }, { "category": "Nursing", "chartdate": "2182-05-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 461054, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient is a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had the following multiple admissions since :\n - - pancreatitis, abdominal pain, and alcoholism\n - 1/22-27/09 - hematemesis requiring endoscopy with banding\n - 2/14-17/09 - abdominal pain\n - 2/23-26/09 - abdominal pain, alcohol intoxication\n - 3/27-27/09 - nausea and vomiting, signed out AMA when narcotics were\n not given\n - - hematemesis with EGD demonstrating varices\n - - nonspecific abdominal pain\n - - abdominal pain and alcohol intoxication\n Upon arrival to the ED, temp 99.5, HR 90, BP 79/47, RR 16, and pulse ox\n 97% on RA. Her exam was notable for generalized abdominal pain. Her\n labs were notable for ALT 45, AST 138, TB 3, serum EtOH 266, serum\n acetaminophen 10.2, and INR 1.8. CT scan in the ED was notable for\n patchy ground glass opacities throughout the lungs, pancreatitis, liver\n cirrhosis, and air in the biliary tree. She received ceftriaxone 2g IV\n x 1, dilaudid 2mg IV x 2, levofloxacin 750mg IV x 1, vancomycin 1g IV x\n 1. It is unclear if she received unasyn.\n Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated.\n Action:\n Pt given vanc, levofloxacin, ceftriaxone in ED for pancreatitis. On\n arrival to unit, given flagyl and cipro. Transplant consulted and\n following patient.\n Response:\n Pt afebrile. Cont to c/o pain. LFTs/Tbili trending down.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U transplant \n recs. ? ERCP today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o RUQ abdominal pain that she states is constant, at rest.\n Action:\n Pt given dilaudid 0.5mg IV @ 0115 and PRN order changed so pt can get\n 0.5mg IV dilaudid Q4hrs.\n Response:\n Post dilaudid, pt slept for a few hours awaking periodically c/o pain\n and need for pain meds but then would quickly fall back to sleep. Pt\n remains somnolent with low RR and BP on low side.\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n Hypotension (not Shock)\n Assessment:\n Pt BP on arrival to ED 79 systolic. Given 3L IVF in ED. BP ranging\n 80s-90s overnoc.\n Action:\n Pt given 1L IVF bolus x2 for MAP <60.\n Response:\n SBP now in 90s with MAP ~ 60.\n Plan:\n Goal MAP 60. need additional boluses if BP drops.\n" }, { "category": "Nursing", "chartdate": "2182-05-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 461049, "text": "51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient is a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had the following multiple admissions since :\n - - pancreatitis, abdominal pain, and alcoholism\n - 1/22-27/09 - hematemesis requiring endoscopy with banding\n - 2/14-17/09 - abdominal pain\n - 2/23-26/09 - abdominal pain, alcohol intoxication\n - 3/27-27/09 - nausea and vomiting, signed out AMA when narcotics were\n not given\n - - hematemesis with EGD demonstrating varices\n - - nonspecific abdominal pain\n - - abdominal pain and alcohol intoxication\n Upon arrival to the ED, temp 99.5, HR 90, BP 79/47, RR 16, and pulse ox\n 97% on RA. Her exam was notable for generalized abdominal pain. Her\n labs were notable for ALT 45, AST 138, TB 3, serum EtOH 266, serum\n acetaminophen 10.2, and INR 1.8. CT scan in the ED was notable for\n patchy ground glass opacities throughout the lungs, pancreatitis, liver\n cirrhosis, and air in the biliary tree. She received ceftriaxone 2g IV\n x 1, dilaudid 2mg IV x 2, levofloxacin 750mg IV x 1, vancomycin 1g IV x\n 1. It is unclear if she received unasyn.\n" }, { "category": "Nursing", "chartdate": "2182-05-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 461262, "text": "Pancreatitis, acute on chronic with air in biliary tree\n Assessment:\n CT scan showing acute on chronic pancreatitis with air in biliary tree.\n LFTs/Tbili elevated. C/o RUQ abd pain .\n Action:\n MRCP ordered. On Cipro/Flagyl/Vanco. Transplant consulted and\n following patient. Increased Dilaudid dose and frequency for RUQ abd\n pain. Additional bld cx\ns sent from TLC w/ AM labs.\n Response:\n Pt afebrile. Cont to c/o pain but does get some relief w/ PRN dilaudid\n (no pain response w/ repositioning). Bld cx\ns from w/ +cocci in\n pairs and clusters.\n Plan:\n Cont vanc, cipro, flagyl. F/U blood cx results. F/U transplant \n recs. MRCP to eval. Pneumobilia. ? ECHO w/ new +bld cx\n Pain control (acute pain, chronic pain)\n Assessment:\n Reports continued moderate to severe RUQ abdominal pain that she states\n is constant, at rest.\n Action:\n Pt given dilaudid 0.5mg-1mg IV dilaudid q3-4hrs.\n Response:\n Cont to c/o pain but does get some relief w/ PRN dilaudid (no pain\n response w/ repositioning)\n Plan:\n Cont to assess pain. Cont with dilaudid PRN for pain management. Close\n monitoring of VS with narcotic administration.\n 2grams Mag repletion done, but still need 20mEq KCl.\n" }, { "category": "Physician ", "chartdate": "2182-05-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 461019, "text": "Chief Complaint: flank pain\n HPI:\n 51yo female with a history of hepatic cirrhosis due to alcohol, alcohol\n abuse, chronic pancreatitis, and asthma was admitted from the Emergency\n Department with flank pain. Patient is a very poor historian due to\n alcohol intoxication.\n She reports that she has had multiple falls over the last 1.5 weeks due\n to gait instability and dizziness. She reports that she had not been\n drinking alcohol during these falls. Then on the morning of admission\n she developed marked worsening of her pain for which she drank two\n drinks of vodka and cranberry juice on the morning of admission. She\n reports that she was hospitalized at \ns for the five days\n prior to admission here and was discharged one day prior to admission\n here.\n Of note, she has had the following multiple admissions since :\n - - pancreatitis, abdominal pain, and alcoholism\n - 1/22-27/09 - hematemesis requiring endoscopy with banding\n - 2/14-17/09 - abdominal pain\n - 2/23-26/09 - abdominal pain, alcohol intoxication\n - 3/27-27/09 - nausea and vomiting, signed out AMA when narcotics were\n not given\n - - hematemesis with EGD demonstrating varices\n - - nonspecific abdominal pain\n - - abdominal pain and alcohol intoxication\n Upon arrival to the ED, temp 99.5, HR 90, BP 79/47, RR 16, and pulse ox\n 97% on RA. Her exam was notable for generalized abdominal pain. Her\n labs were notable for ALT 45, AST 138, TB 3, serum EtOH 266, serum\n acetaminophen 10.2, and INR 1.8. CT scan in the ED was notable for\n patchy ground glass opacities throughout the lungs, pancreatitis, liver\n cirrhosis, and air in the biliary tree. She received ceftriaxone 2g IV\n x 1, dilaudid 2mg IV x 2, levofloxacin 750mg IV x 1, vancomycin 1g IV x\n 1. It is unclear if she received unasyn.\n Allergies:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Vancomycin - 11:37 PM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n (from previous discharge summary on )\n 1. Omeprazole 40mg daily\n 2. Lactulose 30mL PO tid\n 3. Nadolol 20mg PO daily\n 4. Sucralfate 1g PO qid\n 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit capsule qid\n 6. Thiamine 100mg PO daily\n 7. Multivitamin 1 tab daily\n 8. Folate 1mg PO daily\n 9. Albuterol prn\n 10. Morphine 15mg PO q6-8 hours\n Past medical history:\n Family history:\n Social History:\n 1. Alcoholic Cirrhosis\n - dx in \n - complicated by varices, ascites, encephalopathy\n 2. Chronic pancreatitis\n 3. ETOH abuse\n - history of DT's in the past\n 4. Asthma\n - history of intubation in the past\n 5. Uterine and cervical CA s/p hysterectomy\n - s/p hysterectomy ()\n - Mother - died in her early 70s from GI bleeding; EtOH\n - Father - died in mid-70s from cancer, possibly mesothelioma as he\n worked in shipping yard; EtOH\n Occupation: former RN, disabled due to low back pain\n Drugs: history of cocaine use\n Tobacco: smokes PPD\n Alcohol: drinks daily vodka\n Other: Home: lives in alone\n Review of systems:\n Flowsheet Data as of 02:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 77 (77 - 82) bpm\n BP: 95/64(72) {87/55(62) - 96/64(72)} mmHg\n RR: 15 (13 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,204 mL\n 1,024 mL\n PO:\n TF:\n IVF:\n 204 mL\n 1,024 mL\n Blood products:\n Total out:\n 150 mL\n 105 mL\n Urine:\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,054 mL\n 919 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: no acute distress, resting comfortably in bed, smelling of\n alcohol, occasional slurred speech\n HEENT: Clear OP, dry mucus membranes\n NECK: Supple, No LAD, No JVD\n CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops\n LUNGS: decreased breath sounds at the bases bilaterally with no\n wheezes, rales, or rhonchi\n ABD: + BS, Soft, diffusely tender to palpation with no rebound or\n guarding\n EXT: trace lower extremity edema. 2+ DP pulses BL\n SKIN: No rashes\n NEURO: A&Ox3. CN 2-12 intact. 5/5 strength throughout. Normal\n coordination. Gait assessment deferred\n Labs / Radiology\n Other labs: ALT / AST:40/117, Alk Phos / T Bili:175/2.3, Amylase /\n Lipase:92/78\n Fluid analysis / Other labs: \n Na 138 / K 3.7 / Cl 107 / CO2 21 / BUN 15 / Cr 1.1 / BG 118\n ALT 45 / AST 138 / Alk Phos 183 / TB 3 / Alb 2.9 / Lipase 136\n Serum EtOH 266 / Serum Acetaminophen 10.2\n Serum ASA, BDPs, Barb, TCA - negative\n WBC 5.3 / hct 26.8 / Plt 46 / MCV 101\n N 48 / L 30 / M 12 / E 5 / B 2 / Atyp 3\n Lactate 2.7\n INR 1.8 / PTT 37.5\n UA - 0-2 RBCs, 3-5 WBCs, rare bacteria, no yeast, 0-2 epis, 21-50\n hyaline casts\n .\n Baseline Creatinine .5-.8\n Baseline Hct 28-32\n Baseline Platelets 40-80\n Imaging: - - CT Head - Preliminary read - No acute ICH.\n unchanged from study.\n - - CT C spine - Preliminary read - No fracture or misalignment\n - - CT Chest / Abd / Pelvis - Prelim read - Patchy ground glass\n opacities throughout the lungs, may be infectious/inflammatory or\n aspiration. Peripancreatic stranding and fluid, c/w pancreatitis.\n Cirrhotic liver with air in the biliary tree and in the gallbladder.\n Correlate with any prior interventions/ERCPs as this is new from\n .\n - RUQ US - prelim read - new main portal vein thrombosis.\n cirrhosis. Air in CBD and gallblader. no gallstones. Left hepatic vein\n not seen.\n - EGD\n 1. Varices at the lower third of the esophagus\n 2. Erythema, congestion and mosaic appearance in the whole stomach\n compatible with portal hypertensive gastropathy\n 3. Abnormal mucosa in the duodenum\n Otherwise normal EGD to third part of the duodenum\n Microbiology: - Blood Cx x 2 pending\n - Urine Cx pending\n ECG: sinus rhythm at ~80bpm, normal axis, no acute ST changes\n Assessment and Plan\n 51yo female with history of alcoholic cirrhosis, alcohol abuse, and\n chronic pancreatitis was admitted from the ED with septic shock.\n 1. Septic Shock\n Etiology of her septic shock is unclear. Differential diagnosis\n includes likely GI / biliary source given CT scan findings of\n pancreatitis and pneumobilia. Additional possibilities include\n pneumonia given findings of ground glass opacities on CT Chest,\n although her respiratory exam is unremarkable and she has minimal O2\n requirement. Patient has no urinary symptoms. She was hypotensive in\n the Emergency Department on arrival, although her blood pressure has\n improved with IVF boluses. Plan is the following:\n - follow-up final read of CT scan and RUQ US\n - follow-up blood and urine cultures\n - continue broad spectrum antibiotics with vancomycin and levo/flagyl,\n will taper off vancomycin within 48 hours if no positive culture data\n for gram positive infection\n - pain control with IV morphine for now\n - place Foley\n - aggressive IVF resuscitation with NS to aim for MAP > 60, goal UOP\n 30mL/hour\n - add levophed prn to achieve MAP goals if not responding to IVF\n 2. Pancreatitis\n Patient has findings consistent of pancreatitis on CT scan, most likely\n related to alcoholism. Additional possibilities include gallstone\n pancreatitis, although no significant findings of gallstones on RUQ US.\n Although we don't have clear records from her recent hospitalization,\n she may have had an ERCP which would also explain pancreatitis.\n Triglycerides and calcium have been normal in the past.\n - appreciate surgery input\n - follow-up CT Abd/Pelvis and RUQ scan\n - aggressive IVF resuscitation\n - pain control\n 3. Pneumobilia\n Patient has findings of pneumobilia on CT scan of unclear etiology.\n Differential diagnosis includes a recent ERCP if she had one, infection\n with gas-forming organism, cholangitis, or emphysematous cholecystitis.\n - follow-up final read of CT Abd/Pelvis and RUQ scan\n - appreciate surgery input\n - liver consult\n 4. Alcohol Intoxication\n Patient has evidence of alcohol intoxication on exam and also with\n serum alcohol of 162. Patient has had multiple admissions in the past\n with alcohol intoxication. Plan is the following:\n - CIWA scale\n - thiamine, multivitamins, and folate\n - social work consult\n 5. Acute Renal Failure\n Patient's creatinine is 1.1, which is increased from baseline of .5-.7.\n Etiology is most likely prerenal in the setting of infection, although\n she is still at risk for ATN given hypotension in the ED. No new\n medications to suggest AIN. No evidence of urinary obstruction on CT\n Abd/Pelvis.\n - urine lytes\n - monitor close I/Os\n - follow-up final read of CT Abd/Pelvis\n - avoid nephrotoxic agents\n - renally dose medications\n 8. Thrombocytopenia\n Etiology is most likely related to cirrhosis and consistent with prior\n values.\n - continue to trend daily\n 9. Coagulopathy\n Patient has an elevated INR, most likely consistent with liver\n cirrhosis. DIC is possible, although fibrinogen will be difficult to\n interpret in this patient with acute infection and liver disease\n - continue to trend\n 10. Cirrhosis\n Patient has known alcoholic cirrhosis with associated complications of\n varices, portal gastropathy. Plan is the following:\n - continue PPI\n - continue lactulose\n - liver consult\n 11. Portal Vein Thrombosis\n Patient has findings on RUQ US with new portal vein thrombosis; however\n given her history of variceal bleed in the past, will hold off on\n anticoagulation.\n - will follow-up with radiology regarding time course\n - will follow-up with liver in the morning regarding risk / benefit of\n anticoagulation\n 12. ? eumonia\n Patient's CT scan has findings concerning for pneumonia given patchy\n ground glass opacities, although she has minimal O2 requirement and\n minimal findings on physical exam.\n - check urine legionella\n - sputum gram stain and culture if able\n - wean O2 as tolerated\n - follow-up final read of CT scan\n - AM CXR\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: not indicated\n Comments: not indicated\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2182-05-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 461099, "text": "Chief Complaint: Abd pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo F w/ etoh cirrhosis, multiple admissions (8 since ) for\n etoh/pancreatitis/hematemesis, admitted after fall w/ complaint of R\n flank pain. Recent hosp at OSH for similar symptoms. In ED hypotensive\n 79/47 , with generalized abd pain. Afebrile but not hypoxic or tachy.\n Work up revealed transaminitis (ast/alt 138/45). t bili 3, tylenol\n level 10 and etoh 266. CT head and spine neg. CT torso with patchy\n ggo in lungs, evidence of pancreatitis, cirrhosis and pneumobilia, new\n c/t . Given levo, vanco, ctx, and dilaudid. RIJ placed. Surgery\n c/s'd felt ct findings most c/w recent procedure.\n 24 Hour Events:\n PMH: cirrhosis from etoh, ( to 1 pint vodka daily) c/b esoph\n varices, ascities, HE, pancreatitis, h/o DTs, asthma with prior\n intubation, uterine/cervical cx post tah\n Overnight, broadly covered w/ ABX and treated w/ CIWA scale withdrawal\n protocol.\n This AM, continues to note abd pain but sleeping.\n Allergies:\n Penicillins\n Unspecified \n Fentanyl\n Shortness of br\n Last dose of Antibiotics:\n Ciprofloxacin - 02:30 AM\n Metronidazole - 04:30 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n folate, MVI, thiamine, pantoprazole,\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 74 (72 - 82) bpm\n BP: 91/53(61) {87/49(59) - 96/64(72)} mmHg\n RR: 10 (8 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,204 mL\n 3,618 mL\n PO:\n TF:\n IVF:\n 204 mL\n 3,618 mL\n Blood products:\n Total out:\n 150 mL\n 465 mL\n Urine:\n 465 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,054 mL\n 3,153 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (S1: Normal), (S2: Normal), no murmurs\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Wheezes : scattered exp wheezes)\n Abdominal: Soft, Tender: diffusely, no rebound or guarding, Obese, ?\n fluid wave and shifting dullness,\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): name, place, time, Movement: Not assessed,\n Tone: Not assessed, not asterixic\n Labs / Radiology\n 7.7 g/dL\n 35 K/uL\n 102 mg/dL\n 0.6 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 111 mEq/L\n 138 mEq/L\n 24.1 %\n 2.6 K/uL\n [image002.jpg]\n 05:08 AM\n WBC\n 2.6\n Hct\n 24.1\n Plt\n 35\n Cr\n 0.6\n Glucose\n 102\n Other labs: PT / PTT / INR:19.9/40.2/1.9, ALT / AST:39/111, Alk Phos /\n T Bili:130/2.3, Amylase / Lipase:81/78, Differential-Neuts:30.0 %,\n Band:0.0 %, Lymph:54.0 %, Mono:12.0 %, Eos:3.0 %, LDH:218 IU/L,\n Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:2.8 mg/dL\n Imaging: CT c/a/p ()- patchy ggo in lungs, findings c/w\n pancreatitis (stranding), pneumobilia, and findings c/w cirrhosis\n RUQ U/S ()- new portal v thrombosis and pneumobilia\n Microbiology: Blood, Urine- pending\n Assessment and Plan\n PANCREATITIS, ACUTE ON CHRONIC- related to EtOH\n -supportive care, npo, prn antiemetics\n unclear if ERCP at OSH prior to this hospitalization,\n also considering emphysematous cholecystitis though not as toxic as one\n would expect. no imaging evidence of eroded GB wall\n -cont broad ABX coverage w/ vanco + ciproflox + metronidazole\n -Surgery following\n -attempting to obtain OSH records re: poss ERCP or other intervention\n ETOH CIRRHOSIS- c/b coagulopathy, chronic thrombopenia, varices,\n possible ascites, and now portal v thrombosis\n -Hepatology consult\n -no evidence of encephalopathy\n -cont lactulose\n -on PPI\n -? if she should be on SBP prophylaxis if there is ascites, given hx of\n variceal bleed\n NEW PORTAL V THROMBOSIS- deferring anticoagulation for now given\n prior variceal bleed\n -will await Hepatology recommendations re: further mgmt\n ETOH INTOXICATION/ WITHDRAWAL\n -CIWA protocol\n -thiamine, folate\n -Social services involvement\n HYPOTENSION (NOT SHOCK)- possible fluid-responsive sepsis vs\n hypovolemia\n -cont monitoring and prn boluses to support\n -probable chronic hypotension related to chornic liver disease\n SCATTERED GROUND GLASS ON CT- poss aspiration or pneumonia\n -covered w/ broad ABX as above. will attempt to obtain sputum culture\n COPD\n -nicotine patch\n -prn ipratropium and albuterol\n ICU Care\n Nutrition:\n Comments: npo for bowel resting and pending GI workup for pneumobilia\n Glycemic Control:\n Lines:\n Multi Lumen - 11:10 PM\n 18 Gauge - 11:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "ECG", "chartdate": "2182-05-13 00:00:00.000", "description": "Report", "row_id": 148925, "text": "Sinus rhythm. Compared to tracing #1 there is no significant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2182-05-11 00:00:00.000", "description": "Report", "row_id": 148926, "text": "Sinus rhythm. RSR' pattern in lead VI is probably a normal variant. Low\nQRS voltage in the precordial leads. Compared to the previous tracing of \nno significant diagnostic change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2182-05-19 00:00:00.000", "description": "Report", "row_id": 148819, "text": "Possible sinus tachycardia versus accelerated junctional rhythm. Non-specific\nrepolarization changes. Compared to the previous tracing of heart rate\nhas significantly increased. Clinical correlation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2182-05-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1080024, "text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with alcoholic cirrhosis was admitted with pancreatitis and\n ground glass opacity on chest CT.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:01 A.M., \n\n HISTORY: Alcoholic cirrhosis, pancreatitis, and ground glass opacity on chest\n CT.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are lower, mediastinal vasculature is appreciably more distended\n and pulmonary vessels are mildly dilated, all suggesting volume overload and\n borderline cardiac decompensation. Heart size is normal but increased since\n yesterday. Right jugular line ends centrally. Findings were discussed by\n telephone with Dr. at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-18 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1081107, "text": " 3:09 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: r/o obstruction; also please assess for ascites to aspirate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with cirrhosis, ruq pain, elevated bilirubin, fever\n REASON FOR THIS EXAMINATION:\n r/o obstruction; also please assess for ascites to aspirate and mark if\n possible\n ______________________________________________________________________________\n WET READ: JXKc SAT 4:13 PM\n Cirrhosis with splenomegaly. No evidence of cholecystitis or biliary\n dilatation. Right pleural effusion. No ascites\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female with cirrhosis, right upper quadrant pain,\n elevated bilirubin, and fever. Rule out obstruction and assess for ascites to\n aspirate.\n\n COMPARISON: .\n\n FINDINGS: The liver is shrunken and nodular in appearance, compatible with\n cirrhosis. No focal hepatic lesion is identified. On a prior study from , , thrombus of the main portal vein was noted. On today's study, flow\n is demonstrated in the main portal vein. Images of the gallbladder are\n slightly limited due to difficulties with positioning. However, the\n gallbladder does not appear to be distended, without evidence of wall\n thickening or pericholecystic fluid. No son sign was present.\n There is no intra- or extra- hepatic biliary ductal dilatation with the CBD\n measuring 4 mm. The spleen is enlarged measuring 14 cm. Visualized\n pancreatic head and body are unremarkable, the tail is not well visualized due\n to overlying bowel gas. Assessment of the four quadrants of the abdomen\n reveals no evidence of ascites; however, incidentally seen is a right pleural\n effusion.\n\n IMPRESSION:\n 1. Cirrhosis, with splenomegaly.\n 2. No evidence of cholecystitis.\n 3. No evidence of ascites, with a note made of a right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-11 00:00:00.000", "description": "CT PELVIS W/O CONTRAST", "row_id": 1079977, "text": " 5:18 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for acute injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p fall, R chest pain/ttp and abd pain\n REASON FOR THIS EXAMINATION:\n eval for acute injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc SAT 7:53 PM\n Patchy ground glass opacities throughout the lungs, may be\n infectious/inflammatory or aspiration. Peripancreatic stranding and\n fluid, c/w pancreatitis. Cirrhotic liver with air in the biliary tree and in\n the gallbladder. Correlate with any prior interventions/ERCPs as this is new\n from .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female status post fall, right chest pain, tenderness to\n palpation with abdominal pain. Evaluate for acute injury.\n\n COMPARISON: CT.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis without the administration of IV contrast, secondary to poor\n intravenous access. Oral contrast was not administered. Coronal and sagittal\n reformations were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Coronary artery calcifications are seen.\n Otherwise, the heart and pericardium are unremarkable. The great vessels are\n normal in caliber, without evidence of aneurysmal dilatation. There are mild\n atherosclerotic calcifications involving the takeoffs of the brachiocephalic\n and left subclavian arteries. Few scattered mediastinal lymph nodes are not\n pathologically enlarged by CT size criteria.\n\n There are patchy areas of ground-glass opacities involving bilateral upper\n lobes, with dependent atelectatic changes involving the right lower lobe, with\n a possible tiny right pleural effusion. The changes of ground-glass opacities\n may reflect infection or inflammatory changes. No pneumothorax is identified.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Again noted are cirrhotic changes of\n the liver, with the liver nodular in contour and shrunken. Assessment for a\n focal lesion is limited, without intravenous contrast. The spleen is mildly\n enlarged. Again seen are portosystemic collateral vessels, suggestive of\n portal hypertension. These findings are better assessed on a dedicated\n multiphasic CT that was performed .\n\n There is peripancreatic inflammatory stranding, with trace amount of\n peripancreatic free fluid, likely reflecting acute pancreatitis. Additionally,\n air is seen within the common bile duct, left intrahepatic biliary duct, as\n well as within the gallbladder, which were not clearly evident on prior study\n from , and could relate to any recent interventions such as ERCP.\n (Over)\n\n 5:18 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for acute injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The adrenal glands and kidneys are unremarkable.\n\n The stomach, small bowel, and large bowel are unremarkable. There is no free\n air. Few scattered mesenteric and retroperitoneal lymph nodes are not\n pathologically enlarged. No ascites is identified.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Urinary bladder and rectum are\n unremarkable. Patient is status post hysterectomy.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified.\n No fracture is identified. Mild concavity involving the superior endplate of\n the L1 vertebral body likely reflects a Schmorl's node.\n\n IMPRESSION:\n 1. Peripancreatic inflammatory stranding with peripancreatic fluid, most\n compatible with acute pancreatitis.\n 2. Cirrhotic liver, with evidence of portal hypertension.\n 3. Air within the biliary tree and gallbladder, which were not evident on\n prior study on . Correlate with any recent interventions such as\n ERCP.\n 4. Patchy bilateral airspace ground-glass opacities, which may be infectious\n or inflammatory in etiology, with a suggestion of a tiny right pleural\n effusion.\n\n Findings were posted to the ED dashboard at the time of interpretation.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1079975, "text": " 5:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p fall, R chest pain/ttp and abd pain\n REASON FOR THIS EXAMINATION:\n eval for ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SAT 7:03 PM\n No acute ICH. Prominent ventricle and sulci, compatible with brain atrophy,\n unchanged from study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female, status post fall, complaining about right chest\n pain and tenderness to palpation, and abdominal pain. Evaluate for\n intracranial hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Helical MDCT images were acquired through the brain without\n contrast. Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: There is no acute intracranial hemorrhage or fracture. The\n ventricles and sulci are markedly prominent for age, however, appear unchanged\n from the study. There is no shift of midline structures. The paranasal\n sinuses and mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial hemorrhage or fracture. Prominent sulci\n and ventricles, compatible with brain atrophy, unchanged since .\n\n" }, { "category": "Radiology", "chartdate": "2182-05-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1079976, "text": " 5:17 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for acute injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with s/p fall, R chest pain/ttp and abd pain\n REASON FOR THIS EXAMINATION:\n eval for acute injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc SAT 7:52 PM\n No fx or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female status post fall, evaluate for acute injury.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Contiguous axial images of the cervical spine were obtained\n without IV contrast. Coronal and sagittal reformations were obtained.\n\n FINDINGS: There is no prevertebral soft tissue abnormality. Mild\n straightening of the normal cervical lordosis is seen. The patient is\n slightly rotated. However, no fracture or malalignment is identified. There\n is no significant degenerative change. The spinal canal appears grossly\n patent without evidence of an epidural hematoma. Of note, CT is not as\n sensitive as MRI in evaluation of thecal sac.\n\n IMPRESSION: No evidence of fracture or malalignment.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1080003, "text": " 10:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: presence of pneumothorax\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with central line placement\n REASON FOR THIS EXAMINATION:\n presence of pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:37 P.M. ON \n\n HISTORY: Assess new central line placement.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new right internal jugular line projects over the mid-to-low SVC.\n There is no pneumothorax, mediastinal widening, or pleural effusion. Heart\n size is normal. Previous pulmonary edema has cleared.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-13 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 1080168, "text": " 8:04 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval for cause of pneumobillia\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 F w/ pmh of alcoholic cirrhosis here w/ hypotension and air in the biliary\n system\n REASON FOR THIS EXAMINATION:\n please eval for cause of pneumobillia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE ABDOMEN FROM \n\n HISTORY: Alcoholic cirrhosis, low blood pressure. air in biliary system.\n Evaluate pneumobilia.\n\n COMMENT: Multiplanar T1- and T2-weighted images of the abdomen were acquired\n on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during, and after\n IV administration of 17 cc of Magnevist. Multiplanar 2D and 3D reformations\n and subtraction images were generated on an independent workstation.\n\n FINDINGS: There is a moderate right pleural effusion and a small left pleural\n effusion. There is atelectasis in bilateral lower lobes of the lung. Patient\n also has a small amount of ascites. There is also peripancreatic fluid which\n could be due to generalized edema or pancreatitis.\n\n The liver contour is nodular. There are areas of decreased signal intensity\n on the out-of-phase images within the liver compatible with fatty\n infiltration. On the post-contrast images, there is no obvious suspicious\n mass within the liver.\n\n The spleen is mildly enlarged. There is minimal heterogeneous signal\n intensity in the head of the pancreas with increased signal seen on the T2-\n weighted images and slightly decreased enhancement on the post-contrast\n images. Findings are probably inflammatory in nature. No definite mass is\n seen. The pancreatic duct is not dilated. Common bile duct is mildly dilated\n at 8.0 mm and tapers distally. Obvious pneumobilia is not identified but CT is\n more sensitive.\n\n The hepatic veins, portal vein, splenic vein, and proximal celiac and superior\n mesenteric arteries are patent. Varices are seen in the upper abdomen and\n adjacent to the distal esophagus. Subcentimeter probable cysts are seen in\n both kidneys. The gallbladder and adrenals are unremarkable. There is\n subcutaneous edema.\n\n Multiplanar 2D and 3D reformations delineate the dynamic series with multiple\n perspectives.\n\n IMPRESSION:\n 1. Findings compatible with cirrhosis with fatty change in the liver. The\n (Over)\n\n 8:04 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval for cause of pneumobillia\n Admitting Diagnosis: PANCREATITIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portal venous system is patent.\n 2. Ascites as well as peripancreatic fluid. There is mild heterogeneous\n enhancement of the head of the pancreas. Findings are probably due to\n pancreatitis. Recommend clinical correlation.\n 3. Bilateral pleural effusions and atelectasis at the lung bases, right\n greater than left.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2182-05-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1079996, "text": " 8:58 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: eval for stones\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with pancreatitis, ? gallstones,\n REASON FOR THIS EXAMINATION:\n eval for stones\n ______________________________________________________________________________\n WET READ: FBr SAT 9:44 PM\n new main portal vein thrombosis. cirrhosis. AIr in CBD and gallblader. no\n gallstones. Left hepatic vein not seen.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with pancreatitis, please evaluate for\n gallstones.\n\n Comparison is made to the same-day noncontrast CT of the torso performed on\n 23, , and prior CECT of the abdomen performed on .\n\n FINDINGS: The liver demonstrates coarsened echotexture and diffusely\n increased echogenicity and nodularity, compatible with cirrhosis. No focal\n liver lesion was visualized, though evaluation on recent multiphasic CT is\n more sensitive. The main portal vein contains central echoes and no blood\n flow on doppler interrogation. The left portal vein, right anterior portal\n vein, and right posterior portal vein demonstrate patency with appropriate\n direction of flow. The right hepatic vein and main hepatic vein demonstrate\n normal flow. The left hepatic vein was not visualized. The hepatic arteries\n also demonstrate normal flow patterns.\n\n The common bile duct and gallbladder contain air. The common bile duct is not\n dilated and measures 5 mm. No ascites is visualized. No gallstone is\n visualized. No intrahepatic biliary dilatation is visualized. The pancreas\n is better evaluated on the same-day CT.\n\n IMPRESSION:\n\n 1. Cirrhotic liver with new thrombosis of the main portal vein which was not\n present on the multiphasic CT of the abdomen of .\n\n 2. Air within the gallbladder, better appreciated on CT from today. No\n gallstones.\n\n 3. Nonvisualization of the left hepatic vein.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2162-12-25 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 812229, "text": " 8:51 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: eval for hydrocephalus, vent drain placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with frontal/intraventricular hemorrhage now with increased\n ICP's and increased lethargy. Vent drain repositioned.\n REASON FOR THIS EXAMINATION:\n eval for hydrocephalus, vent drain placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Noncontrast CT of the head.\n\n INDICATION: 64 year old male with intracranial hemorrhage and increased\n intracranial pressure. Evaluate for hydrocephalus and drain placement after\n repositioning of ventricular drain.\n\n TECHNIQUE: Axial noncontrast CT imaging of the brain. Comparison is made to a\n prior CT performed the same day.\n\n FINDINGS: An intraventricular drainage catheter passes from a right frontal\n approach, crosses the midline, and terminates within the region of the\n anterior of the left lateral ventricle. The supratentorial ventricular\n system is unchanged in size. There is unchanged extensive subarachnoid and\n intraventricular hemorrhage. A small focus of intraventricular air is stable\n in appearance. There is no evidence of shift of normally midline structures.\n There is no evidence of new mass effect or change in the edema surrounding the\n areas of intraparenchymal hemorrhage within the right frontal region.\n\n A small amount of fluid is present within the right maxillary sinus. A\n fracture of the frontal bone is unchanged.\n\n IMPRESSION: Drainage catheter in place with its distal tip in the anterior\n of the left lateral ventricle. Unchanged size of the supratentorial\n ventricular system. Otherwise stable examination with unchanged evolving\n intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813849, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fever\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n fever\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n This under-penetrated markedly rotated film does not reveal evidence of a new\n infiltrate shows lines and tubes to remain in place. There is no significant\n change compared to prior accounting for technical differences.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-04 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 813223, "text": " 11:58 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Fever - r/o phlepi\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ICB\n REASON FOR THIS EXAMINATION:\n Fever - r/o phlepi\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial bleed, fever. Assess for DVT.\n\n BILATERAL LOWER EXTERMITY VEINS ULTRASOUND: scale and color images of\n both common femoral, superficial femoral, and popliteal veins were obtained.\n Normal wave forms, compressibility, and augmentation was demonstrated. No\n intraluminal thrombus was identified.\n\n IMPRESSION: No evidence of lower extremity DVT.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 814596, "text": " 8:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with frontal/intraventricular hemorrhage now with increased\n ICP's and increased lethargy. Vent drain repositioned.\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Frontal/intraventricular hemorrhage. Now with increased\n intracranial pressure and increased lethargy.\n\n COMPARISON: Noncontrast head CT from .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There has been interval removal of the right frontal ventricular\n drain. A small amount of air is present in the right frontal of the\n lateral ventricle likely secondary to the removal of this drain. There is\n continued mild to moderate dilatation of the ventricles, stable from the prior\n study. Again seen is extensive hypodensity involving the inferior frontal\n lobes bilaterally as well as the rostral corpus callosum, findings which may\n be secondary to malacic effect from prior hemorrhage or perhaps vasospasm\n causing infarction. There continues to be a small amount of high attenuation\n material within the right occipital and right sylvian fissure, stable in\n appearance from the prior exam, which represents residual subarachnoid and\n intraventricular blood. No new areas of hemorrhage are identified. There is\n no shift of normally midline structures. A small amount of fluid is present\n within both sphenoid sinuses, new from the prior exam. Otherwise the remainder\n of the visualized paranasal sinuses are clear. The surrounding osseous and\n soft tissue structures are unchanged.\n\n IMPRESSION:\n\n 1. Interval removal of right frontal ventricular drain, resulting in a small\n amount of pneumocephalus within the right frontal .\n\n 2. Stable mild to moderate dilatation of the ventricles.\n\n 3. Extensive hypodensity involving both inferior frontal lobes and rostral\n corpus callosum, likely reflecting malacia and/or infarction as a result of\n prior hemorrhage in this locale.\n\n 4. Residual amount of intraventricular hemorrhage and subarachnoid\n hemorrhage, stable from prior exam.\n\n\n (Over)\n\n 8:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812695, "text": " 6:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage, r/o CHF.\n\n SUPINE AP CHEST: Comparison made to the prior chest x ray on .\n There is again present an ETT in satisfactory position. The left sided\n subclavian central venous catheter and NG tube are unchanged. There is\n cardiomegaly. The left hemidiaphragm is not fully seen. There is a suggestion\n of bilateral diffuse haziness to the lung fields which may represent layering\n of effusion. There is no definite evidence of pulmonary consolidation.\n\n IMPRESSION: Technically limited study with the suggestion of effusion and\n possibly some degree of edema.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-06 00:00:00.000", "description": "MR T-SPINE W &W/O CONTRAST", "row_id": 813525, "text": " 5:10 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: R/O epidural hematoma, cord contusion other cord pathology-\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with waxing and waneing neurological exam\n REASON FOR THIS EXAMINATION:\n R/O epidural hematoma, cord contusion other cord pathology- axial and sagital\n images\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid hemorrhage with neurologic symptoms.\n\n TECHNIQUE: T1 and T2 weighted axial and sagittal images were obtained of the\n thoraic and lumbar spine. No gadolinium contrast was administered.\n\n THORACIC MR: The axial images are slightly limited due to decreased signal\n intensity. No abnormal signal is present within the spinal cord. The lower\n portion of the brain is visible on the sagittal sequences and there are signal\n abnormalities within the subarachnoid spaces consistent with the patient's\n known subarachnoid hemorrhage. No masses or abnormal signal is present in the\n epidural space in the thoracic spine. At T7-T8 disc degenerative changes are\n present, with a decrease of signal within the disc and narrowing of the disc.\n There is also endplate edema. There is a mild bulge of the disc at this level\n which contacts the spinal cord but does not cause significant spinal canal\n narrowing. No neural foraminal narrowing is present. The intercostal vessels\n are enlarged at multiple levels of the thoracic spine. The significance of\n this is uncertain. No intraspinal vessel abnormalities are present.\n\n LUMBAR MR: The spinal canal is widely patent throughout the lumbar region.\n There is no neural foraminal stenosis. At L4-L5, there is marked narrowing of\n the disc and endplate edema consistent with degenerative changes. No loss of\n vertebral body height is present. The vertebrae are normally aligned. The\n visualized abdominal and paraspinal soft tissues are unremarkable.\n\n IMPRESSION:\n\n 1. Mild degenerative disc changes at T7-T8. No spinal cord abnormalities, no\n epidural lesions, and no nerve root abnormalities.\n\n 2. Prominent intercostal vessels. This is of uncertain etiology and clinical\n significance.\n\n 3. Degenerative disc changes at L4-L5. No spinal cord or nerve root\n abnormalities in the lumbar spine. No epidural or spinal canal masses.\n\n (Over)\n\n 5:10 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: R/O epidural hematoma, cord contusion other cord pathology-\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-12-31 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 812830, "text": " 8:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR-ANGIO HEAD; -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval brain\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SAH\n\n REASON FOR THIS EXAMINATION:\n eval brain\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n\n 64 year old male with known subarachnoid hemorrhage. Multiple axial T1 T2\n FLAIR susceptibility and diffusion weighted images are performed. In addition\n MR angiography and MR venography was performed.\n\n FINDINGS:\n\n The study is compared to the previous CAT scan examination performed on\n .\n\n Again noted is massive bifrontal edema surrounding the bifrontal intra-\n parenchymal hemorrhages. Again noted is evidence of intraventricular\n hemorrhage as well as subarachnoid hemorrhage. Again noted is hemorrhage in\n the sylvian fissure. Again noted is a left temporal lobe hemorrhage most\n probably contusion. Focal hyperintensity noted in the right caudate nucleus\n the significance of which is difficult to evaluate. The study is limited\n secondary to extensive artifacts from the extensive intracranial hemorrhage.\n There is increased signal in the bifrontal region consistent with the\n patient's known infarct in the bifrontal region on the previous CAT scan.\n However the exact extent is difficult to evaluate secondary to shine-through\n artifacts secondary to the hemorrhage.\n\n Again noted is partial opacification of the mastoid air cells bilaterally and\n remain unchanged since the prior CAT scan examination.\n\n MRA OF THE BRAIN:\n\n Study limited secondary to extensive shine-through artifacts from previous\n hemorrhage. Study is also limited by motion. Again noted are extensive\n intraventricular/intraparenchymal and subarachnoid hemorrhage and are not\n changed since the prior examination. However it is difficult to compare with\n the previous CAT scan as no previous MRI is available.\n\n MR ANGIOGRAPHY:\n\n Evaluation of the MR good flow through the internal\n carotid arteries bilaterally, anterior and middle cerebral artery branches.\n There is good flow through the vertebral arteries and basilar artery. No\n definite aneurysm is noted. Evaluation of the anterior communicating artery\n (Over)\n\n 8:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n MR-ANGIO HEAD; -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval brain\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n region is limited secondary to shine-through artifacts from the extensive\n intracranial hemorrhage.\n\n MR VENOGRAPHY:\n\n Evaluation of the MR good filling of both transverse\n sinuses, superior sagittal sinus and both jugular veins. There is no good\n flow through the straight sinus. This could be secondary to congenital\n hypoplasia vs acquired. Please correlate clinically.\n\n Increased signal noted in the region of the posterior corpus callosum on\n diffusion weighted images. Please correlate clinically to exclude acute\n infarct in this region..\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812847, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated patient with subarachnoid hemorrhage.\n\n PORTABLE CHEST: An AP semiupright image obtained at 5:05 AM is compared to\n . The endotracheal tube, central venous catheter and feeding tube are in\n stable position. Cardiac and mediastinal contours are normal. There may be a\n left pleural effusion, as on the prior study.\n\n IMPRESSION: Left pleural effusion. No pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812929, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64 year old man with subarachnoid hemorrhage.\n\n PORTABLE SUPINE CHEST AT 5:30AM.\n\n Exam is limited due to patient rotation and poor inspiration. There is no\n significant change when compared to prior study one day earlier. Patchy\n opacity at the left base is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2162-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812377, "text": " 12:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX and eval L_SC line\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n r/o PTX and eval L_SC line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP:\n\n INDICATION: Evaluate position of left subclavian line.\n\n COMPARISON: .\n\n FINDINGS: AP portable: Normal heart size. The aorta is unfolded. Allowing\n for rather poor inspiratory effort, the lungs are clear. There is a left-\n sided subclavian line with the tip in the distal SVC. No pneumothorax. There\n is an NGT, the tip of which is below the diaphragm.\n\n IMPRESSION: S/P placement of left subclavian line. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812969, "text": " 12:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R IJ\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n s/p R IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64 y/o man with subarachnoid hemorrhage s/p right IJ catheter.\n\n SUPINE PORTABLE CHEST @ 1 P.M.:\n\n Compared to prior study earlier on the same date, there has been placement of\n a right internal jugular central venous catheter whose tip is in the superior\n vena cava. There is no evidence of pneumothorax. Patchy opacity at the left\n base is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 813082, "text": " 11:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: REASSES sah\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sah, transfer from osh, s/p angio (negative for\n aneurysm on ), please re-assess amount of hemorrhage\n\n REASON FOR THIS EXAMINATION:\n REASSES sah\n CONTRAINDICATIONS for IV CONTRAST:\n elevated creat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage, follow up.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Again noted is an intraventricular drainage catheter which passes\n through the right frontal lobe and terminates within the right lateral\n ventricle. There has been interval decrease in the size of the lateral\n ventricles. The hemorrhage involving the frontal lobes is less apparent on the\n current study, consistent with interval absorption of blood. There is\n surrounding extensive edema within the frontal lobes. Prominent\n intraventricular and subarachnoid hemorrhage is again noted, not significantly\n changed in appearance from the prior exam. No new areas of hemorrhage are\n identified. There is no shift of normally midline structures. Again seen\n within the right maxillary sinus is a small amount of loculated fluid,\n unchanged from the prior study. A small amount of fluid is now present within\n the left maxillary sinus which is new in the interval between scans. The\n ethmoid air cells are partially opacified. Again demonstrated is\n opacification of the mastoid air cells bilaterally, stable from the prior\n exam. The surrounding osseous and soft tissue structures remain unchanged\n from the prior exam.\n\n IMPRESSION:\n\n 1. No new areas of hemorrhage. Intraparenchymal and subarachnoid hemorrhages\n are less apparent on the current study, consistent with some interval\n absorption of blood products. Stable extensive intraventricular hemorrhage.\n\n 2. Interval improvement in hydrocephalus.\n\n 3. Opacification of sinuses as described above consistent with intubation.\n\n\n (Over)\n\n 11:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: REASSES sah\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-12-30 00:00:00.000", "description": "ORBITS (WATERS, CALDWELL & LAT)", "row_id": 812624, "text": " 8:37 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: rule out metal particles before MRI scan. patient has a hist\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with grade 3 SAH\n REASON FOR THIS EXAMINATION:\n rule out metal particles before MRI scan. patient has a history of metal\n working\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for metallic particles prior to MRI scan, history of\n trauma. Subarachnoid hemorrhage.\n\n ORBITS, TWO VIEWS: No radiopaque foreign bodies are detected over the orbits.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813296, "text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n eval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 y/o male with subarachnoid hemorrhage.\n\n COMPARISON: .\n\n AP SUPINE PORTABLE CHEST RADIOGRAPH:\n\n The right IJ central line and the NG tube are unchanged in position. There is\n interval extubation of the patient. The heart is increased in size. The aorta\n is unfolded. Pulmonary vascularity is within normal limits. There is no\n evidence of CHF. The lung fields are clear. There is no focal consolidation.\n There is minor atelectasis at the lung bases. There is no pleural effusion.\n There is low lung volumes.\n\n IMPRESSION:\n\n The study is essentially unchanged when compared to the previous study from\n . There is no evidence of CHF.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 814420, "text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage now febrile and changed MS.\n\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid hemorrhage with fever and mental status\n change. Rule out pneumonia.\n\n Comparison is made to prior study of .\n\n CHEST, AP SUPINE @ 0319 hours.\n\n FINDINGS: The external support tubes (RIJ line and stomach tube) in\n satisfactory position. Heart and mediastinal contours are normal. The\n pulmonary hila and vasculature is normal. No active lung infiltrates. The\n osseous structures are unremarkable.\n\n IMPRESSION: External support tubes in place. No active cardiopulmonary\n process.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-14 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 814331, "text": " 10:21 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: aspiration\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SAH\n REASON FOR THIS EXAMINATION:\n aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64 year old man with subarachnoid hemorrhage. Evaluate for\n aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW STUDY: The study was performed in conjunction\n with the Speech and Swallow Department. Various consistencies of barium were\n administered to the patient. There is mildly impaired bolus formation, AP\n tongue movement and bolus control. There is premature spillover into the\n pharynx. There is minimal residue in the piriform sinuses after swallow.\n There is normal laryngeal elevation and epiglottic deflection. No penetration\n or aspiration was observed during study. For full details, please see the\n speech and swallow report in the patient's online medical record.\n\n IMPRESSION: No aspiration observed.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-07 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 813590, "text": " 11:23 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: R/O FRACTURE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with ICB\n REASON FOR THIS EXAMINATION:\n please perform recons\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Arm weakness.\n\n Axial imaging was performed throughout the cervical spine. No contrast was\n administered. Comparison to a cervical spine MR of . Note that the\n current examination and the prior cervical spine MR are severely degraded by\n motion artifact. This greatly limits sensitivity for detecting soft tissue\n abormalities in the spinal canal.\n\n FINDINGS: The C1-2 level demonstrates no large abnormalities.\n\n At C2-3, there are intervertebral and uncovertebral osteophytes. The inter-\n vertebral osteophytes narrow the spinal canal. There may be a bulge or\n protrusion of the intervertebral disc. However, this is poorly evaluated due\n to motion artifact. There appears to be bilateral neural foraminal narrowing\n due to uncovertebral osteophyte formation.\n\n At C3-4, motion artifact limits evaluation. There is an intervertebral\n osteophyte producing some component of spinal canal narrowing. Uncovertebral\n osteophytes narrow the neural foramina. The severity of canal and foraminal\n narrowing cannot be reliably assessed on this study.\n\n At C4-5, there is a small intervertebral osteophyte. There may be a right\n sided protrusion of the intervertebral disc. Again, this is poorly evaluated\n on the current examination. The spinal canal appears narrowed and cord\n compression is a possibility.\n\n At C6-7, there is an intervertebral osteophyte producing mild canal narrowing.\n Uncovertebral osteophytes narrow the neural foramina bilaterally. There may be\n a bulge or protrusion of the intervertebral disc. This is not well evaluated\n on the current examination.\n\n At C7-T1, severe motion artifact greatly limits evaluation. I cannot determine\n whether there may be an intervertebral osteophyte. The neural foramina do not\n appear grossly narrowed. However, the study is limited.\n\n There is opacification of the mastoid air cells bilaterally, greater on the\n left than right. A jugular catheter and nasogastric tube are in place.\n\n CONCLUSION: Severely limited study due to motion artifact. There are\n degenerative changes at multiple levels with indication of neural foraminal\n (Over)\n\n 11:23 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: R/O FRACTURE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n narrowing and possible cord encroachment. A repeat examination may be\n advisable when the patient is capable of remaining motionless.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 814328, "text": " 10:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: F/U with Drain clamped.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sah, transfer from osh, s/p angio (negative for\n aneurysm on ), please re-assess amount of hemorrhage\n\n REASON FOR THIS EXAMINATION:\n F/U with Drain clamped.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage assess amount of hemorrhage and\n ventricular size with drain clamped.\n\n TECHNIQUE: Axial noncontrast CT scans of the brain were obtained.\n\n Comparison is made to the previous CT scan of and the MRI of .\n\n There is extensive hypodensity in the inferior frontal lobes bilaterally\n consistent with resolving edema related to injury. There is resolution of most\n of the hyperdense blood products within the brain parenchyma. There is still\n small amount of blood evident in the ventricles and the subarachnoid space.\n There has been widening of the sulci and ventricles in the interval since the\n previous examinations. Some volume loss may be secondary to injury. A thin\n left hemispheric extra- axial collection identified on the MRI is not clearly\n seen on today's CT.\n\n The right frontal ventricular drain is unchanged in position and terminates in\n the left frontal . There is mild-to-moderate dilatation of the ventricles.\n\n IMPRESSION: Resolving frontal hemorrhage with residual edema and probably a\n component of infarction related to injury. There is enlargement of the\n ventricles compared to the previous examinations which may reflect poor CSF\n drainage and can, in part, be the result of brain injury and volume loss.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-05 00:00:00.000", "description": "MR CERVICAL SPINE", "row_id": 813391, "text": " 5:32 PM\n MR CERVICAL SPINE; -52 REDUCED SERVICES Clip # \n Reason: WITHOUT CONTRAST - eval for epidural hematoma or cord contus\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SAH\n\n REASON FOR THIS EXAMINATION:\n WITHOUT CONTRAST - eval for epidural hematoma or cord contusion - extremity\n weakness\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL SPINE.\n\n Limited T2 sagittal images of the cervical spine were only obtained. The\n study is non-diagnostic and significantly limited by motion artifact. Despite\n normal alignment of the vertebral bodies, cord signal intensity is\n significantly attenuated. A repeat examination could be performed if the\n patient is sedated.\n\n IMPRESSION: Non-diagnostic sagittal images of the cervical spine due to\n patient motion artifact.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-05 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 813392, "text": " 5:32 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: EVAL FOR EPIDURAL HEMATOMA OR CORD CONTUSION\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SAH\n\n REASON FOR THIS EXAMINATION:\n DWI ONLY\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITH DIFFUSION IMAGES.\n\n INDICATION: To evaluate for epidural hematoma.\n\n Multiplanar T1- and T2-weighted images of the brain, in addition to diffusion\n images and ADC mapping were performed. Comparison is made to the prior exam\n of of .\n\n There are no new hemispheric infarcts seen on diffusion images. Persistent\n foci of restricted diffusion are again noted along the corpus callosum and the\n regions of the inferior frontal lobes most likely related to the presence of\n extracellular hemoglobin related to the patient's recent hemorrhage.\n\n T2-weighted images, however, reveal moderate sulcal effacement which has\n worsened since the prior exam, highly suspicious for worsening cerebral edema.\n FLAIR images are significantly degraded by motion artifact. There is\n significant amount of intraventricular hemorrhage without hydrocephalus.\n Extensive subarachnoid hemorrhage is also noted. There is no significant\n enlargement involving the previously seen subacute left-sided subdural bleed.\n A small focus of hemorrhage is seen near the right caudate nucleus, unchanged.\n The fourth ventricle remains in the midline. There is T2 hyperintensity\n within the mastoid sinuses which has worsened since the prior exam indicating\n inflammatory mastoiditis. There is slight worsening opacification of the\n sphenoid sinuses.\n\n IMPRESSION:\n\n 1) No new areas of hemispheric infarction seen since the prior exam. Stable\n areas of restricted diffusion, as noted previously.\n\n 2) Worsening cerebral edema due to generalized sulcal effacement along the\n frontoparietal convexity.\n\n 3) Stable subacute left-sided subdural hematoma.\n\n 4) Extensive subarachnoid hemorrhage and intraventricular hemorrhage, as noted\n previously. Most of the hemorrhage is seen inferior to the frontal lobes and\n in the interhemispheric fissure which usually raises the suspicion for an\n anterior communicating artery aneurysm. A repeat cerebral angiogram could be\n considered, given the patient's clinical condition and based on clinical\n grounds.\n (Over)\n\n 5:32 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: EVAL FOR EPIDURAL HEMATOMA OR CORD CONTUSION\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2162-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812437, "text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n There is subarachnoid hemorrhage and intubation. Endotracheal tube is 5 cm\n above the carina. Left subclavian CV line is in distal SVC. Distal end of\n feeding tube is in fundus of stomach. Distal end of NG tube is in distal\n antrum of stomach. No pneumothorax. There is cardiomegaly. No definite\n pulmonary consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813426, "text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progress\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n REASON FOR THIS EXAMINATION:\n eval progress\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 y/o male with subarachnoid hemorrhage. ____ fluid status.\n\n COMPARISON: .\n\n AP SUPINE CHEST RADIOGRAPH:\n\n Right IJ central line is located in the superior SVC. The NG tube tip is\n extending beyond the borders of the imager in the stomach. The heart and\n mediastinum is stable in appearance. The pulmonary vasculature is unchanged.\n Overall, there is no significant change.\n\n IMPRESSION:\n\n There is no significant change when compared to the previous x ray.\n\n" }, { "category": "Radiology", "chartdate": "2162-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812127, "text": " 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation, pls check placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n REASON FOR THIS EXAMINATION:\n s/p intubation, pls check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation, assess ET tube.\n\n Portable supine frontal radiograph. No prior studies for comparison.\n\n FINDINGS: The heart is normal in size. There is an endotracheal tube\n terminating several cm above the carina and in satisfactory position. There\n are low lung volumes bilaterally. There is no pneumothorax. There is minimal\n atelectasis at the left lung base. There are no pleural effusions and the\n pulmonary vasculature is normal on this supine radiograph.\n\n IMPRESSION: ET tube in satisfactory position. No pneumothorax. Left basilar\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2162-12-24 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 812128, "text": " 3:13 PM\n CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: eval sah\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sah, transfer from osh\n REASON FOR THIS EXAMINATION:\n eval sah\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transfer for outside hospital with subarachnoid hemorrhage.\n\n TECHNIQUE: Axial CT images of the skull were obtained without and with\n intravenous contrast.\n\n CONTRAST: 150 cc of Optiray were administered secondary to the requirement for\n fast rate of injection. There were no immediate complications.\n\n CT HEAD WITHOUT AND WITH INTRAVENOUS CONTRAST: The noncontrast images\n demonstrate large quantities of high-attenuation fluid in the basilar\n cisterns, the dependent portions of the lateral ventricles and in a\n parafalcine configuration within the anterior skull. Some of this hemorrhagic\n material appears to extend into the parenchyma of the right frontal lobe and\n probably the left temporal lobe. Within the basilar cisterns, there is\n asymmetric widening of the right ambient cistern, which is filled with high-\n attenuation material. High-attenuation hemorrhagic products can also be seen\n in the interpeduncular cistern, anterior to medulla and distributed throughout\n multiple sulci along the cerebral convexities. Hemorrhagic material is seen\n within the anterior body of the corpus callosum. The ventricles and sulci are\n symmetric and without gross effacement or enlargement. There is no shift or\n normally midline structures. Low-attenuation edema is seen surrounding the\n areas of intraparenchymal hemorragic dissection.\n\n The soft tissue window images demonstrate a superficial right scalp hematoma.\n Bone window images demonstrate a parasagittal fracture extending through the\n frontal bones. Fluid layers within the right maxillary sinus.\n\n Following the administration of intravenous contrast, the components of the\n circle of and its major tributaries are visualized. No focal aneurysmal\n dilatation is identified; however, the entire series of reformatted images has\n not been made available at the time of this dictation.\n\n IMPRESSION:\n 1. Incomplete evaluation requiring full set of reformatted images; when these\n become available, an addendum will be issued.\n 2. Large quantities of intracranial hemorrhagic material, lying predominantly\n in the subarachnoid cisterns, with some intraventricular and intraparenchymal\n components. The distribution of hemorrhage, as well as the hemorrhage into the\n corpus callosum, favors an anterior cerebral arterial source. A rupture of an\n aneurysm of the anterior communicating artery is one likely possibility. Less\n likely, and consistent with the asymmetric hemorrhage into the right ambient\n (Over)\n\n 3:13 PM\n CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: eval sah\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n cistern, a ruptured aneurysm of the right posterior communicating artery could\n also produce some of these findings; the extensive parafalcine subarachnoid\n hemorrhage is not consistent with such a source.\n 3. Given the large skull fracture, multiple intraparenchymal components, and\n the lack of a demonstrable aneurysm on the preliminary set of images, all the\n imaging findings could be related to massive head trauma.\n\n" }, { "category": "Radiology", "chartdate": "2162-12-24 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 812146, "text": " 6:53 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 268\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage rule out intracranial\n aneurysm.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of intracranial aneurysm or arteriovenous\n malformation.\n\n INDICATION: Mr. was transferred to with a CT showing evidence of subarachnoid hemorrhage namely in the\n anterior cerebral artery distribution in the interhemispheric region. He is\n undergoing this cerebral angiogram to determine the source of this hemorrhage\n and potential for treatment.\n\n CONSENT: The patient's family were given a full and complete explanation of\n the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death, were outlined. The\n patient's family understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 4 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: right common carotid artery,\n right internal carotid artery, right external carotid artery, right subclavian\n artery, right vertebral artery, left common carotid artery, left internal\n carotid artery, left external carotid artery, left subclavian artery, and left\n vertebral artery.\n\n RESULTS: Injection of the innominate artery shows no evidence of\n atherosclerotic disease or stenosis in the major great vessels. Injection of\n the right common carotid artery shows normal carotid artery bifurcation with\n (Over)\n\n 6:53 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 268\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n no atherosclerotic change. Injection of the right internal carotid artery\n shows a normal intracranial circulation. Cross compression shows a patent\n anterior communicating artery and no evidence of anterior cerebral artery\n distribution aneurysm or other malformation. The venous phase is unremarkable.\n The right posterior communicating artery is patent. Injection of the left\n common carotid artery shows no evidence of atherosclerotic disease in the\n cervical region and intracranially injection of the left internal carotid\n artery shows a normal intracranial circulation with a patent left fetal type\n posterior cerebral artery with no evidence of intracranial aneurysm or\n arteriovenous malformation. Both of these findings were confirmed by three-\n dimensional rotational angiography. Finally injection of the bilateral\n subclavian arteries shows normal anatomy. Injections of bilateral vertebral\n arteries in the cervical segment are within normal limits. The vertebrobasilar\n junction is free of atherosclerotic disease. Intracranially the basilar apex\n is characterized by an absent left posterior cerebral artery origin. It is\n otherwise unremarkable. Injection of the bilateral external carotid arteries\n revealed no evidence of abnormal arteriovenous shunting.\n\n IMPRESSION: No evidence of intracranial aneurysm or other vascular\n malformation to serve as a source for the patient's intracranial hemorrhage.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2162-12-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 812181, "text": " 7:25 AM\n CT HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: REASSESS AMOUNT OF BRAIN HEMORRHAGE, CHECK VENTRICULAR SIZE\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sah, transfer from osh, s/p angio (negative for aneurysm\n on ), please re-assess amount of hemorrhage\n\n REASON FOR THIS EXAMINATION:\n re-assess amount of hemorrhage, check ventricular size, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up of intracranial hemorrhage.\n\n COMPARISONS: \n\n TECHNIQUE: Noncontrast axial images of the brain.\n\n CT HEAD W/O CONTRAST: Again noted is the large amount of hemorrhage within\n the basilar cistern, parafalcine configuration and occipital horns of the\n lateral ventricles. Smaller amounts of hemorrhage are noted within the sulci\n overlying the temporal and posterior frontal lobes. In addition, the\n parenchymal hemorrhage with surrounding edema along the midline frontal lobes\n and left temporal lobe and anterior body of the corpus callosum. There is\n minimal change in the surrounding edema and no new mass effect. The ventricles\n and sulci are symmetric without gross effacement or evidence of hydrocephalus.\n There is no shift of normally midline structures. There has been interval\n placement of a right lateral intraventricular drain which extends barely into\n the frontal of the right lateral ventricle. There is increasing\n hemorrhage within the occipital horns of the lateral ventricles, bilaterally.\n Again noted is the midline frontal bone fracture, extending into the sagittal\n suture. There is a trace amount of fluid within the right maxillary sinus.\n\n There is a new small focus of air within the medial left frontal lobe just\n anterior to the frontal of the left lateral ventricle.\n\n IMPRESSION:\n\n 1) Evolving intracranial hemorrhage as described above. There is no new mass\n effect or hydrocephalus. There is, however, slightly increased hemorrhage\n within the occipital horns of the lateral ventricles.\n 2) Unchanged midline frontal bone fracture, extending into the sagittal\n suture.\n 3) New focus of air within the medial left frontal lobe just anterior to the\n left lateral ventricle possibly related to recent manipulation.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 813171, "text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid status\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with subarachanoid hemorrhage\n\n REASON FOR THIS EXAMINATION:\n fluid status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Subarachnoid hemorrhage. Check fluid status.\n\n FINDINGS: A single AP supine view. Comparison study dated .\n The position of the ETT, the NG line and the right IJ central line remain\n unchanged and are satisfactory. The heart shows slight LV enlargement and the\n aorta is slightly unfolded. The pulmonary vessels are well within normal\n limits and there is no evidence of cardiac failure at this time. No pleural\n effusions are demonstrated. The hila and mediastinum are unremarkable.\n\n IMPRESSION: The overall appearances of the heart and pulmonary vessels have\n improved since the prior study. There is no evidence of cardiac failure or\n hyperhydration. No new cardiopulmonary abnormality is demonstrated.\n\n" }, { "category": "Radiology", "chartdate": "2162-12-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 812765, "text": " 10:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o hydrocephalus\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sah, transfer from osh, s/p angio (negative for aneurysm\n on ), please re-assess amount of hemorrhage\n\n REASON FOR THIS EXAMINATION:\n r/o hydrocephalus\n CONTRAINDICATIONS for IV CONTRAST:\n renal\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST\n\n HISTORY: Rule out hydrocephalus in a 64 year old male status post subarachnoid\n hemorrhage. Has there been an increased in amount of hemorrhage?\n\n Contiguous 5 mm axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of new hemorrhage since the prior study.\n However, there is massive bifrontal edema surrounding the bifrontal\n intraparenchymal hematoma previously noted. This suggests evolution of\n frontal contusion or infarction. Again identified is extensive\n intraventricular hemorrhage, as well as subarachnoid hemorrhage. There is\n hemorrhage in the sylvian fissures and in the ambient cistern, predominantly\n on the right. A ventricular catheter is in place, terminating in the right\n lateral ventricle. There is a right caudate hypodensity that represents\n evolution of the hemorrhage noted on the prior study.\n\n There is partial opacification of the mastoid air cells bilaterally, this is\n more prominent on the left than right, and is new since the prior study.\n There is partial opacification of the ethmoid air cells, also new since the\n prior study. There is loculated fluid in the right maxillary sinus, a small\n amount of fluid was present in this location on the previous study.\n\n CONCLUSION: Evolution of bifrontal infarction or contusion since .\n There is extensive intraventricular, intraparenchymal, and subarachnoid\n hemorrhage, but no evidence of new bleeding since the prior study. A\n ventricular catheter is in place and there is no hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2163-01-05 00:00:00.000", "description": "C-SPINE (PORTABLE)", "row_id": 813413, "text": " 11:24 PM\n C-SPINE (PORTABLE) Clip # \n Reason: Patient with decreased movement on left. Rule out cervical s\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with SAH.\n REASON FOR THIS EXAMINATION:\n Patient with decreased movement on left. Rule out cervical spine\n fractures/dislocations\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage. Now with decreased movement on left side.\n\n C-SPINE, 2 VIEWS: Vertebral bodies of C1 through C4 vertebrae are well\n aligned, with no spondylolisthesis. Posterior elements of C1 and C2 are\n unremarkable. Posterior elements of C3 and C4 are not well visualized.\n Remaining cervical spine is not visualized due to patient position.\n\n IMPRESSION: Non-diagnostic radiographic evaluation of the cervical spine.\n Further assessment by C-spine CT is recommended.\n\n" }, { "category": "Echo", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 76500, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 265\nBSA (m2): 2.31 m2\nBP (mm Hg): 129/61\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 11:37\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is not well visualized.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function cannot be reliably assessed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTIC VALVE: The aortic valve is not well seen.\n\nMITRAL VALVE: The mitral valve is not well seen.\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function cannot be reliably assessed.\n\n\n" }, { "category": "ECG", "chartdate": "2162-12-29 00:00:00.000", "description": "Report", "row_id": 195405, "text": " be sinus rhythm by consider also ectopic atrial rhythm. Baseline artifact.\nModest diffuse non-specific low amplitude T waves. Since the previous tracing\nof there may be no significant change, but baseline artifact makes\ncomparison difficult and T wave morphology appears smaller and more difficult\nto assess.\n\n" }, { "category": "ECG", "chartdate": "2162-12-29 00:00:00.000", "description": "Report", "row_id": 195406, "text": "Normal sinus rhythm\nNonspecific ST-T wave changes\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2162-12-24 00:00:00.000", "description": "Report", "row_id": 195407, "text": "Sinus bradycardia\nLong QTc interval\nAnt/septal+lateral ST-T changes may be due to myocardial ischemia\n\n" }, { "category": "Radiology", "chartdate": "2162-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1260479, "text": " 6:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK NG TUBE PLACEMENT\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n The NG tube appears to be within the stomach. The lungs are clear. There is\n no pneumonia or failure.\n\n CONCLUSION: NG tube placement in the stomach.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-14 00:00:00.000", "description": "Report", "row_id": 1475414, "text": "Condition Update\nD: SEE CAREVUE FOR SPECIFICS\n PATIENT SPIKE TEMP THIS AFTERNOON TO 101.6. 1 SET PERIPHERAL BLOOD CX DRAWN, UNABLE TO GET ANY BLOOD RETURN FROM CVL, WHEN ATTEMPTING TO CHANGE FOLEY AND OBTAIN URINE SPEC PUSS POURED OUT OF PENIS UPON REMOVAL OF FOLEY. SICU TEAM AWARE-PENILE DRAINAGE SENT FOR CULTLURE, CONDOM CATH APPLIED-WILL OBTAIN CLEAN CATCH URINE SPEC WITH NEXT VOID AND KEEP FOLEY OUT OVERNIGHT. PATIENT HAS NOT REQUIRED ANY SUCTIONING-SO NO SPUTUM SENT. PT CURRENTLY ON VANCO LEVELS DRAWN AROUND NOON DOSE TODAY.\n PATIENT WENT DOWN TO FLOURO FOR SWALLOW EVAL THIS AM-PASSED EVAL BUT AFTERWARDS VOMMITED. PT APPEARED TO ADEQUATELY CLEAR AIRWAY WITH A VERY STRONG COUGH AND HEAD WAS ELEVATED TO 90 DEGREES-SICU TEAM AWARE. LUNGS REMAIN CLEAR AND DIM IN BASES. WEANED OFF NASAL CANNULA WITH SATS 98-100%. PT STILL NPO AT THIS TIME RECEIVING TF. BLOOD SUGARS REMAIN ELEVATED BEING COVERED WITH SSI.\n HEMODYNAMICALLY STABLE HR 70-80 IN NSR. BP VERY STABLE. ALINE REMOVED -CYCLING CUFF BP 140/50'S. CVP 4-5. MAKING ADEQUATE URINE.\n VENT DRAIN CLAMPED ALL DAY TODAY AT 20. ICP'S . HEAD CT DONE THIS AM. STATED NO PLAN TO REMOVE DRAIN TODAY-POSSIBLY TOMORROW. NO CHANGE IN NEURO STATUS. SPONT. OPENING EYES, MOVING ALL EXTREMETIES, FOLLOWS COMMANDS BUT ONLY ORIENTEDX1.\nPLAN:\n CONT NEURO CHECKS\n ? D/C VENT DRAIN TOMORROW\n FOLLOW-UP WITH CULTURE RESULTS\n OBTAIN URINE SPEC VIA CONDOM CATH WITH NEXT VOID\n NOTIFY H.O WITH ANY CHANGES.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-15 00:00:00.000", "description": "Report", "row_id": 1475415, "text": "focus update note\nT max 99.8 60-80s NSR no ectopy, SBP consistently 130-140s CVP 1-8 RR 20s on 3liters via N/C o2sat 95-97%, LSC and dim at bases\n\nneuro: ICP 0-6, at assessed pt and decreased movement in noted- pt only moving on bed, DR called from and he assessed pt. decision by made to open vent drain- when vent drain opened- yellow sediment seen and spec sent for culture and vent drain set up changed. vent drain cont 20 at tragus and not draining in buret- but pulsitile mmhg seen in vent drain tubing which was assessed by and found to be patent Dr aware of no CSF out, prior to vent drain tubing change- 14 cc CSF out for specimen.\n\nGU/GI: nepro cont at 35cc/hr- 500cc 1/2 NS bolus given for CVP 2 and low UO. urine via condom cath amber clear- stool liquid via rectal bag, BS positive\n" }, { "category": "Nursing/other", "chartdate": "2163-01-15 00:00:00.000", "description": "Report", "row_id": 1475416, "text": "CONDITION UPDATE\nD: NEURO: ALERT AND COOPERATIVE BUT ORIENTED ONLY TO SELF. PT ABLE TO LIFT AND HOLD ALL EXTREMITIES EXCEPT LEFT LEG WHICH HE IS ABLE TO MOVE ON THE BED. VENT DRAIN CLAMPED AT 0645 BY NEURO TEAM. ICP 2-15. PUPILS 3-4 MM WITH EQUAL REACTION. IVF STARTED FOR ELEVATED NA.\nCV: SEE CAREVUE FOR SPECIFICS. AFEBRILE. SBP 130-160.\nRESP: NP AT 3 LITERS. BS DIMINISHED IN BASES BUT OTHERWISE CLEAR. COUGHING WITHOUT RAISING.\nGI: PT FT OUT AT CHANGE OF SHIFT- TEAM AWARE AND DECIDED TO LEAVE OUT SECONDARY TO RESULTS OF SWALLOWING STUDY YEST. PT ABLE TO TAKE ALL MEDS FINE. ABD SOFT AND NON-TENDER. FIB CHANGED- DRAINING MOD AMTS GOLDEN BROWN LIQUID STOOL\nGU: CONDOM CATH IN PLACE- VOIDED X 2 IN GOOD AMTS\nENDO: NPH D/C'D SECONDARY TO LACK OF TF, BS FOLLOWED BY SLIDING SCALE.\nA: HEMODYNAMICS MONITORED, NEURO STATUS MONITORED, OOB TO CHAIR VIA FOR 2 HRS. ASPIRATION PRECAUTIONS\nR: STABLE AT PRESENT, CONTINUE TO MONITOR NEURO STATUS CLOSELY\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-16 00:00:00.000", "description": "Report", "row_id": 1475417, "text": "7p-7a; Full assessment in flow sheet.\n\nA+O to self only. Pleasantly confuse. Follow commands. MAE - lift and hold except Left leg. PERLA. Clear speech. equal smile. tongue midline. No pain per pt. Ventricle drain - clamp (20 cm tragus). no headache, no n/v. ICP 5-9. NSR/SB with rare PVC. BP 140-155/56-68. Afebrile. warm, dry, no edema. Clear in upper lobes, dimish at bases. 3L NC - >98%. Encourage deep breathing and coughing while awake. soft abd. problem swallowing pills or water. Per prior shift - pt pass swallow evaluation. +BSX4. no flatus. +bowel movement - loose golden stool, negative guiac. condom foley intact - yellow/clear urine. skin intact. AM lab done.\n\nPlan; Continue to monitor. Safety precaution.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-16 00:00:00.000", "description": "Report", "row_id": 1475418, "text": "CONDITION UPDATE\nD: NEURO: VENT DRAIN D/C'D THIS AM, PT ALERT AND ORIENTED TO SELF ONLY. ABLE TO LIFT AND HOLD ALL EXTREMITIES EXCEPT RIGHT LEG. FOLLOWS COMMANDS. PUPILS 3MM WITH EQUAL REACTION.\nCV: PERIODS OF BRADYCARDIA WHILE SLEEPING OTHERWISE VSS- SEE CAREVUE FOR SPECIFICS\nRESP: ROOM AIR SATS 99%, BS DIMINISHED IN BASES\nGI: DIET ADVANCED TO DIABETIC DIET= TOL WELL, FIB INTACT WITH SM AMTS GOLDED BROWN LIQUID STOOL\nGU: CONDOM CATH IN PLACE- VOIDING QS\nACTIVITY: OOB MOST OF AFTERNOON TO CHAIR VIA \nENDO: BS COVERED BY SLIDING SCALE\nA: NEURO STATUS MONITORED, DIET ADVANCED\nR: STABLE, MONITOR OVERNIGHT PER NEURO THEN TRANSFER TO FLOOR AFTER CT SCAN.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-17 00:00:00.000", "description": "Report", "row_id": 1475419, "text": "update\nNeuro: unchanged, perl, confused. oriented to person only. pt d/c'd central line, no bleeding at site, no hematoma noted. periph iv started by iv nurse. CT scan for today, then ? transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-27 00:00:00.000", "description": "Report", "row_id": 1475356, "text": "nsg ;\n neuro: pt alert and confused oriented times one. mae to command more active with rt arm. pupils equal icp <10 draining blood tinged fld.\n\ncv. on labatelol gtt and iv lopressor to maintain bp <150. nimodipine given q 4 hrs labatelol usually turned down or off for 2.5 hrs after dose then increased again until next dose given please see carevue for details pt in nsr rate 50's 60's no ectopy.\n\ngi npo geting nimodipine sl. pt appeared to asp after last dose strong cough. no stool\n\nendo insulin gtt pts blood sugar very labile ins gtt from 0 to 6 units per hr.\n\nresp on 2 liters nasal prongs reap rate 16 to 24 sats >96 mostly 98 %. abg initally at 2am with o2 67 possibly drawn when pt had pulled off o2 blood gas repeate with adequate o2. pt with compensated metabolic acidosis. dry cough lungs clear.\n\na stable with meds for bp controll\n to angio again today type and cross sent for 2 units packed cells.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-27 00:00:00.000", "description": "Report", "row_id": 1475357, "text": "REVIEW OF SYSTEMS:\n\nNEURO: Pt opens eyes to voice, consistently follows commands and has purposeful movements, MAE X 4. Pt confused, knows name but unsure where he is, ststes he is in at his facility despite frequently reorienting pt. Occasionally will know the year, pt able to say that it is winter and who the president is. PERRL 3mm/bsk. +gag, +cough, + corneals. Receiving phenytoin, no seizure activity noted, has some tarditive dyskenesia. Restarted on home meds/psych per NG tube. Ventriculostomy site is CDI, at 12 cm > tragus open to drainage, blood tinged CSF. ICPs .\n\nCV: SB-SR, no ectopy noted. Goal for systolic < 150-had difficult time- titrating labetolol gtt, as high as 8 mg/h, currently at 5. Taking nimodipine with good response in BP, taking Lopressor-changed to Per NGT. DP/PT pulses are present and easily palpable bilaterally. Art line in left radial with good wave form.\n\nPulmonary: Continues on 2 liters O2 per NC, O2 sats 98-100%, RR 20s-30s, Color pink. Lung sounds are clear bilaterally in the upper lobes and diminished bilaterally in the bases. Last ABG:7.37/23/80/-. Received 500 cc NS bolus for base excess.\n\nGI: NPO, belly is soft/obese + BS, -stool.\n\nGU: Foley patent to gravity, Uop on low side, H.O. aware, picked up after fluid bolus. MIVF at 80/hr.\n\nID: Afebrile, Vanco dose held, trough 19.5.\n\nENDO: Continues on insulin gtt, see care view for trends.\n\nSocial: Friend for stopped by and visited with pt, pt able to say hello and seemed pleased per affect with visit.\n\nSkin: Ventriculostomy dressing is CDI, P boots on, skin other wise wholly intact.\n\nPlan: Continue with Q@H neuro checks, monitor for changes, monitor ICP, monitor oxygenation. Goal for systolic < 150, titrate labetolol gtt.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 1475362, "text": "S/P SAH\n\nPt . restless, attempts to sit up, follows commands. Propofol increased to prevent overbreathing vent. Vent drain remains open-15@Tragus, sm. amt. blood-tinged fluid. ICP 7-11. Dilantin as ordered.\n\nNSR-no ectopy. BP stable. Dopamine @5mcg/kg. Bicarb gtt @50cc/hr. Heparin SC and pneumoboots on. Pedal pulses palpable. KCL repleted.\n\nMultiple vent changes to correct acidosis. Suctioned q4hr for sm. amt. white sputum. Breath sounds clear. Pt has very sensitive gag/cough reflex. Sats 100%.\n\nUrine output increasing to 150cc/hr.\n\nTube feeds started via pedi tube @10cc/hr. NGT clamped. No bowel sounds. Abd. soft.\n\nInsulin gtt restarted. BS flucuating.\n\n friend . ) called and updated on pt. condition. He plans to visit tomorrow.\n\nPlan: Continue to correct metabolic acidosis; monitor renal and respiratory function; monitor neuro status-await timing on repeat angio.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-29 00:00:00.000", "description": "Report", "row_id": 1475363, "text": "S/P SAH T/SICU NPN 11P-7A\nS-INTUBATED\nO-NEURO-PT FOLLOWS SIMPLE COMMANDS WHEN LIGHTENED FROM PROPOFOL GTT.PROPOFOL 70-90MCG/KG/MIN.PERRLA 2MM.STRONG COUGH.ICP 5-13,VENTRICULOSTOMY DRAINING ~30CC BLOOD TINGED CSF Q 2HRS.\nCV-SBP 120'S-150'S,HR 60'S NSR NO VEA NOTED.3+ DP/PT .CVP 10-12.\nRESP-SEE RESP FLOWSHEET FOR VENT DETAILS.PT W/ PERSISTENT METAB ACIDOSIS COMPENSATED BY PCO2'S IN 20'S + NA BICARB GTT.PT LS CTA X 1 FOR SM AMT THICK WHITE SPUTUM.\nGI/GU-PT ABD OBESE +HYPOACTIVE BS,NO STOOL OVER NOC,TF IMPACT W/ FIBER CURRENTLY @ 20CC/HR VIA PEDI FT,LOW , NGT CLAMPED.U/O 60-400CC/HR VIA FOLEY CATH,URINE CLEAR YELLOW.\nSKIN-PT BACK + BUTTOCK GROSSLY INTACT.\nENDO-PT BS 52-96 INSULIN GTT OFF.\nA-ALT MS D/T SAH\nP-NEURO CHECKS,SEDATION/ORDERS,LABS/ORDERS,VS,I+O,VENT/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN,MONITOR BS/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-29 00:00:00.000", "description": "Report", "row_id": 1475364, "text": "T/Sicu NSg Progress Note\n0700>>1530\n\nEVENTS: ventriculostomy drain raised to 20cm above the tragus.\n MRI/MRA scheduled for today..not done yet\n lasix drip started; dopa infusion conts; fluid intake restricted as much as possible. Tube feeds changed to Nepro(for decreased volume intake).\n remains intubated on vent support with propfol sedation\n\nNeuro- perrl @ 2-4mm/brisk. Remains on propofol but amt dose weaned down to maintain sedation effect but to decrease hourly volume from drip as much as tolerated; currently at 50mcg/kg/min. Pt lightens easily & cont to follow commands consistently-MAE's (RUE>LUE). friends- & - visited; pt able to respond to visitors. Dilantin cont; level now therapeutic. No seizure activity. Free dilantin level pnd as requested by renal service.\nICP remains open to drain; values ranging .\n\nCVS- bp remaining within goal range: >110 <150; nimodipine cont q4/hr. No prn hydralizine required this shift. CVP mid teens.\nHR 50-60's in regular rythym & normal looking QRS complexes, but unable to obtain PR interval on EKG; p wave noted in most leads with minimal voltage. NO VEA.\n\nResp- CMV mode with spontaneous breaths ~ 10 over set rate. Adeqaute oxygenation ion 50% with 5 PEEP. PCO2 ranging in mid 20's still with ph wnl. Base deficit improved today to -5 and -6 following 3 amps bicar over 24/hr. Breath sounds are clear>coarse with small amt thick white sputum. Strong cough.\n\nRenal- Dopa infusion cont at 5mc/kg/min. Adequate jourly output BUT remains positive q/hour d/t volume of iv drips q/hr. Lasix drip startd this afternoon with goal of 50-80cc negative balance.\n..k+ repleted as needed.\n..creat stable at 1.8 with BUN of 32.\n\nID- no issues- afebrile with WBC WNL\n VANCO (FOR ICP COVERAGE) HELD FOR LEVEL OF >19.\n\nHeme- no issues\n\nGI- tube feedings changed to Nepro with goal of 35cc/hr. Tolerating agvancement of feeds. + bowel sounds; no stool.\n..protonix cont\n\nEndo- labile blood sugars cont. Drip restarted and increased for bump to 230's; currently on 6u/hr with last bs @ 180.\n\nSkin- no issues; no breakdown\n warm extremities with palpable peripheral pulses\n sc heparin ongoing\n\nsocial- pt's closest friend visited today. Pt lightened from sedation and able to respond somewhat to visitors. to return on Sat. Pt has NO living relatives and NO legal quardian or proxy. Our social worker is looking into legal quardianship status and if this is necessary in Mr situation.\n\nASsess/Plan- s/p SAH with renal impairment> met acidosis following contrast exposure with angiography.\n\n cont vent support until met acidosis resolves more\n cont mngmnt of renal status to maximize renal perfusion & recovery. Diurese as tolerated. Replet electrolytes as needed.\n cont bp mngmnt within goal(<150/systolic)\n advance tube feeds as tolerated; begin bowel regimen\n blood sugar mngmnt to ~ 120\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-30 00:00:00.000", "description": "Report", "row_id": 1475365, "text": "S/P SAH T/SICU NPN 7P-7A\nS-INTUBATED\nO-NEURO-PT SEDATED ON PROPOFOL GTT @ 50MCG/K/MIN,PT AWAKENS CALMLY OFF PROPOFOL MAE'S TO COMMAND,PERRLA 2-3 MM.STRONG COUGH + GAG.ICP'S ,VENTRICULOSTOMY REMAINS @ 20CM H20 ABOVE TRAGUS.DRAINING 8-30CC BLOOD TINGED CSF Q2HRS.\nCV-SEE FLOWSHEET FOR VS DETAILS,HR 60'S-70'S NSR NO VEA NOTED,3+DP/PT ,SBP 120'S-150'S.\nRESP-PT LS >COARSE DECREASED @ BASES,O2 SATS 98-100%.SEE RESP FLOWSHEET FOR VENT DETAILS,PT REMAINS ON AC 700 X 8,PT BREATHING OVER VENT,STRONG COUGH AS NOTED,PT Q 2-4HRS FOR SM AMTS THICK WHITE SPUTUM.METAB ACIDOSIS COMPENSATED PERSISTS.\nGI/GU-PT ABD OBESE,+HYPOACTIVE BS,TF NEPRO @ GOAL 35CC/HR VIA PEDI FT,LOW , NGT CLAMPED.U/O BRISK ON LASIX GTT.SEE FLOWSHEET FOR DETAILS.NO STOOL OVER NOC.\nSKIN-PT OBESE BACK + BUTTOCK GROSSLY INTACT.BATHED.\nENDO-PT REMAINS ON INSULIN GTT 2-8U/HR,PT BS 190'S->130'S.\nA-ALT MS R/T SAH\nP-NEURO CHECKS,SEDATION/ORDERS,VENTRIC/ORDERS,VS,I+O,VENT/ORDERS,LABS/ORDERS, INSUL GTT/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 1475358, "text": "PT IS OFF LABETALOL GTT SINCE 11PM. SBP HOLDS < 150. DRAMATICLY DROPS WITH NIMODIPINE TO LOW 100s.\n\nLUNGS ARE A BIT WHEEZY WITH FINE BASE CRACLES.WAS SUCTIONED FOR LARGE AMOUNT LOOSE SECRITIONS, HAS GOOD COUGH. PT DENIES SOB OR ANY OTHER PAIN.TLC L. SC WAS INSERTED (TOOK AN HOUR).CVP 12-20. WILL GET 10 LASIX IV.\n\nICP 9-12, OPEN TO DRAIN DRAINING 5-30/HOUR.FOLLOWS , ,MUMBLED SPEACH,DISORIENTED IN PLACE/TIME.\n\nWRITEN BY .,RN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 1475359, "text": "S/P SAH-T//SICU NPN 2A-7A\nS-\" ,,\"\nO-NEURO-PT A+ O X 1,NAME ONLY,FOLLOWS COMMANDS MAE'S,STRONG COUGH + GAG.VENTRICULOSTOMY DRAINING MOD AMTS BLOOD TINGED CSF,REMAINS 12CM ABOVE TRAGUS,ICP'S .\nCV-SEE FLOWSHEET FOR VS DETAILS,SBP 130'S-160'S,LABETALOL GTT 0-2MCG/MIN.HYDRALIZINE IVP ADDED THIS AM.3+ DP/PT .HR REMAINS 50'S-60 SB->NSR.\nRESP-O2 SAT 96-98% ON 2 L NC,PT INITIALLY AUDIBLY WHEEZING,PT GIVEN 10 MG IV LASIX W/ MOD DIURESIS,METAB ACIDOSIS PERSISTS.\nGI/GU-PT ABD OBESE +BS,NO STOOL OVER NOC,U/O SEDIMENTY YELLOW URINE VIA FOLEY CATH,NPO EXCECT MEDS.NGT CLAMPED.\nSKIN-PT BACK + BUTTOCK GROSSLY INTACT.\nENDO-PT BS 59-90'S,INSULIN GTT INTITIALLY ON 2U/HR,TURNED OFF @ 3AM.\nA-ALT MS D/T SAH/BASELINE BIPOLAR DZ\nP-CONT TO MONITOR NEURO STATUS/ORDERS,VS,I+O,MONITOR RESP STATUS PRN,MONITOR SKIN INTEGRITY QS AND PRN,BS MONITORING/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 1475360, "text": "SOCIAL WORK\nSW contact pts friend, , for support and to obtain information on pt. Mr reports that pt has no family to contact and that they have been friends for 18 years. Pt has hx of biploar d/o and met Mr at a day treatment center. Pt is described as a shy, intelligent man who self-educated\" by magazines daily at the Library. Pt works as a dietary aide at and was placed in his job by Elder Svc of . Pt currently lives in at Place in . Mr will try to visit tomorrow and has numnber for unit.\n\nElder Services of called unit asking for medical information. This agency should be referred to Mr for medical information. Mr to this plan. Pls pg SW prn.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-28 00:00:00.000", "description": "Report", "row_id": 1475361, "text": "T/SICU NSG NOTE\n0700>1530\n\nEVENTS- Increasing WOB/ Worsening RESP DISTRESS>>INTUBATED\n Renal consult for elevated creat & persisting met acidosis post angio w/contrast.\n labile blood sugars cont\n Repeat angiogram again deferred (d/t pt's renal status)\n\nNeuro- PERRL at 4mm/brisk. Pt consistently follows commands, is purposeful, & MAE's. His speech is at times difficult to understand d/t dentures out and thick dry oral mucosa. HE is confused & disoriented ads to place/time; he is unable to retain information provided about his recent events/condition.\n..dilantin cont; no level today. ? focal seizure of le's x1 vs involuntary skaking/tremors of other etiology..pt awake & response during tremors but could not control shaking. facial distortions noted and ue's tensing. pt becoming more restless/agitated with attempts to climb OOB.\n...ICP ranging ; level increased to 15cm above the tragus by NS team this am. Drainage cont to be blood tinged. Tegaderm dsg intact\n\nCVS- bp goal of <150 maintained with nimodipine & prn hydralizine x1; able to wean labaetalol off. NSR w/o vea.\n..cvp mid teens climbing to low 20's with increasing resp work.\n\nRenal- given lasix during night with effctive response; by am hourly u/o decreasing. Renal consult obtained: lasix 20mg and dopamine drip suggested and started. To follow response.\nCreat 1.9(1.8) K+ <4.0.. to replete\nIVF at kvo rate\n\nResp- Use of abdominal & accessory muscles to breathe observed; pattern - heavy & labored. Mod deep breaths with prolonged exp phases with audilble wheezing throughout the day. RR in 20's. Sat drop x1 with need for ^^ fio2. Abg's revealing ongoing met acidosis with resp compensation. WOB becoming more labored throughout the day>>> electiveley intubated at 1330. See careview. Started propofol for sedation/vent tolerance.\n.Bicarb replacement recommended by renal service; pt receiving bicarb via drip over 24/hr.\n..small amt thick white sputum obtained with suctioning. Strong cough.\n\nGi- FT placed and is confirmed in stomach; tube feeds to start.\n + bowel sounds w/o stool.\n pepcid ongoing\n\nEndo- blood sugar 178..drip restarted>> 89 drip stopped\n\nID- afebrile, wbc wnl, vanco qd with dosing per level.\n\nHeme- hct stable\n INR 1.4 with 1 u ffp transfused; repeat INR still 1.4\n\nSkin- intact w/o noted breakdown\n palpable peripheral pulses\n\nAssess- impaired renal function post- angio/contrast with worsening met acidosis and resp fatique>>failure. Required intubation today.\n BP goal achieved.\n labile blood sugars ongoing\n nutrition support to start.\n neuro staus stable; repeat angio deferred d/t renal/resp issues.\n\nPlan- per current plan/orders.\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-30 00:00:00.000", "description": "Report", "row_id": 1475366, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN CMV MODE, NO CHANGES MADE THIS SHIFT. BS ESSENTIALLY CLEAR BILAT, FOR SM AMT LOOSE CLEAR-WHITE SEC. PT WELL SEDATED, OVERBREATHING BUT WELL IN SYNCH W/VENT. AM ABG REFLECTS COMPENSATED RESP ALKALOSIS W/NORMOXIA. RSBI 47. WEANING PENDING FURTHER DISCUSSION W/TEAM IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-30 00:00:00.000", "description": "Report", "row_id": 1475367, "text": "SOCIAL WORK\nSW left message with of legal re appropriatness of guardianship for this pt. Awaiting response.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-30 00:00:00.000", "description": "Report", "row_id": 1475368, "text": "SICU NPN\nPt remains intubated and sedated in SICU awaiting repeat angio vs MRI study while being diuresed.\nROS:\nNeuro: Pt sedated on propofol-when light, pt able to follow commands, MAE and nods appropriately, however becomes very tachypnic, gagging and coughing on ETT, as well as hypertensive. Pupils 3mm and briskly reactive. Drain raised to 25cm above the tragus by team this AM, ICPs today with mod ammt blood tinged drainage. Unable to obtain MRI study today as pt has no family to verify PMH. X-rays obtained of head to eval for metal, SICU team to review. NP Chip , likely wait for kindey function to improve and re-angio pt. MRI cancelled for time being.\n\nResp: Pt tachypnic most of day despite vent changes. Pt currently on 5PS/8PEEP, RR 24-30 with MV 16-18, 40% FIO2. ABGs continue to have low PCO2 despite vent changes. Pt unable to tolerate being off propofol for hypersensitive cough and gag, RR up to mid 30's and coughing fits whenever pt lightened up. Pt suctioned Q2-3 hours for mod ammts thick white sputum. ETT rotated and retaped.\n\nCV: HR 60-70's, SR without ectopy noted. SBP 120-140's on propofol, up to 180's when awake. Attempts made to wean from propofol and control BP with nipride, however pt too agitated on vent and required propofol to be restarted, then eliminating need for nipride. Dopamine gtt d/c'd this AM per team. Hydral given PRN for hypertensive episodes. CVP 6-10 today. A-line, TLC and periph IV sites all intact, P-boots on all day. Extremities warm and well perfused with easily palpable pulses.\n\nGI: Abd obese, hypoactive BS throughout. TF at goal, nepro at 35cc/hr, via feeding tube. NGT d/c'd this AM per team. Pt with small ammt mucoid/lt brown stool this PM, FIB placed and intact. Pt on protonix for GI prophylaxis.\n\nGU/renal: Pt continues on lasix gtt for goal ~2L negative today. Urine >150cc/hr, lt clear urine. Lytes repleted PRN. All gtts maximally concentrated.\n\nEndo: Pt continues on insulin gtt, sugars continue to be sl labile requiring titration. See flowsheet for levels.\n\nID: Low grade temps, Tmax 100.7 PO. Pt given vanco dose this PM per team for theraputic vanco level.\n\nSkin: Grossly intact, no reddened areas on back or coccyx.\n\nSocial: No family/friend contact today. Social work attmepting to locate any family, also in process of establishing legal guardianship to consent for any further treatment.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-31 00:00:00.000", "description": "Report", "row_id": 1475369, "text": "Respiratory Care:\nPatient remains on ventilatory care with no changes made throughout the nigt. MDI albuterol and atrovent given with each vent check(see CareVue). Morning ABG results reveal a compensated metabolic acidemia with good oxygenation.\n\nRSBI = 42.3 on 0-PEEP , 0-PSV, and ATC on 100%.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-31 00:00:00.000", "description": "Report", "row_id": 1475370, "text": "S/P SAH-T/SICU NPN 7P-7A\nS-INTUBATED\nO-NEURO-PT SEDATED ON PROPOFOL GTT 50MCG/KG/MIN.PT Q 2HRS PT OPENS EYES TO VOICE + SPONT.MAE'S,FOLLOWS SIMPLE COMMANDS.STRONG COUGH.\nCV-SEE FLOWSHEET FOR VS DETAILS.3+ DP/PT .\nRESP-SEE RESP FLOWSHEET FOR VS DETAILS,PT X 2 OVER NOC FOR SM AMT THICK WHITE SPUTUM,PT LS >COARSE SATS 97-98%.RR 20'S VT'S ~700'S.\nGI/GU-PT ABD OBESE,+BS SM AMT TAN LOOSE STOOL VIA RECTAL BAG OVER NOC,U/O 200-300 Q1-2HRS ON LASIX GTT.TF @ GOAL NEPRO 35CC/HR VIA PEDI FT LOW .\nSKIN-PT BACK + BUTTOCK GROSSLY INTACT.\nENDO-PT REMAINS ON INSUL GTT BS 86-160'S.\nID-T MAX 100.6\nA-ALT MS R/T SAH\nP-NEURO CHECKS,SEDATION/ORDERS,VS,VENT/ORDERS,LABS/ORDERS,I+O,MONITOR SKIN INTEGRITY QS AND PRN,INSUL GTT/ORDERS,IV ABX/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-31 00:00:00.000", "description": "Report", "row_id": 1475371, "text": "SOCIAL WORK\nSW contact the following providers and friends of pt to verify that pt has no known next of :\n\n , friend, \n Owners of Place \n Bower, colleague and friend at Northeast Independent Living .\nATS Mental Health Clinic in Medical Records and , pts therapsti .\n\nThe above information has been sent to of legal. Sw will continue to follow. Pls pg prn.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-31 00:00:00.000", "description": "Report", "row_id": 1475372, "text": "NPN: REVIEW OF SYSTEMS\nNEURO: Pt is sedated on propofol which is intermittently turned off to assess neuro status. Head Ct done today d/t decreased movement of left side. During initial assessment this morning Pt opened eyes to voice, lifted his thumbs, opened his mouth and moved his legs to command. He also nodded when speaking to him. Over the course of the day Pt's neuro status declined. He became increasingly unresponsive. He continued to open his eyes, but then it started taking him longer to follow commands and ultimately he no longer followed commands. His movement also decreased and now he withdraws to nailbed pressure. Sicu team and neuro surgery were aware of events, MRI was scheduled and drain was decreased to 10cm H20 above the tragus from 25. ICP have ranged from throughout the day. Drainage is blood tinged. Dr. assessed Pt this evening. He continues on dilantin-> no seizure activity witnessed. Dilantin and Na level is pending. PERRL. Strong cough and gag reflex.\n\nResp: Mechanically vented. Breathing over the vent. Sxning thick white secretions. Sao2=100%.\n\nCV: SR. No ectopy. SBP < 160 when sedated. Can increase to high of 200s when light-> hydralazine administered.\n\nGI: Nepro at goal rate of 35cc/hr. Will change to nepro w/ promod when it is brought up by dietary. Abdomen is soft/obese. (+) Bowel sounds. Rectal bag intact. mucous present.\n\nEndo: Insulin drip. Titrating to maintain blood sugar 80-120.\n\nID: Vancomycin held d/t level > 15. Level to be checked in am. (+) MRSA.\n\nGU: Foley to gravity. Urine dilute yellow. Increasing lasix drip for Uo 80-100 per hour.\n\nSkin: Intact.\n\nSocial: Friend, called regarding Pt's condition. This RN gave dr. his number so he can inform him odf Pt's current condition. Mr has also been in touch w/ social services.\n\nA: Decreased responsiveness.\n\nP: MRI. Continue to monitor per plan.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1475373, "text": "TO MRI/MRA @2100, RESULTS ARE PENDING,TOLERATED WELL;ON PROPOFOL GTT SEDATED WELL WITH >40 MCG. OFF FOR NEURO CHECKS- FOLLOWS SIMPLE COMMANDS, OPENS EYES TO NAME.ICP WITH DISTINCT WAVE(LIKE A LINE) IN RANGE,MOST OF THE TIME CLOSED TO DRAINAGE.\nSBP >160-GOT HYDROLIZINE PRN IV W/ MODERATE EFFECT.\nICP TRANDUCER WAS CHANGED, A- LINE IS POSITIONAL\n" }, { "category": "Nursing/other", "chartdate": "2163-01-03 00:00:00.000", "description": "Report", "row_id": 1475381, "text": "Altered Neuro Status\n\nPt is flaccid, no response to pain or commands. Opens eyes to voice when Propofol off, grimaces, RR up-pt coughs. Maintained on Propofol @40mcg. ICP 3-9; open at 10 @tragus; drainage is bloody.\n\nSR. BP up-Labetolol @1mg/min. Pneumoboots on.\n\nPSV 8 /PEEP 8/40%; Suctioned q2hr for white thick sputum. Breath sounds clear, sats 98% RR 20 spont. TV 690.\n\nNGT with TF@goal. Stool via rectal bag is clear and liquid. Abd. soft.\nFamotidine. Water via NGT to decrease sodium.\n\nLasix 20mg x2 with moderate diuresis. Lytes repleted.\n\nTemp remains 102.4 despite Tylenol q4hr. WBC down.\n\nInsulin drip stable at 4u/hr.\n\nNo calls.\n\nPlan: Continue to monitor, ?wean from vent; diureses.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-03 00:00:00.000", "description": "Report", "row_id": 1475382, "text": "T/SICU NPN 0700-15:30:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT OFF PROPOFOL PRIOR TO START OF THIS SHIFT: NEURO EXAM GRADUALLY IMPROVED THROUGHOUT DAY -> PT OPENS EYES TO VERBAL STIMULI - MORE ABLE TO TRACK TO SPEAKER CONSISTENTLY AS DAY PROGRESSED, PERRLA 3MM/BSK. COUGH/GAG/CORNEALS INTACT. INCONSISTENTLY ABLE TO GRASP R HAND, MOVE R TOES, AND OPEN MOUTH TO COMMAND - @1400 PT NOTED TO MOVE <LIFT/FALL> R FORARM SPOTANEOUSLY WHEN COUGHING. TO PAINFUL STIMULI, PT WILL WITHDRAW LEGS ON BED R>L, NO RESPONSE TO LUE - PT WILL GRIMACE TO ANY/ALL STIMULI PAINFUL STIMULI. VENT DRAIN OPEN @10ABOVE TRAGUS - 10-25CC/HR BLOODY DRAINAGE - ICP WAVE FORM SHARP: , CPP>70, DRAIN PATENT. DILANTIN GIVEN. REPEAT HEAD CT W/O CONTRAST DONE AT 11AM - RESULTS PENDING.\n\nCV: HR SR/SB 50-60'S, NO ECTOPY NOTED, SBP MANAGED <150 ON LABATOLOL GTT. RECEIVES LOPRESSOR 10MG Q4HR (FOR HR >50 AND SBP>100) TOLERATING. NO HYDRALAZINE GIVEN THIS SHIFT - ALSO ORDERED FOR RECURRING NIMODIPINE. CVP 9-12. PULSES WEAKLY PALPABLE - BRISK CAP REFILL THROUGHOUT. HEPARIN/PB'S FOR DVT PROPHYLAXIS.\n\nRESP: LUNG SOUNDS COARSE IN UPPER FIELDS, DIMINISHED AT BASES B/L. STRONG/PRODUCTIVE COUGH EFFORT. HOURLY FOR SM<->MOD AMTS THICK WHITE SECRETIONS. RR 20'S, SATS 98-100%. CONTINUES ON CPAP+PS 40%//VT 600'S. BREATHING EQUAL/UNLABORED.\n\nGI: ABD OBESE, BS/RF(+), CLEAR LIQUID STOOL DRAINING IN TO FECAL COLLECTION BAG - SCANT VOLUME OUT THIS SHIFT. TF NEPRO W/PROMODE @30CC GOAL RATE. FREE H2O FLUSHES RESUMES IN RESPONSE TO ELEVATED NA+. PROTONIX FOR PROPHYLAXIS.\n\nGU: FOLEY CATHETER PATENT, U/O CLEAR/YELLOW - 20MG LASIX X1 GIVEN W/ FAIR RESPONSE - GOAL 1L NEGATIVE BALANCE TODAY.\n\nENDO: PT ON INSULIN GTT TITRATED TO THERAPEUTIC RANGE - FURTHER DEATIL IN CAREVIEW.\n\nID: PT FEBRILE 102.4 THIS AM - TYLENOL X 2 W/FAIR EFFECT. FAN ON PT AS SECONDARY COOLING DEVICE - TEMPS 101 THIS AFTERNOON. WBC FLAT. LEVOFLOX FOR GM(-) IN SPUTUM: PT (+)MRSA/NASAL - SURVEILANCE MRSA SPEC'S SENT TODAY PER ICU ROUTINE.\n\nSKIN - INATCT: VENT DRAIN SITE COVERED W/OCCLUSIVE DSG - D/I. VANCO FOR DRAIN PROPHYLAXIS.\n\nSOCIAL: NO IMMEDIATE FAMILY - RN, RESIDENT CARE DIRECTOR FROM PT'S FACILITY FOR PT UPDATE - SHE PLANS TO VISIT TOMORROW (TUESDAY) AND WILL ARRANGE TO SPEAK W/ SW. PER REPORT - HOSPITAL WOPRKING ON GUARDIANSHIP ISSUES.\n\nA/P: CONTINUE PER CURRENT PLAN OF CARE: MANAGE SBP AND GLUCOSE LEVELS ON GTTS AS ORDERED: SBP GOAL RANGE 120-150. MONITOR TEMPS. NEURO EXAMS AS ORDERED. EEG PLAN FOR LATER TODAY. F/U ON MORNING CTS. PULMONARY HYGEINE, PAIN MGT, DIURESIS AS TOLERATED TO NET 1L NEG FLUID BALANCE. FULL SUPPORT/COMFORT.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-03 00:00:00.000", "description": "Report", "row_id": 1475383, "text": "Pt. transported to CT for Head CT.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-03 00:00:00.000", "description": "Report", "row_id": 1475384, "text": "Respiratory Care:\n\nPatient remain intubated on Psv. Current vent settings Psv 8, Cpap 8, Fio2 40%. Spont vols 700-800's with RR 16-18. Bs clear bilaterally. Sx'd for sm amounts of thick white sputum. Albuterol/Atrovent MDI's given Q4hr. Abg reveal compensated metabolic acidosis. Pt. appears comfortable. Still with increased temps. No further changes made. Continue with mechanical support.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-03 00:00:00.000", "description": "Report", "row_id": 1475385, "text": "NPN T/SICU 3P-11P\nREVIEW OF SYSTEMS:\n\nNEURO- REMAINS OFF ALL SEDATION.OPENS EYES TO VOICE,ATTEMPTS TO FOLLOW COMMANDS ON RT SIDE INTERMITTENLY, NO MOVEMENT ON LT SIDE.ICP 3-5,OPEN TO DRAIN, DRAINING BLOODY DRAINAGE.\n\nCARDIAC- REMAINS ON LABATALOL GTT, TITRATED TO KEEP SBP 120-150'S.CONTINUES ON LOPRESSOR IV.IN SB W/O ECTOPY.LT RADIAL ALINE WAVEFORM SHARP,RT IJ MULTILUMEN CATHETER INTACT.PULSES PALPABLE.\n\nRESP- CONTINUES ON CPAP 8W/PS8.ABG 7.35,PCO2 29,PO2 157,CO2 17, BE -7,T/SICU TEAM AWARE.SX Q 2-3 HRS FOR WHITE TO BLOOD TINGED SPUTUM.\n\nGI- TUBE FEEDS AT GOAL.RECTAL BAG REMINS INTACT,PUTTING OUT CLEAR,FOUL SMELLING LIQUID.BS PRESENT.\n\nGU- ADDITIONAL 40 MG LASIX GIVEN WITH MODERATE URINE OUT, REMAINS IN POSITIVE FLUID BALANCE.\n\nNA 147,RECIEVING FREE WATER BOLUSES AS ORDERED.\n\nENDO- CONTINUES ON INSULIN GTT AT 3-5 UNITS PER HR\n\nID- T MAX 102.1 ORALLY. PAN CULTURED.TYLENOL/FAN WITH GOOD EFFECT, T DOWN TO 100.7\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475391, "text": "NURSING PROGRESS NOTE CONT\n PT SOON WOKE TO VOICE AND AGAIN FOLLOWED, PUPILS REMAIN EQUAL AND REACTIVE\n PT CONT TO REQUIRE Q3-4 FOR B/P CONTROL, PT CONT ON LOPRESSOR 10MG Q4 AND NIMODIPINE 60MG Q4. PT IN NSR AT RATE OF 70-80. WE ARE FOLLWING NON INVASIVE B/P AND NOT THE ARTERIAL LINE WHICH HAS A DIFFERENCE IN SYSTOLIC OF 30 POINTS. FINSIHED RECEIVING UNIT OF PC,LYTES REPLETED\n PT REMAIN EXTUBATED AS NOTED HE EXHIBITS PERIODS OF UPPER AIRWAY OBSTRUCTION, SOMETIMES RELATED TO REPOSITIONING, SATS 97-100. RR 20-35. PT HAS STRONG SPONTANEUOS COUGH AND ABLE TO CLEAR AIRWAY WITHOUT DIFFICULTY.\nID- CONT TO HAVE FEVERS UP TP 101.8 TYLENOL GIVEN.\n PT REMAINS ON INSULIN GTT NOW AT 4U HR WITH LAST FS OF 120, HE IS NOW RECEIVING NPH 12U .\n PT CONT ON NEPRO TF AT 35CC HR, ABD SOFT AND DISTENDED NO STOOL THIS SHIFT, RECTAL BAG INTACT\nGU- FAIR RESPONSE FORM LASIX GIVEN AT 1400, NOW DOWN TO 60Q1, PT STILL RECEIVING 250CC HR OF FREE H2O- I/O FAIRLY EVEN FOR TODAY. LAT NA 144\nSKIN- INTACT\nSOCIAL - NO CONTACT THIS SHIFT FROM FRIENDS.\nA/P- B/P CONT TO BE ELEVATED REQUIRING PRN , PT HAVING NON CONSISTANT NEURO EXAM. CONT TO SUPPORT, FOLLOW NIBP. POSITION PT FOR OPTIMAL BREATHING\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-05 00:00:00.000", "description": "Report", "row_id": 1475392, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: AROUSABLE. ANSWERS APPROP...BUT OCCAS DOESN'T\n ANSWER,...ESPECIALLY AS MORE QUESTIONS ASKED.\n ABLE TO STATE NAME. AND PICKS HOSPITAL OUT OF\n LIST. BUT FORGETS WHY HE IS HERE.\n DILANTIN IV CONTINUES. NIMODIPINE.\n ICP 6-9 WITH 5-10 CC OUT Q 1 HOUR.\n\nCV: HR STABLE. BP REQUIRED EXTRA HYDRALAZINE X1.\n IN ADDITION TO LOPRESSOR.\n\nRESP: GOOD SATS. STRONG COUGH.\n\nRENAL: LABS IMPROVING. GOOD UO...AND LASIX 40 IV GIVEN.\n\nGI: NEPRO AT 35 GOAL. NO BM VIA RECTAL BAG.\n\nHEME: STABLE. BOOTS ON. SC HEPARIN.\n\nENDO: NPH ...AND INSULIN DRIP AT 4 UNITS/HR WITH\n BS 100-130.\n\nID: TYLENOL ON EVES...TEMP 100.4 WBC STABLE.\n ANTIBXS GIVEN. VANCO ON HOLD WITH HIGH LEVEL.\n\nSKIN: NO ISSUES.\n\nSOCIAL: NO CALLS.\n\nA: STABLE S/P EXTUBATION. WAXING/ MENTAL STATUS.\n IMPROVING RENAL ISSUES.\nP: FOLLOW RESP, MENTAL, RENAL STATUS.\n ?OOB WITH DRAIN/ PT CONSULT/ CHANGE MEDS TO PO.\n ?CLAMP DRAIN.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-25 00:00:00.000", "description": "Report", "row_id": 1475350, "text": "Nursing Admission Note\n\nAdmitting Diagnosis: Bilateral Frontal Lobe Subarachnoid Hemorrhage.\n\n This 64 year old gentleman was transferred from Hospital in Methune for evaluation & management of a subarchnoid hemorrhage. The pt had experienced a headache & thought that it was d/t his diabetes. He arrive in the ED where he had vomitted. A head CT showed extensive frontal lobe subarachnoid bleeding extending to the ponds area. He was intubated at the outlying hospital with #8 ETT (22cm at LL) then tranferred here. In the , ICP was inserted then pt was transferred Neuro Intervention Radiology. They attempted to do an angio but were not able to find the bleeding due to the area being obiterated & a bleed was not visible. No coils were inserted.\n Pt sent to MICU \"A\" & was admitted to Rm 795. Pt was on a nipride drip & propofol drip which was d/c'd Neurologically pt was unresponsive d/t sedation. He was hypertensive & nipride was titrated to obtain SBP<130. Refer to CareVue for objective data.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-25 00:00:00.000", "description": "Report", "row_id": 1475351, "text": "nursing note 11-7a\n\npt remains on vent 60%/700/9 and 5 of peep, pt has spont resp , tv 350-500, pt suctions for small amount of secreations, lung clear ant, sats 98%\nCV Pt remains on nipride and labatolol, multi attempts were made to ween nipride completely however pt became to hypertensice ^ 210 /sbp\npt remains not on Labatolol at 1.5 mg per min , and nipride at .5 mcgs/kg /min BP 120-135 , hr 79-85. pulses palp\nNeuro pt continues to be more responsive as the nigth went on is not wiggling toes and fingers, pt will hand grasp however thsy are weak bilat. pupilsplus 2 bilt, and more resctive, pt has pos cough and gag can stik out tongue. tracks and opens eyes to voice. icp 12-14.\nAbout 3 pm noticed pt was tremelous pt afebrile at the time call places to TSicu adn Nsicu resident, Dr aware told him that pt is responsive but very tremelous ,which seem to have increased since 3 am,triggeing vtack alarm, pt med with .5 mg iv ativan in hopes of drcreasing tremmor.\npt's tremor slightly better, also tenp checked and pt was afebrile, resident to coame see pt this am, ? if there is any remote hx of etoh and home this is not withdrawal.\nGu foley patent draining dark urine.\nGI ngt in place, absent bowel sounds.\nId pt remains afebrile.\npt started on an\n insulin drip bs 241-340 insuline now at 5.5u /hr and bs are now starting to decrease.\nA pt more responsive, BP under good control, bs remains ^ and tremmor issue still needs to be addressed.\nP maintian sbp< 130, continues with insulin drip follow mental status\n" }, { "category": "Nursing/other", "chartdate": "2163-01-07 00:00:00.000", "description": "Report", "row_id": 1475398, "text": "RENAL: NA 147...FREE WATER CONTINUES. K REPLETED\n WITH DIURESIS.(LASIX 40 MG IV UP TO TID NOW)\n WEIGHT DOWN SLIGHTLY. CREAT STILL UP.\n\nGI: FS NEPRO WITH PROMOD AT GOAL 30 VIA POST\n PYLORIC TUBE. LOOSE BROWN STOOL...2ND\n CDIFF SENT.\n\nHEME: LABS STABLE. BOOTS ON. SC HEPARIN.\n EPOGEN QWEEK.\n\nENDO: NPH . SLIDING SCALE RESUMED. WILL WEAN\n INSULIN DRIP.\n\nID: TEMP SPIKE ON EVES TO 103.3\n CSF/BLOOD X2/ URINE/ CDIFF SENT.\n VANCO LEVEL DOWN TO 13...DOSE WILL BE GIVEN TODAY.\n IV LEVOFLOXACIN.\n\nSKIN: NO ISSUES EXCEPT ALL OVER EDEMA.\n\nSOCIAL: HAS FRIEND FROM HIS RESIDENCE... \n WILL HELP WITH QUESTIONS...BUT DOESN'T WANT\n (OR IS UNABLE?) TO BE HCP.\n\nOTHER: IV DILANTIN CONTINUES.\n\n\nA: STABLE.\nP: FOLLOW ICP. CONTROL SBP<160. FOLLOW LABS.\n DIURESE. FOLLOW UP CDIFF/ AND CULTURES.\n INCREASE NPH DOSE AND WEAN INSULIN DRIP.\n CONTINUE WITH ATTEMPT TO FIND A GUARDIAN.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-07 00:00:00.000", "description": "Report", "row_id": 1475399, "text": "SOCIAL WORK\nSW spoke with of legal re guardianship process. to email necessary paperwork to case manager . SW to contact to update on process. Pls pg SW prn.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-07 00:00:00.000", "description": "Report", "row_id": 1475400, "text": "S/P SAH T/SICU NPN 7A-7P\nS-\" \"\nO-NEURO-NO SIGNIFICANT NEURO CHANGE,SEE FLOWSHEET FOR ASSESSMENT DATA.CT C-SPINE THIS PM.VENTRIC^^ 20CM H20 ABOVE TRAGUS,DRAINING CLEAR/BLOOD TINGED CSF.\nCV-SEE FLOWSHEET FOR VS DATA,A-LINE W/ OCCAS DAMPENING->FLING 130-160'S,HR 80'S-90'S NSR NO VEA.\nRESP-LS CTA->COARSE DECREASED BASES,O2 SATS 96-98% ON 2 L NC.NARD,RR 20-26.STRONG COUGH.\nGI/GU-PT ABD OBESE LOOSE BROWN STOOL VIA RECTAL BAG,U/O ADEQ VIA FOLEY CATH,CONT'S ON LASIX TID IV.TF NEPRO W/PROMOD @30/HR VIA PEDI FT.\nSKIN-NO NEW ISSUES.\nID-T MAX 102 X 1,CONT'S ON PO LEVOFLOX + IV VANCO.\nENDO-NPH ^^20U ,FSBS 92-170\nA-ALT MS R/T SAH\nP-CONT NEURO CHECKS,VENTRIC/ORDERS,VS,I+O,LABS/ORDERS,MONITOR CX DATA QD + PRN,O2 PRN,MONITOR SKIN INTEGRITY QS AND PRN.ABX/ORDERS,FSBS/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-08 00:00:00.000", "description": "Report", "row_id": 1475401, "text": "NPN 7P-7A\n\nNEURO:ANSWERS SIMPLE QUESTIONS,FOLLOWS SOME COMMANDS.GARBLED SPEECH AT X'S.O X 1.PERRL. MAE'S,R>L.VENT DRAIN 20 AT TRAGUS,CSF CLEARING, 5ML/HR.CSF LEAK NOTED AT DRAIN INSERTION SITE.N/S INFORMED.ICP 8-16.\n\nCV:SBP 130-140S PER NIBP.A-LINE DAMPENED.SR,70-90S,NO ECTOPY.\n\nRESP:SAO2>95% ON 2LO2 PER NC.LS CLEAR,DIM IN BASES.STRONG,NON-PROD COUGH.\n\nGI:TF AT GOAL.LOOSE BROWN STOOL TO RECTAL BAG.\n\nGU:U/O ADEQ.DIURESING WELL FROM SCHED LASIX.\n\nSKIN:INTACT.\n\nENDO:BS>200.COVERED PER SS.\n\nHEME:NO ISSUES.\n\nID:TMAX 101.6 ORALLY.GIVEN TYLENOL.PAN CX AM.\n\nSOCIAL:,FRIEND,CALLED FOR UPDATES.TO VISIT ON MONDAY.\n\nPLAN:CONTINUE NEURO CHECKS,ICP MONITORING.N/S TO ASSESS VENT DRAIN SITE FOR CSF LEAK.MAINTAIN SBP<160.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-10 00:00:00.000", "description": "Report", "row_id": 1475405, "text": "S/P SAH T/SICU NPN 7P-7A\nS-\"I'M ALL RIGHT\"\nO-NEURO-NO SIGNIFICANT NEURO CHANGES,SEE FLOWSHEET FOR ASSESSMENT DATA.\nCV-SEE FLOWSHEET FOR VS DATA,SBP 120'S-160'S.HR 80'S-90'S NSR NO VEA LYTES REPLETED PRN.\nRESP-PT LS CTA DECREASED BASES,O2 SATS 95-98% ON RA RR 20'S ON RA.NARD.\nGI/GU-PT ABD OBESE +BS ~600 CC BROWN LIQ OUTPUT,U/O ADEQ CLEAR YELLOW VIA FOLEY.LASIX HELD @ 6A D/T ^^Na+ LEVEL.\nSKIN-NO NEW ISSUES.\nID-T MAX 101.7 X 2.VANCO LEVEL 15.NO DOSE TODAY/TM.\nENDO-BS >200 TM TO INCREASE SS TODAY REMAINS ON 30U NPH .\nA-ALT MS R/T SAH\nP-NEURO CHECKS,VS,I+O,LABS/ORDERS,MONITOR SKIN INTEGRITY QS AN DPRN,MONITOR CX DATA QD AND PRN,FSBS.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-10 00:00:00.000", "description": "Report", "row_id": 1475406, "text": "SOCIAL WORK\nSW recd guardianship paperwork from legal and passed along to MD to complete medical certificate. and aware that ICU resident will complete paperwork. SW will fax to legal when complete. Pls pg SW prn.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-10 00:00:00.000", "description": "Report", "row_id": 1475407, "text": "nursing note 7a-7p\nreview of systems\n\nneuro: aox1 and very pleasant and cooperative. moving all extremeities and following commands consistantly. vent drain remains 10cm above tragus and draining clear fluid with minimal leaking around site. conts on nimodipine. dilantin d/c. mri canceled. pt dangled at side of bed but unable to hold himself up at all. was transfered to chair by full lift and tol well for almost 2 hrs. ? shunt in future.\n\ncv: hr 90's sr with no ectopy. aline with fling so going by nibp. sbp 140-160. conts on lopressor po with effect. +pp with skin warm and dry.\n\nresp: l/s clear and diminished at bases. no sob or resp distress noted. sats 94-95% on ra so 2l applied. dry cough noted.\n\ngi: abd obese with +bs. peditube intact infusing nepro with promod at 35cc/hr. rectal bag changed d/t leaking and no stool since. +flatus.\n\ngu: u/o adequate. conts on lasix tid. k repleted prn and na 154 so 500cc free h2o x3 ordered.\n\nheme: no issues. sc heparin conts.\n\nendo: bs 96-104. no ss insulin coverage needed. conts on nph 30u .\n\nid: tmax 101.8. tylenol x2. cultures deferred by sicu ho. conts on vancomycin and levofloxin.\n\nskin: pink coccyx but otherwise intact.\n\nsocial: friends into visit. updated on status and asking appropriate questions.\n\nplan: ? shunt in future.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1475374, "text": "Respiratory Care:\nPatient to MRI earlier in shift. Remains on ventilatory support (A/C) with no changes made through the night. ABG results demonstrate compensated metabolic acidemia with excellent oxygenation.\n\nRSBI = 50.7 on 0-PSV, 0-PEEP, and ATC on 100%.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1475375, "text": "SBP IS STILL LABILE,ESPECIALLY WHEN OFF SEDATION AND WHEN TURNED OR SUCTIONED. AM BATH WAS GIVEN-TOLERATED WELL.LOPRESSOR AND HYDRALAZINE WERE GIVEN PRN.\nBLOOD GLUCOSE IN LOW 100s, RI GTT @6u/H, STILL HAS U/O>100/H LASIX @ 6MG/H.GENERALIZED EDEMA, MOSTLY HANDS.\nON AC ,SO2 >97%,+ PROD. COUGH\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-01 00:00:00.000", "description": "Report", "row_id": 1475376, "text": "T-SICU Nsg Note\n Pt on propofol most of day. Propofol off 15-45mins for neuro exam, at best, pt opened eyes to voice, squezed with R hand and lifted R arm of bed briefly, wiggled R toes. PERRL, strong cough & gag. Vent drain now open at all times at 10cm above tragus, lots of bloody drainage, ICPs low at 1-9.\n Wnen propofol off, BP up. Labetalol drip up from pharmacy, but not started, as BP down again with propofol. COntinues on 10mg metoprolol IV q 4, Nimodipine sub-lingual q 4.\n Strong cough, prod of thin yellow sputum. Pt has spont cough, then needs suctioning to clear. Suctioned about q 1 hr. Also lots of oral drainage. Lungs usually sound coarse, but sound clear right after suctioning. Remains on CMV, 40% FIO2 & 8cm PEEP.\n Lasix drip DC'd this am. Repleting K+ & Mag. Urine has greenish tint from propofol.\n TF continue, liquid stool, via rectal bag, only about 100cc out during day.\n Insulin drip titrated from u/hr, blood glucose labile despite continuous feedings.\n friend in to visit today. I answered questions. He talked to pt.\nA:Continues less responsive than has been in past.\nP: Informational & emotional support to pt & . Replete lytes. Monitor blood glucose & titrate insulin drip. Labetalol drip prn.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-02 00:00:00.000", "description": "Report", "row_id": 1475377, "text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with no changes made throughout the night. ABG results demonstrates a compensated metabolic acidemia with good oxygenation.\n\nRSBI = 50.5 on 0-PEEP, 0-PSV, and ATC on 100%.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-02 00:00:00.000", "description": "Report", "row_id": 1475378, "text": "Altered Neuro Status\n\nPropofol @70mcg/kg-ICP low. Vent drain 10cm @tragus and open. Drainage is dark blood colored. Pt does not move to painful stimuli, opens eyes, no commands. PERLA 3mm.\n\nSR. BP up to 178/84-Labetolol on for short time. HCT stable. KCL repleted.\n\nNo vent changes. Suctioned for thick yellow sputum. Breath sounds clear. Sats 98%. RR 8 above vent. Lg. amt. oral secretions.\n\nNepro with Promode @ 30cc/hr. Sm. amt. clear liquid. Abd. is soft.\n\nTemp up to 102.3-pt cultured and Tylenol given.\n\nNo contact with friend.\n\nPlan: Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-02 00:00:00.000", "description": "Report", "row_id": 1475379, "text": "T/Sicu Nsg Note\n0700>>\n\nNeuro- NO signifcant changes: perrl/@ 4mm/brisk. +cough/gag even with propofol infusing. With propofol suspended for exam: pt does not move spontaneously, nor does he move extremities to painful stimulation. Only movement noted is le internal rotation with vigorous ongoing coughing and with noxious stimuli to chest. HOWEVER, pt did open eyes to voice and appeared to attempt to squeeze with right hand to command. ICP remains at 10cm above tragus & open to drain with blood tinged csf draining. ICP values remain <10. No seizure activity noted; dilantin ongoing; levels therapeutic.\n..propofol ongoing for sedation/vent tolerance/bp mngmnt.\n\nCVS- hr stable w/o ectopy\n BP goal remains >110<150 with q4/hr nimodipine and iv lopressor.\n **labaetalol was restarted ~ 1800 for persistent bp elevation at or above 'high' goal range. Arterial tracing now with fling artifact & falsely high systolic readings. NBP assessment being monitored. With labaetalol now on, propofol is being weaned as tolerated with hopes of obtaining more neuro responsiveness.\ncvp remains mid teen range\n\nResp- RSBI 50 today; pt with consistent spont breaths over vent. Vent mode changed to PSV 8 with peep 8. Adequate abg's/sats. Mild met acidosis persisting(-5,-6). Spont Vt's 650-800cc with rr teens to low 20's. No further vent changes tonight d/t poor neuro exam. Re-evaluate in am if able to cont weaning propofol with bp within goal range and pt not agitated/overstimulated.\n..small amt thick white sputum. Vigorous cough reflex.\n..breath sounds are clear>coarse & diminished at bases.\n\nRenal- adequate hourly u/o. not being diuresed today & is in positive fluid balance. BUN/creat stable elevated.\nK+ repleted prn for <4.0\n...FREE WATER boluses via FT for free water deficit(elevated serum sodium @ 147)\n\nID- temp persistent @ 101.2 to 101.4; tylenol x2 given w/o effect\n central line site changed and old line sent for culture.\n CSF sent for culture by NS\n PO levaquin started today(renal dose) for GNR in sputum(culture pnd).\n\nHeme- no issues.\n\nGI- nepro w/promod feedings cont at goal. Soft obese abd with bowel sounds; NO stool.\n protonix ongoing\n\nEndo- insulin drip cont @ 3-5u/hr to maintian blood sugars <150\n\nSkin- edematous but without evidence of breakdown or pressure areas.\n..sc heparin q12/hr\n..compression boots ongoing.\n\nSocial- no contact calls today\n... RN to forward request to SW concerning quardianship issues since pt has NO family memebers or HCP/legal qurdian.\n\nAssess- elderly male s/p SAH complicated by renal impairment & resp failure. Now with diminished neuro responsivenes of ? etiology (rebleed ruled out but ^^ swelling per CT scan).\n NOW with fevers...cultures pnd.\n\nPlan- attempt to wean off propofol.assess neuro exam for change\n maintain bp within goal range..labaetalol as needed to achieve goal\n replace free water\n diurese per order\n wean from vent support as tol in am with extubation as goal\n initiate bowel reg\n" }, { "category": "Nursing/other", "chartdate": "2163-01-02 00:00:00.000", "description": "Report", "row_id": 1475380, "text": "T/Sicu Nsg Note\n(Continued)\nimen\n follow cultures.\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475386, "text": "S/P SAH-T/SICU NPN 11P-7A\nS-INTUBATED\nO-NEURO-PT OPENS EYES SPONT + TO VERBAL STIM,PT FOLLOWS SIMPLE COMMANDS INCONSISTENTLY,PT SQUEEZES BILAT HANDS TO COMMAND,STICKS OUT TONGUE TO COMMAND,SPONT MOVEMENT NOTED BUE + RLE,SL FLEX NOTED OF LLE TO NOXIOUS STIM,PERRLA 3MM.STRONG COUGH + GAG.VENTRICULOSTOMY REMAINS 10CM ABOVE TRAGUS,DRAINING 10-45 CC BLOOD TINGED CSF Q 2HRS.\nCV-SEE FLOWSHEET FOR VS DETAILS,SBP 110'S-150'S,HR 50'S-70'S SB->NSR NO VEA NOTED.3+ DP/PT .LABETALOL GTT OFF @ 12 AM.ATC LOPRSSER + HYDRALIZINE PRN\nRESP-PT REMAINS ON INTUBATED/VENTILATED CURRENTLY ON 8PSV/8PEEP,VT ~500-~800,RR 16-26,PT Q 1-2HRS OVER FOR SM-MOD THICK WHITE SPUTUM.STRONG COUGH AS NOTED.PT LS >COARSE TO DECREASED @ BASES.METAB ACIDOSIS PERSISTS/ABG.\nGI/GU-PT ABD OBESE +BS,TF NEPRO @ 30CC/HR VIA PEDI FT,LOW ,250CC H2O BOLUS VIA FT X1 OVER FOR ^^Na+.U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH.20MG IV LASIX OVER PT W/ SM DIURESIS.PT RECTAL BAG INTACT DRAINING SM AMTS CLEAR LIQUID MUCOID STOOL.\nSKIN-NO NEW SKIN INTEGRITY ISSUES.\nID-T MAX 100.6,PT REMAINS ON LEVOFLOX + VANCO IV.\nENDO-BS 91-200'S,INSULIN GTT 5U/HR->OFF->>3U/HR\nA-ALT NEURO STATUS R/T SAH\nP-CONT NEURO CHECKS,VS,VENT/ORDERS,LABS/ORDERS.MONITOR CX DATA QD AND PRN,I+O,MONITOR SKIN INTEGRITY QS AND PRN,IV ABX/ORDERS,FSBS/INSUL GTT/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475387, "text": "Resp Care: pt continues intubated and on ventilatory support with psv, no vent changes overnoc, good oxygenation with met acidosis; BS coarse, thick white secretions, rx with albuterol/atrovent mdi as ordered, rsbi not done d/t pH, will cont support.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475388, "text": "T/Sicu NSg Note.\n0700>>1600\n\nEVENTS- ~ extubated 1600\n ~ transfused 1u PC's\n ~ Epogen to start today & Q week\n ~ lasix increased to 40mg \n ~ prn hydralizine increased to 20mg q4/hr prn\n ~ LENI's done>>NO CLOT\n\nNeuro- perrl @ /brisk. Pt opens eyes spont & to voice; tracks to speaker. Pt follows commnads to squeeze with hands & wiggle toes- but repsonse to minimal & profoundly weak.; extremities are flaccid. No spont movements appreciated.\nNo seizure activity; dilantin ongoing\nICP drain remains at 10cm above tragus & open to drain. ont with blood tinged drainage. ICP values remains < 10.\n\nCVS- nsr with rare apc. BP with gradual but persistent rise throughout the day to range above goal. Responds transiently to regularly scheduled meds and to prn hydralizine. This afternoon, bp more acutley and persistently elevated above goal range; hydralizine dose increased to 20mg but with only transient effect. Pt ot appearing agitated. BP check done by method and consistently found to be 20-30 points BELOW arterial BP trace.(making bp appropriatley within goal range. Arterial values >170. Arterial tracing with known fling on occassion. H.O. notified and decision was made to follow to manage bp so systolic pressures would not be overtreated(and made too low).\n..labaetalol remains off. See careview for vs details.\n..cvp 7-12\n\nRESP- tolerated spont breathing trial with abg within baseline range\n Pt extubated without problem & is maintaining adequate sats/rr.\n Strong cough- congested & productive..small amt thick white sputum.\n\n\nRenal- adequate u/o..clear/yellow. lasix increased to 40mg .\n ** attempting to achieve negative balance for the day.\n electrolytes wnl\n\nID- wbc wnl; temp 101 to 101.4; cultures pnd. vanco held d/t high trough level. levaquin conts pft. Stool for c.diff sent.\n\nHeme- hct 28; 1u pc's orderd for transfusion\n Epogen started today.\n\nGI- tolerating tf at goal; rate increased to 35cc/hr now that propofol os off. Abd is soft/distended with active bowel sounds. FIB changed for leakage. Stool is liquid to loose brown and foul smelling.\n..protonix cont\n\nEndo- insulin drip continues @ 2-4u/hr\n NPH insulin started this am @ 12u/am & pm\n blood sugars ranging 120's to 170\n\nSKIN- no new issues; compression boots cont; sc heparin cont\n small skin trar noted with FIB removal at coccyx site.\n\nSocial- ..RN coordinatot from (pt's residence) visited today and spoke with pt & this RN. Friend called & will be visiting tomorrow. Physician from pt's Health Clinic called to provide additional information to ICU as needed regarding pt's PMH/pre-admission meds. SW, remains involved in pt's case and has set in motion request for legal quardianship since pt has NO relatives or HCP.\n\nAsses- extubated\n more awake but profoundly weak/debilitated\n persistent low grade fever\n cont difficulty mnging blood sugars ad\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475389, "text": "T/Sicu NSg Note.\n(Continued)\neqautely\n\nPLAn- cont with current & new orders with ongoing evaluation of effectiveness. Monitor for resp distress or worsening met issues.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-04 00:00:00.000", "description": "Report", "row_id": 1475390, "text": "Nursing Progress Note\nS/O- Review of Systems\n pt initially awake and following commands with all extremities, all extrems are extremely weak and barely moving , no spontaneous movement note, PERL, several hours after extubation, pt was only opening eyes to painful stimuli and not following, icp was , drained 40cc over an hour of bloodtinged drainage, pt would withdraw from painful stimuli. notified.Ptwas also hypertensive, hydralizine given, and pt appeared to be having upper airway obstruction, sats remained 98% and ABG was unchanged from pre extubation ABG\n" }, { "category": "Nursing/other", "chartdate": "2163-01-05 00:00:00.000", "description": "Report", "row_id": 1475393, "text": "7a-7p NPN Handwritten in chart.\n\nPlease see for specifics of shift.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-06 00:00:00.000", "description": "Report", "row_id": 1475394, "text": "Fecal incont. bag not removed. Liquid brown stool out\n" }, { "category": "Nursing/other", "chartdate": "2163-01-06 00:00:00.000", "description": "Report", "row_id": 1475395, "text": "Neuro: exam findings inconsistant b/t checks. At best alert and oriented to self and place. Squeezes w/hands and moves right arm at random more then left arm. Minor random movements of lower extremities but not to command. See flow record for details. Ventriculostomy drain in place draining a bloody fluid. Drain remains open at all times @ 10 CM ^ tragus. ICP 3-9.\n\nCV: Sinus rhythm no ectopy noted. S1S2. Generalized edema. Peripheral pulses strong and =. HTN tx w/hydrolozine 20 mg to keep SBP <160. Discussed w/HO HTN management, lopressor ^ to TID. See flow record for VS details. Left radial ABP w/fling, following NIBP for tx. Right IJ MML w/distal port transduced for CVP 3-8\n\nResp: Lung sounds clear after coughing and clearing upper airway noises. SaO2 98%. O2 @ 4L/NP. Sleep apnea noted followed by snorous and gasping respirations. Resp. even and non labored, no resp. distress noted.\n\nGI: Pedi tube via left nare w/TF infusing at goal. Abd obese w/active BS. Fecal incont bag removed as no stool out.\n\nGU: Foley patent draining clear yellow urine in amt sufficant. Receiving lasix 40 TID w/significant diuresis.\n\nEndo: Insulin gtt on at 3 units/hr. Rate had been up to 8 units/hr. Accu check 221-89.\n\nLytes: Na 150, 250cc H2O bolus via Ng. K+ 3.5, repleated w/40 KCL.\n\nABGs : PcO2 29, NaCO3- gtt rate ^ to 60cc/hr. PcO2 ^ to 32 after rate change. Goal to keep Pco2 >30 w/NaCO3- gtt.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-06 00:00:00.000", "description": "Report", "row_id": 1475396, "text": "S/P SAH T/SICU NPN 7A-7P\nS-\" ,HOME.\"\nO-NEURO-PT A+ O X 1 NAME ONLY,MAE'S L SL < R,FOLLOWS SIMPLE COMMANDS,PERRLA 3MM.STRONG COUGH + GAG.PT TO MRI ENTIRE SPINE @ 6PM.VENTRIC RAISED TO 15CM ABOVE TRAGUS DRAINING ~20 CC BLOOD TINGES CSF Q 2HRS,ICP'S .\nCV-PT SBP 130-160,HR 70'S-80'S NSR NO VEA NOTED.LYTES REPLETED PRN.3+DP/PT .BICARB GTT STOPPED THIS AM.\nRESP-PT LS CTA DECREASED BASES OCCAS COARSE BS,O2 SATS 96-98% ON 4L NC,STRONG PROD COUGH,RR 18-24.NARD.\nGI/GU-PT ABD OBESE + BS,SM AMT LOOSE BROWN STOOL VIA RECTAL BAG.U/O ADEQ AMTS CLEAR YELLOW URINE VIA FOLEY CATH,40 MG LASIX THIS PM DIURESED~ 1L.NPO FOR ?INTUBATION FOR MRI.\nSOC-NO CONTACT TODAY.\nID-T MAX 100.6.,PT CONTS ON LEVOFLOX PO,VANCO DOSE HELD TODAY FOR LEVEL >15.\nSKIN-NO NEW ISSUES.PT BACK + BUTTOCK GROSSLY INTACT.\nA-ALT MS R/T SAH.\nP-NEURO CHECKS,VS,I+O,O2 PRN,ABX/ORDERS,MONITOR SKIN INTEGRITY QS AND PRN.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-07 00:00:00.000", "description": "Report", "row_id": 1475397, "text": "TRAUMA ICU NURSING PROGRESS NOTE\n\nREVIEW OF SYSTEMS:\n\nNEURO: AROUSABLE TO VOICE...FALLS BACK TO SLEEP\n QUICKLY AND EASILY. WEAK FOLLOW COMMANDS\n WITH HANDS. NO MOVING LEGS...HAD BEEN\n ABLE TO GIVE SMALL \" SLIDE\" ON BED PRIOR.\n ICP AT 15 AND OPEN. DRAINING 10 CC Q2 HOUR.\n\nCV: HR AND BP STABLE. PO LOPRESSOR. PO NIMODIPINE.\n NO EXTRA BP MED NEEDED OVERNIGHT.\n SBP<160.(CONTINUE TO FOLLOW RATHER THAN ALINE.)\n\nRESP: 2LNC WITH GOOD SATS. NP.\n EXTUBATED SPUTUM CX WITH SERRATIA AND\n STAPH AUREUS.\n ACIDOSIS IMPROVED...BICARB DRIP NOT ON.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-08 00:00:00.000", "description": "Report", "row_id": 1475402, "text": "T/SICU Nursing Progress Note\n7A-7P:\nS/p head bleed: Please refer to Carevue for details of HD status.\nNeuro: Easily arousable. Oriented to person. Able to participate in conversation. Follows simple commands. Visited with friend who visits him in the where he lives. Vent drain at 25 cm above the tragus, draining blood-tinged fluid. Notable amount of clear yellow fluid noted from around the vent drain; awaiting neuro. On call to MRI of cervical spine.\n\nCV: hemodynamically stable. Awaiting A-line placement.\n\nResp: dry non-productive cough. Wearing NC with SpO2 > 95 %.\n\nGI: abd soft and non-tender. +BS. Liquid brown stool via rectal bag. Tolerating FS TFs at goal of 35cc/hr.\n\nGU: brisk u/o via foley. K+ repleted to maintain > 4.0\n\nEndo: received 20 units of NPH this AM. Reg insulin per SS.\n\nSocial: Friend called for update and plans to visit on Monday. This afternoon received a visit from and his father. visits every Sunday in his Center where they talk about and listen to Jazz music.\n\nA: HD stable, neuro unchanged.\n\nP: cervical MRI, give ativan to help with his tremors. As per NCP.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-09 00:00:00.000", "description": "Report", "row_id": 1475403, "text": "S/P SAH T/SICU NPN 7P-7A\nS-\" ,I'M OK\"\nO-NEURO-PT REMAINS A+O X 1,CALM COOPERATIVE,PERRLA 3MM,STRONG COUGH,VENTRIC INITIALLY @ 25CM ABOVE TRAGUS,DOWN TO 15 CM ABOVE TRAGUS D/T CSF LEAKING FROM INSERTION SITE,ICP 8-14.\nCV-SEE FLOWSHEET FOR VS DATA,NEW ALINE PLACED IN PM,3+DP/PT .HR 80'S-90'S NSR NO VEA,ABP W/ FLING ~30-40PTS>.\nRESP-PT LS CTA DECREASED BASES,NARD,RR 20'S.NARD,O2 SATS 96-100% 2L NC NOW OFF.STRONG COUGH EFFORT.\nGI/GU-PT ABD OBESE +BS,MOD LIQ BROWN STOOL VIA RECTAL BAG,U/O ADEQ->BRISK W/ LASIX,URINE CLEAR YELLOW,TF NEPRO W/ PROMOD @ 30CC/HR.\nSKIN-NO NEW ISSUES.PT BACK + BUTTOCK GROSSLY INTACT.\nID-T MAX 101.8 PAN CX'D.\nA-ALT MS R/T SAH\nP-NEURO CHECKS,VS,I+O,MONITOR SKIN INTEGRITY QS AND PRN,ABX/ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-09 00:00:00.000", "description": "Report", "row_id": 1475404, "text": "S/P SAH T/SICU NPN 7A-7P\nS: \"I AM OK\" \" EVERYTHING IS FINE\"\n\nO: REVIEW OF SYSTEMS\n\nNEURO\n\nPT ALERT AND ORIENTED X 1; CALM, COOPERATIVE.; W/ A PERIOD OF TACYPNEA AND ANXIETY. ATIVAN 0.5 MG X 1 GIVEN W SLIGHT EFFECT. PERLLA 3MM BILATERAL AND BRISKLY REACTIVE. STRONGT COUGH. CONTINUES W/ TARDIVE DYSKINESIA. VENTRIC INITIALLY @ 10CM ^^ TRAGUS. CHIP NP IN TO SUTURE DRAIN SITE SECONDARY TO CSK LEAK. DRAIN 60CC Q 4/HR OF PINKISH DRG NOTED. ICP 8-->12. CPP 80--98.\n\nCV\n\nHR 80-90'S, NSR W/ NO ECTOPY NOTED. A LINE W 30 POINT FLING. ? NEW A-LINE, + ACCESS VIA TLCL. LABILE BP. SBP 120-->180 VIA NONINVASIVE. LOPRESSOR 5MG IV X 3 AND HYDRALAZINE 20 IV GIVEN. + DP/PT.\n\nRESP\n\nLS CTA ; DECREASED AT BASES. RR 20'S. SAO2 90-->98 ON R/A. PT W STRONG COUGH + EFFORT.\n\nGI/GU\n\nABD OBESE, SOFT, NT , ND. RECTAL POUCH CHANGED X 1 20-30CC'S Q 4/HR'S. TF NEPRO W PROMO @ 35/HR TOLERATING WELL VIA L NGT. U/O VERY DILUTE 400CC;S Q 2/HR'S/ LASIX HELD. 1500-->2L FREE WATER FLUSHES TODAY. LYTEL PENDING. SEE CAREVIEW.\n\nSKIN\n\nNO NEW ISSUES. BACK/BUTTOCKS GROSSLY INTACT.\n\nID\n\nTMAX 100.1 TYLENOL 1 CUP GIVEN. TEMP 98.9.\n\nA- ALT MS R/T SAH\n\nPLAN NEURO CHECKS. I&O. SKIN INTEGRITY QS AND PRN. MONITOR FEVER CURVE. CONTINUE MONITORING HEMODYNAMICS/ PRN LOPRESSOR/HYDRALAZINE. ? PULL A-LINE W 30 POINT FLING.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-11 00:00:00.000", "description": "Report", "row_id": 1475408, "text": " NPN 7a-7p:\n\nWill update as needed--3am\n\nNeuro: Alert and oriented x1-2. Able to state \"\" and \"\" at times. Word searching noted. Speaking in full sentences. Follows commands. MAE weakly. Arms move better than legs. PERL. Cooperative with care. Vent drain to right side of head leveled at 10cm H2O above tragus. Draining clear yellow to rusty fluid. ICP 4-8.\n\nCV: SR/ST with rare PVCs. Color pink. Skin warm and dry. Palp DP and PT pulses bilat. Generalized non-pitting edema. BP monitoring by as a-line has fling. Keeping BP <150. Goal attained with PO lopressor .\n\nResp: Denies shortness of breath. Lung sounds clear, diminished in bases. Equal chest expansion. Sats 95-97% on 2L via NC. Non-productive cough.\n\nGI: Abdomen obese, soft, nontender. Denies nausea. No vomiting. NPO. Pedi feeding tube in place with FS Nepro with Promod at 35cc/hour. Tolerates with minimal residuals. Active bowel sounds. Incontinent brown liquid stool. + flatus. Rectal bag in place.\n\nGU: FOley with clear yellow urine. Repleting KCL and other lytes as needed. Lasix TID.\n\nEndo: Coverage with SSRI for BG >200. 30 units NPH insulin .\n\nID: Temp up to 101 and tylenol given. Fan on for pt comfort.\n\nSkin: Intact with no areas of breakdown noted.\n\nHeme: SQ heparin and pneumo boots. No issues at this point.\n\nSocial: No contact with friends overnight.\n\nPlan: Continue with hemodynamic and neurologic monitoring. Monitor lytes and replete as needed. Increase activity and work with PT/OT. VP shunt needed in near future. Monitor temps. Ongoing emotional support to pt.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-11 00:00:00.000", "description": "Report", "row_id": 1475409, "text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X1-2. AT TIMES DOES NOT KNOW PLACE OR DATE. PERL. FOLLOWING COMMANDS. LIFTING AND HOLDING UPPER EXTREMITIES AND MOVING LOWER EXTREMITIES IN BED. DENIES HA OR DISCOMFORT. VENTRICULAR DRAIN IN PLACE AT 10CM ABOVE TRAGUS UNTIL 1000 WHEN DR. INCREASED IT TO 15CM ABOVE TRAGUS. 3ML DRAINAGE SINCE LEVEL CHANGE. CALLED TO EVALUATE. NEURO STATUS UNCHANGED AND ICP 4-5 WHICH WAS UNCHANGED. DRAIN FLUSHED BY WITHOUT CHANGE IN DRAINAGE. POSITIVE FLUCTUATION. VENT DRAIN RESUTURED TO HEAD BY DR. AND NEW DSG APPLIED. NO DRAINAGE/LEAK NOTED AT SITE.\n\nLUNGS CLEAR WITH DIMINISHED SOUNDS LOWER BASES. SATS 96-100% ON 2L NCO2. FEBRILE TO 101.\n\nABD SOFT, OBESE AND NON-TENDER. POSITIVE BOWEL SOUNDS. LIQUID BROWN STOOL PER FECAL INCONT. BAG. TOL TF AT GOAL RATE. FAILED BEDSIDE SWALLOW EVALUATION. FREE WATER BOLUSES PER FT FOR HYPERNATREMIA.\n\nURINE OUTPUT GOOD, CONTINUES ON SCHEDULED LASIX DOSES. K REPLETED AS NEEDED.\n\nOOB TO CHAIR X3HRS.\n\nPLAN:\nPOSSIBLE FLUORO SWALLOW EVALUATION IN AM. CONTINUE TO MONITOR NEURO STATUS CLOSELY AND CALL FOR ANY CHANGES. CHECK AND REPLETE LYTES AS NEEDED. CONT FREE WATER BOLUSES X6DOSES TOTAL AND MONITOR NA LEVEL.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-01-11 00:00:00.000", "description": "Report", "row_id": 1475410, "text": "ADMIT\nPT ARRIVED FROM AT APPROX 1810. SEE FLOWSHEET FOR SPECIFICS OF INITIAL ASSMT, UNCHANGED FROM TRANSFER REPORT EXCEPT PT MORE LETHARGIC, FALLING ASLEEP DURING ASSMT. ICP 14. NP INFORMED. VENT DRAIN DECERASED TO 10CM ABOVE TRAGUS AS ORDERED, AND DRAINING GD AMTS CLEAR CSF. NP TO COME AND EVAL.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-12 00:00:00.000", "description": "Report", "row_id": 1475411, "text": "data/action: vss sb/b by cuff 160-130. a-line pressure much higher(20pts) pt alert to name not time/place. moving all extremies arms more than legs. vent drain 15cm to tragus w/ icp 6-10 w/ good wave form. liq. brown stools fib in place very hyperactive bs.\nfree h2o bolus's given na remains high (na52). slept well.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-12 00:00:00.000", "description": "Report", "row_id": 1475412, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT ALERT MOST OF DAY. LETHARGIC AT TIMES, FALLING ASLEEP DURING ASSMT. ICP 8-13 (13 WHEN LETHARGIC). AND SICU TEAM INFORMED OF LETHARGY, RESOLVED WITHOUT INTERVENTION. DRG CLEAR. MOVES ALL EXTREMITIES R>L. FOLLOWS ALL COMMANDS. ORIENTED TO PERSON ONLY. PERRL. VENT DRAIN RAISED TO 20CM ABOVE TRAGUS PER THIS EVE.\nRESP: LS CLEAR BUT DIM AT BASES. O2 SATS >98% ON 2LNC.\nCV: TMAX 100.9. BP <150 BY CUFF. LASIX DOSE DECREASED. H2O BOLUSES DECREASED IN AMT BUT CONTINUE Q4H. NA 150 (FROM 152 THIS AM). K REPLETED.\nGI: LOUD BOWEL SOUNDS. LG AMTS STOOL, BROWN LIQUID VIA FIB. SENT FOR CDIFF. TF'S CONT AT GOAL.\nGU: ADEQUATE AMTS CLEAR YELLOW U/O.\nENDO: FSBG COVERED PER RISS AND WITH STANDING AM NPH.\nPLAN: CONT TO MONITOR NEURO STATUS. ASSESS TOLEREANCE OF INCREASED DRAIN LEVEL. SEND SECOND CDIFF SPEC IN AM. CONT PER CURRENT MGMT.\n" }, { "category": "Nursing/other", "chartdate": "2163-01-13 00:00:00.000", "description": "Report", "row_id": 1475413, "text": "STATUS\nD: NEURO SIGNS UNCHANGED P=RL MOVES ALL EXTREM'S EXCEPT RT LEG\nA: ICP DRAIN CLAMPED..ICP <15 SM AMT CLEAR DRAINAGE..HOYA OOB TO CHAIR TOL WELL..TF'S AT 35CC/HR TOL WELL..FIB>>MOD AMT LIQ BROWN STOOL.. ADQUATE HUO\nR: STABLE\nP: DC DRAIN IN AM..TRANSFER TO FLOOR AFTER DRAIN OUT\n" }, { "category": "Nursing/other", "chartdate": "2162-12-25 00:00:00.000", "description": "Report", "row_id": 1475352, "text": "Nursing Note 0700-1900\n\nDx: Subarchnoid Hemorrhage\n\nNeuro: Pt went for CT scan in am which showed not significant changes from day prior. Extubation was based on CT scan. At 17:20, pt had what appear to be a seizure. He rolled his eyes back, extended his UE in a decorticate manner, dropped his BP, HR, & stopped breathing for one minute. Labatolol & Nipride drips stopped briefly but were restarted after rebound hypertension occurred. For objective data please refer to CareVue. Neuro . & Trauma SICU resident notified. Both examined pt & recommended to monitor pt closely. Pt has been inconsist in his responding to commands. Pupils have been + & become more brisk. Pt has not been opening his eyes for the RN but for the MD's he has been responding.\n\nInteg: Warm, dry, pale & intact. Some minor bruising noted on Rt side of head & Lt clavical area.\n\nPain: According to Grimace scale pt does not appear to be in pain. Pt does not respond to question of being in pain.\n\nCV: SB->SR with no ectopic beats. HRR:50's-70's. A-line in Rt radial with a good waveform & squarewave. Frequently has been zero'd. ABP has been very labile. Close titration of Labatolol & Nipride require to keep SBP<130. Attempting to titrate Nipride off first but presently unsuccessful. Pt very sensitive to Nipride (ie 0.1mcg/kg/min will make significant changes). Labatolol is not as effective in managing SBP but is the first drug of choice for TX of this pt with HTN & subarachnoid hemorrhage. NOTE: According to Neuro . the A-line is to be placed at the pt's head for better BP monitoring in correlation to bleeding.\n\nPul: Pt extubated at 15:00. Presently on Humidified Face Mask FiO2 70% Sating 97-100%. ABG's drawn when FiO2 100%:7.37/97/33/20/-4. RR:low 20's. At 1720, pt had an episode where he was noted to be having a \"seizure\" & became apnic for 1 minute. He recovered quickly. Both an oral & nasal airway have been place in the room. Pt to be monitored.\n\nGI: NPO. BS present but hypoactive. No nausea, vomiting, BM or flatus. OG tube was remove when pt extubated. PO med presently on hold according to Dr. .\n\nGU: Foley patent & draining very small amts of yellow urine 30-40cc Q2h. Dr. advised of low urine output but no orders given.\n\nIV Access: Has two peripheral IV in each hand #18g & two #20g anticube IVs in each arm which are double lumen butterfly IVs from another hospital. All are patent & asymptomatic.\n\nLabs: Blood for Dilantin level & Chem 7 sent at 18:20 sent & are pending\n\nSocial: Pt has no immediate family. All according to RN have passed away. His best friend, is to be considered his contact person & advocate. Attempted to obtain further information regarding pt fall from ambulance service & witness but was unsuccessful.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-26 00:00:00.000", "description": "Report", "row_id": 1475353, "text": "MICU NURSING TRANSFER NOTE:\n\n~7pm neuro team arrived on micu A to attempt to thread ICP further in. Procedure was ~45mins in length during which several attempts were made. Pt rec'd 3mg versed and 12.5mcg fentanyl during this procedure. Verbal order given to zero drain at 12cm abv tragus. At this time decision made to transfer pt to ., and rn's arrived to take pt, and take to CT scan then . micu and sicu nurse hung another dilanitin bolus, 2g mgso4 and cont'd to titrate labetalol and nipride to goal of sbp. At ~ 9pm pt transferred to CT by micu and 2 nurses.\nOf note: upon rec-ing pt found that nipride gtt was documented incorrectly. The concentration on the pump screen was 50mg in 250(also like this in carevue) but actual concentration of bag was 100mg in 250. Therefore pt was rec-ing double the dose that was documented. incident report to be filed.\n" }, { "category": "Nursing/other", "chartdate": "2162-12-26 00:00:00.000", "description": "Report", "row_id": 1475354, "text": "TO HEAD CAT SCAN @9PM LAST NIGHT FROM MICU, STILL HAD VENTRICULAR AND INTRACEREBRAL BLOOD.BACK FROM CT TO WITH SPB FLUCTUATING 70 TO 180. WAS WEANED OFF LABETALOL GTT BY 2300.REMAINS ON NIPRIDE GTT CURRENTLY @ .5 MCG/KG/MIN WITH SBP @130s.\n\n\nNEURO: BEGAN FOLLOW SIMPLE COMMANDS AFTER SEDATION WAS WEARING OFF.\nMOVES ALL EXTREMITIES ARMS>LEGS,PURP. MOVEMENT WITH R. ARM. OPENS EYES TO VOICE.SPEACH IS BECOMING MORE COMPREHENSIBLE BUT STILL CONFUSED/DISORIENTED. HAS SOME DYSKYNESIA/TREMMORS TIME TO TIME( S.EFFECTS FROM PSYCH MEDS ?).VENTR DRAIN IS IN PLACE, ICP 7-10.\nOPEN TO CONT. DRAINAGE.NO SEIZUE ACTIVITY,GETTING DILANTIN AS ORDERED.\n\nRESP.:LS CLEAR/DIM @ BASES, ON NC 3L 100%,HAS DRY COUGH\n\nCV: REMAINS IN NSR, A-LINE INTACT, NO EDEMA, + PULSES BILAT. FEET WARM/DRY\n\nSKIN: IN SOFT WRIST RESTRAINS, REPOSITIONED Q 2-3H, HAD AM BATH + SHAVING\n\nGU YELLOW URINE FOLEY 30-40 CC. CREATININE UP 2.1 MD AWARE\n\nGI- BENIGN\n\nWRITTEN BY RN\n\nSIGNED BY \n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-12-26 00:00:00.000", "description": "Report", "row_id": 1475355, "text": "T-SICU Nsg Note\n Neuro - usually pt resting with eyes closed, opens eyes to voice. pt seems agitated, muscles tense - tardive dyskinesia movements and face tense. PERRL. Strong cough & gag. Able to lift & hold all limbs off bed. Follows commands consistently. Purposeful in spont movements. Both wrists restrained to protect ICP. ICP 9-15 today. Continues to drain bloody CSF. Oriented to self and recognized names of people who called for him today. Did answer that it was winter, once said it was , but also answered it was and . Has not know where he is at all. Speech difficult to understand; dentures placed, but speech only a little improved.\n Pt brady cardic to 50's. Now on Metoprolol 10mg q 4 hrs IV and labetalol drip prn to maintain sys BP < 150. Nimodipine works well to decrease BP. Nipride drip off this am.\n Vanco trough high, so only part of noon dose given, about 700mg only infused.\n Skin of back & buttocks intact.\n On insulin drip. D10W also on 10cc/hr as pt is not on TPN, nor tube feedings. Blood glucose labile. See flow sheet for insulin drip titration and glucose levels.\nA: neuro status stable, ICP 8-15, glucose still labile. BP more stable.\nP: continue plan of care.\n" } ]

[ { "category": "Radiology", "chartdate": "2125-11-28 00:00:00.000", "description": "CTA NECK W&W/OC & RECONS", "row_id": 1170192, "text": " 8:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? ANEURYSM\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with IPH\n REASON FOR THIS EXAMINATION:\n please evaluate for aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh WED 9:32 PM\n 1. L frontal IPH w/ IVH not significantly changed from prior OSH scan;\n surrounding edema slightly more prominent\n 2. ant & post circulations patent - no aneurysm or active extravasation\n detected\n 3. recons pending\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with intraparenchymal hemorrhage on outside imaging, for\n further evaluation.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of contrast material. Subsequently, rapid axial imaging was\n obtained from the aortic arch through the brain after an uneventful\n intravenous administration of intravenous contrast.\n\n Correlation is made with prior CT of .\n\n FINDINGS:\n\n There is a 47 x 31 mm intraparenchymal hematoma within the left frontal lobe.\n The medial end of the hematoma abuts and appears to extend into the adjacent\n frontal of the left lateral ventricle. There is hypodensity surrounding\n the intraparenchymal hematoma, most consistent with surrounding edema. There\n is approximately 4 mm of midline shift towards the right. In addition, there\n is another 5-mm focus of intraparenchymal hemorrhage adjacent to the larger\n hematoma in the left corona radiata. There is periventricular hypodensity,\n most likely consistent with sequelae of microvascular ischemia. There are no\n other lesions identified. The visualized paranasal sinuses are clear. There\n are no worrisome bone lesions identified.\n\n HEAD AND NECK CTA: There is a bovine arch. There is minimal atherosclerosis\n at the bifurcation of the common carotid arteries. There is also minimal\n atherosclerosis in the intracavernous course of the internal carotid arteries.\n There is no evidence of a flow-limiting stenosis, thrombosis or an aneurysm\n within the proximal intracranial branches of the internal carotid arteries.\n\n The vertebral arteries, basilar artery and their intracranial branches are\n patent without evidence of an aneurysm, flow-limiting stenosis or occlusion.\n\n There are multilevel degenerative changes seen throughout the cervical spine.\n\n (Over)\n\n 8:30 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? ANEURYSM\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Large left frontal intraparenchymal hematoma with possible extension into\n the adjacent frontal of the left lateral ventricle.\n\n 2. Minimal atherosclerosis at the common carotid artery bifurcation\n bilaterally. No cervical or intracranial arterial aneurysm, stenosis or\n occlusion, within the limitations of the resolution of CT.\n\n" }, { "category": "ECG", "chartdate": "2125-11-28 00:00:00.000", "description": "Report", "row_id": 257155, "text": "Sinus rhythm with atrial premature depolarizations. Otherwise, tracing is\nwithin normal limits. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2170-10-29 00:00:00.000", "description": "Report", "row_id": 82108, "text": "PATIENT/TEST INFORMATION:\nIndication: CAD. Known LV dysfunction. GI bleed. Positive cardiac biomarkers.\nHeight: (in) 60\nWeight (lb): 156\nBSA (m2): 1.68 m2\nBP (mm Hg): 145/55\nHR (bpm): 55\nStatus: Inpatient\nDate/Time: at 13:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith <35% decrease during respiration (estimated RAP (indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No LV mass/thrombus. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: septal apex -\nhypo; inferior apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter. No\n2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Frequent atrial premature beats.\n\nConclusions:\nThe left atrium is normal in size. The right atrial pressure is indeterminate.\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with focal hypokinesis of the\ndista septum and apex. The remaining segments contract normally (LVEF = 50 %).\nNo masses or thrombi are seen in the left ventricle. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The left ventricular inflow pattern suggests impaired\nrelaxation. There is mild pulmonary artery systolic hypertension. There is a\ntrivial/physiologic pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild\npulmonary artery systolic hypertension.\nCompared with the prior study (images reviewed - 2D only of , the\ndistal anterior wall dysfunction is not seen on the current study, but the\nprior study was of higher quality and used echo contrast. Overall systolic\nfunction may be slightly improved.\n\n\n" }, { "category": "ECG", "chartdate": "2170-10-27 00:00:00.000", "description": "Report", "row_id": 205733, "text": "Normal sinus rhythm with downsloping ST segment depressions in\nleads I and aVL consistent with possible anterolateral ischemia. Compared\nto the prior tracing of the inferior T wave abnormalities\nare no longer present and the downsloping ST segment depressions in\nleads I and aVL are new. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2170-10-27 00:00:00.000", "description": "Report", "row_id": 205732, "text": "Sinus rhythm. Probable ventricular premature beat. Non-specific ST-T wave\nchanges. Modestly prominent U waves. Findings are non-specific but\nclinical correlation is suggested for possible drug/electrolyte/metabolic\neffect. Since previous tracing earlier same date no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2170-10-29 00:00:00.000", "description": "Report", "row_id": 1495015, "text": "NPN 7A-7P\nPlease see carevue and FHP for additional data.\nNKDA\nFull Code\n\nNeuro: AOx3. Primarily Vietnamese speaking, able to make needs known. OOB to commode independently. No c/o pain. Pleasant, cooperative with care.\n\nResp: LS CTA. Sats 97-99% on RA. No cough or sob noted.\nCV: NSR 61-74. Rare PVC's noted. Sbp 102-133. Last HCT 32.9. Next HCT due at 0800. NSTEMI this admit likely to demand ischemia GIB. CV consulted, reqs. appreciated. Plan for low dose beta blocker if HCT stable. +pp. No s&s of bleeding noted.\nGI/GU: NPO. UGIB. EGD done, anterior ulcer noted to prior surgical site, cauterized. On Protonix gtt. Surgery consulted as further bleeding would necesitate surgical intervention given ulcer location at prior suture location. If patient experienced any abd pain will likely need CT, and ? surgery. Voiding in toilet, clear, yellow urine.\nskin: w/d/i.\nA/P: Cont. to follow HCT Q 4-6 hrs. If further HCT drop or abd. pain will likely need CT, and ? . intervention. Next HCT 0800. Cont. protonix gtt. Cont. providing supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-27 00:00:00.000", "description": "Report", "row_id": 1495011, "text": "FOCUS; NURSING PROGRESS\nRFA- BLACK TARRY STOOLS X2 DAYS WITH WEAKNESS\nALLERGIES- NKDA\nPMH- GIB WITH DUODENAL ULCER S/P ELECTROCAUTERIZATION , S/P EXPLORATORY LAP, DUODENOTOMY, OVERSEWN DUODENAL ULCER, PYLOPLASTY, AND PLACEMENT OF GASTROTOMY AND J TUBE PLACEMENT,CAD S/P NSTEMI IN SETTING OF GIB , PRIOR SEEN ON CT WITHOUT DEFICITS, SUBDURAL HEMATOMA WITH SUBARCHNOID HEMORRHAGE, CERVICAL SPINE FX AND DM.\nHPI- ADMITTED TO ED WITH 2 DAY HX OF BLACK TARRY STOOLS AND WEAKNESS. HCT IS 41 AT BASELINE IN ED IT WAS 26.9. SHE HAD 2 # 18 GUAGE IV'S PLACED AND WAS TRANSFUSED WITH 2 U PRBC. HR IS 81, RESP 20 WITH SAT OF 100% ON RA.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-27 00:00:00.000", "description": "Report", "row_id": 1495012, "text": "focus; addendum\nREVEIW OF SYSTEMS-\nNEURO- APPEARS COOPERATIVE WITH CARE. AWAITING INTERPERETOR SERVICE TO ASSESS OREINTATION. APPEARS TO UNDERSTAND SOME ENGLISH.\nRESP- ON RA SAT 100%. BS CLEAR. RESP 24\nCARDIAC- HR IN THE 80'S NSR WITHOUT ECTOPI. SBP 140'S ON ADDMISSION. POS PALP PEDAL PULSES.\nGI- ABD SOFT WITH POS BS. DENIES PAIN.\nGU- VOIDS IN BEDPAN.\nACCESS- 2 #18 PERIPHERAL IV'S.\nPLAN- SCVOPE IN AM. FOLLOW SERIAL HCTS. AWAITING ORDERS\n\n\n" }, { "category": "Nursing/other", "chartdate": "2170-10-28 00:00:00.000", "description": "Report", "row_id": 1495013, "text": "NPN 7a-7p\nPlease see carevue and FHP for additional data.\nFull Code\nNKDA\n\nNeuro: Pt is pleasant, cooperative, primarily Vietnamese speaking. She does speak and understand some English. Seemingly oriented. No c/o pain. MAE. Follows simple commands, able to make needs known.\nResp: LS CTA. No cough or sob noted. Sats 98-100% on RA.\nCV: NSR 61-86. Rare pvc's noted. Sbp 101-132. Patient ruling in for MI, likely ischemia. CV consulted, recommended Beta blocker. Lopressor 12.5 mg PO implemented. HCT 32 after 2 units prbc's in ED. AM labs pnding. No S&S of bleeding noted.\nGI/GU: Abd soft, +BS. No stool. Voiding clear, yellow urine in bed pan. Plan for EGD today.\nEndo: ISS, no coverage needed thus far.\nSkin: w/d/i.\nID: afeb. No issues.\nA/P: GIB- No s&s of bleeding noted. Awaiting am HCT, last HCT bumped appropriately to prbc's.\nMI- CV consulted likely ischemia in setting of GIB and CAD. Implemented low dose Lopressor. Cont. to trend enzymes and follow HCT. Cont. providing supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2170-10-28 00:00:00.000", "description": "Report", "row_id": 1495014, "text": "micu nursing note\n69 yr old female admitted for gi bleed, and also ruled in for mi\n\nCv pt stable Bp 108-127/ 60-80 hr 69 sr , pulses present no edema, no cp or sob.\nResp pt on room air sats 98% lungs clear\nGi pt has egd this morning showing anterior ulcer which was oozing posterier ulcer clear, pt given 50 fentenyl and 2 versed for porcedure tol well, no stool no abd pain, pt started on protonix drip this afternoon at 8 mg/hr. pt remains on clear liquids\niv access R&L 18g\nGU pt up to br voiding on own\nheme repeat hct this morning 34 , and repeat afternoon hct pending\nA/P At present no active bleeding no abd pain, no cp\nneeeds repeat hct at this eveing\ncontinune with protonix drip, If pt developes abd pain pt would need abd ct, because ulcer is over old surgical site.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2106-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178198, "text": " 6:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV (last VL 22 million)and B-cell lymphoma who presented\n from Hospital for further workup of bloody diarrhea, abdominal\n distension, and BLE purpura.\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: HCV and B-cell lymphoma, intubated.\n\n ET tube tip is 5 cm above the carina. Right IJ catheter tip is in the mid\n SVC. Right PICC is in the cavoatrial junction. Cardiac size is normal.\n Bibasilar opacities have improved on the right consistent with improved\n pulmonar edema, consolidation and redistribution of pleural effusion. Mild\n pulmonary edema has improved.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179818, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:04 A.M. \n\n HISTORY: Respiratory failure, intubated, question change.\n\n IMPRESSION: AP chest compared to through :\n\n Lung volumes have improved since , probably due to decrease in some of\n the pulmonary edema. Heart size is normal and mediastinal veins are no longer\n dilated. Pulmonary vascular caliber is harder to see but probably normal as\n well. Small bilateral pleural effusions persist. There is still, however,\n extensive consolidation in both lungs with a peripheral pre-disposition and\n even a suggestion of cavitation. These findings are not new but are strongly\n suggestive of residual widespread infection. The heart is normal size. ET\n tube is in standard placement, nasogastric tube passes below the diaphragm and\n out of view. Left jugular line ends in the left brachiocephalic vein, right\n supraclavicular central venous catheter and a right PIC both end in the low\n SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177501, "text": " 2:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with DAH, concern for cryoglobulinemia, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj FRI 10:59 AM\n PFI: Stable appearance of the chest.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate interval change.\n\n COMPARISON: to .\n\n FINDINGS: Extensive bilateral alveolar opacities are similar in appearance to\n prior study, no effusion or pneumothorax is present. The endotracheal tube,\n right internal jugular sheath, orogastric tube are in stable appropriate\n location.\n\n IMPRESSION: Stable appearance of the chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177502, "text": ", MED MICU 2:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with DAH, concern for cryoglobulinemia, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Stable appearance of the chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180013, "text": " 5:53 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for pneumothorax\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with apparent subcutaneous crepitus\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n WET READ: JBRe SUN 6:41 PM\n New, bilateral chest wall and supraclavicular subcutaneous emphysema. No PTX.\n ETT slightly more proximal then prevously (7 cm above the carina).\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n the development of supraclavicular and chest wall subcutaneous emphysema. No\n evidence of pneumothorax. Endotracheal tip now lies approximately 7 cm above\n the carina. Diffuse bilateral pulmonary opacifications persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179646, "text": " 1:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:17 A.M. :\n\n HISTORY: Respiratory failure. Intubated, question interval change.\n\n IMPRESSION: AP chest compared to through :\n\n ET tube, right internal jugular line, left internal jugular line, and right\n PIC line are in standard placements. Nasogastric tube ends in the mid\n stomach. Extensive infiltrative pulmonary abnormality has not changed\n appreciably since . There is a strong suggestion of pulmonary nodules\n on several of the preceding studies, not as clear today. CT scanning would be\n helpful for characterization. The heart is normal size. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179001, "text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval changes\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with hepatitis C/low-grade B cell lymphoma with persistent\n hypoxic respiratory failure - also wtih influenza, fluid overload\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:13 A.M. ON \n\n HISTORY: Hepatitis. B-cell lymphoma. Hypoxic respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Substantial progression of right lower lobe consolidation, with minimal change\n in the severity of extensive left-sided consolidation suggests progression of\n widespread pneumonia. Lung nodules are present, particularly in the lower\n lungs and one of which projecting over the right fourth anterior interspace\n may have cavitated, what one would expect from septic emboli or small lung\n abscesses.\n\n ET tube and right internal jugular line and PIC line are in standard\n placements. Nasogastric tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178349, "text": " 2:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval changes, ETT placement\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV and B-cell lymphoma who presented from OSH with\n increasing abdominal distension, shortness of breath, and bloody diarrhea, now\n with hypoxia\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval changes, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with known B-cell lymphoma\n and new ET tube placement.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The ET tube tip is 6 cm above the carina. The right internal jugular line tip\n is at the level of low SVC. The right PICC line tip is at the level of\n cavoatrial junction. The NG tube tip is not clearly seen and can be followed\n till the level of the hiatus.\n\n The left lower lobe consolidation is demonstrated, highly concerning for\n infectious process. Right basal consolidation is seen as well, grossly\n unchanged. As compared to the CT torso from , the degree of\n consolidations appears to be grossly unchanged. Small bilateral pleural\n effusion is redemonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180041, "text": " 2:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with influenza, pneumonia, ARDS\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and ARDS.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Diffuse bilateral pulmonary opacifications persist\n with subcutaneous gas along the right chest wall and overlying the pectoral\n soft tissues.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177793, "text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV (last VL 22 million)and B-cell lymphoma who presented\n from Hospital for further workup of bloody diarrhea, abdominal\n distension, and BLE purpura.\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:57 A.M. ON \n\n HISTORY: B-cell lymphoma. HCV. Bloody diarrhea, abdominal distention and\n purpura.\n\n IMPRESSION: AP chest compared to through 19:\n\n Superimposed on the background of a persistent interstitial abnormality which\n has shown slow clearing over the past few days, there is new consolidation in\n the left lower lung partially obscuring the left heart border, probably\n pneumonia or, alternatively, hemorrhage. I should think it would be useful to\n perform a chest CT scan to better characterize the interstitial abnormality\n and see if there are lung nodules. There is no evidence of central adenopathy\n or pleural effusion. Heart size is normal. ET tube is in standard placement.\n Nasogastric tube should be advanced several centimeters to move all the side\n ports into the stomach. A dual-channel right supraclavicular and right\n subclavian lines both end in the mid SVC. No pneumothorax.\n\n Findings were discussed by telephone with the house officer caring for this\n patient at 10:30 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-03 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1177206, "text": " 1:11 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 1315\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with HCV and cryoglobulinemia, now s/p HD catheter placement.\n REASON FOR THIS EXAMINATION:\n Please assess for catheter placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HD catheter placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a dialysis catheter with its tip in the mid portion of the SVC.\n A little change in the appearance of heart and lungs. No evidence of\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177690, "text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV (last VL 22 million)and B-cell lymphoma who presented\n from Hospital for further workup of bloody diarrhea, abdominal\n distension, and BLE purpura.\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:55 A.M., .\n\n HISTORY: HCV. B-cell lymphoma. Bloody diarrhea and abdominal distention.\n\n IMPRESSION: AP chest compared to through 18:\n\n After the initial development of pulmonary edema between and\n 14th, heart size and mediastinal vascular engorgement have returned to \n and yet severe pulmonary abnormalities remain. What looks like a combination\n of lung nodules, large and small and diffuse interstitial abnormality was\n present on , and all of it has improved. I suspect the residual is\n due to areas of pulmonary hemorrhage and conceivably disseminated infection.\n Chest CT scanning would be helpful to exclude cavitation, a clear indication\n of infection, or the development of lung abscess, particularly in the lingula.\n ET tube is in standard placement. Right internal jugular line ends in the low\n SVC and nasogastric tube passes below the diaphragm and out of view. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1180039, "text": " 2:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: obstruction?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with influenza, pneumonia, ARDS, worsening abdominal\n distention and increased NG output. Concern for obstruction.\n REASON FOR THIS EXAMINATION:\n obstruction?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:46 PM\n IMPRESSION: Non-diagnositc abdominal radiograph. Imaging should be repeated.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention and increased NG tube output.\n\n COMPARISONS: to .\n\n FINDINGS: A single portable abdominal radiograph is obtained which is\n centered around the upper abdomen and lower chest. The abdomen is not fully\n included in the field of view and the penetration is sub-optimal There is a\n paucity of bowel gas. Patchy opacities in both lung bases and subcutaneous\n emphysema are better appreciated on dedicated chest radiograph. A NG tube\n terminates in the stomach.\n\n IMPRESSION: Non-diagnositc abdominal radiograph. Imaging should be repeated.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1180040, "text": ", MED MICU 2:35 AM\n PORTABLE ABDOMEN Clip # \n Reason: obstruction?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with influenza, pneumonia, ARDS, worsening abdominal\n distention and increased NG output. Concern for obstruction.\n REASON FOR THIS EXAMINATION:\n obstruction?\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: Non-diagnositc abdominal radiograph. Imaging should be repeated.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180195, "text": " 2:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with influenza and ARDS, also with ? subcutaneous emphysema\n and crepitus on exam of anterior chest wall, intubated in ICU\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Influenza and ARDS with no wall crepitus.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. There are somewhat improved lung volumes, though the\n diffuse bilateral pulmonary opacifications persist, consistent with the\n clinical diagnosis of pneumonia and ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179946, "text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with influenza, pneumonia, ARDS\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:59 A.M., \n\n HISTORY: 59-year-old woman with influenza pneumonia and ARDS. Question any\n change.\n\n IMPRESSION: AP chest compared to through :\n\n Severe multifocal consolidation has remained remarkably stable over the past\n five days except for worsening of the right lower lobe component. Pulmonary\n vasculature is mildly engorged, but this may be redirection of blood flow\n rather than hemodynamic destabilization because the heart is normal size and\n mediastinum is narrow. Pleural effusion, if any, is small on the right. ET\n tube, bilateral internal jugular lines, right PIC line, and a nasogastric tube\n are in standard placements. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180320, "text": " 4:16 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with influenza, pneumonia; worsening difficulty with\n oxygenation\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Influenza and pneumonia with worsening difficulty on oxygenation, to\n assess for change.\n\n FINDINGS: In comparison with the earlier study of this date, there is\n increasing opacification primarily involving the mid and lower zones\n bilaterally. This is consistent with worsening pneumonia.\n\n Monitoring and support devices remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177301, "text": " 3:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with DAH, concern for cryoglobulinemia, intubated\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diffuse alveolar hemorrhage, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive bilateral alveolar opacities, with a tendency for\n consolidation in the left lung. No newly appeared opacities.\n\n Unchanged monitoring and support devices. No major pleural effusions,\n unchanged size of the cardiac silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180357, "text": " 1:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ARDS in the setting of flu.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS related to flu.\n\n FINDINGS: In comparison with the study of , there is little change.\n Monitoring and support devices remain in place and diffuse bilateral pulmonary\n opacifications persist. The appearance is consistent with severe pneumonia\n with vascular congestion and possibly ARDS.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1180163, "text": " 7:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change, ?worsening pulmonary edema vs atelectesis v\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 F w/ HCV, NHL and cryoglobulinemia w/ ARDS\n REASON FOR THIS EXAMINATION:\n interval change, ?worsening pulmonary edema vs atelectesis vs ?new VAP\n ______________________________________________________________________________\n WET READ: IPf MON 11:04 PM\n Interval worsening multifocal/multilobar consildation. Lines and tubes in\n place.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Diffuse bilateral pulmonary opacifications are\n consistent with widespread pneumonia and ARDS.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1178008, "text": " 12:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute intracranial process\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old male with hepatitis C/low grade B cell lymphoma now with\n cryoglobulinemia with pulmonary involvement, intubated; today with decreased\n responsiveness despite reduced sedation. Also with unequal pupils (L>R)\n however both are reactive.\n REASON FOR THIS EXAMINATION:\n eval for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc TUE 2:06 AM\n No acute intracranial process. Extensive paranasal sinus opacification.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient is a 59-year-old female with hepatitis C and\n low-grade B-cell lymphoma intubated with decreased responsiveness. Evaluate\n for acute process.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: No prior imaging is available for direct comparison.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered. Coronal and sagittal reformations are\n provided for review.\n\n FINDINGS:\n\n There is no evidence of hemorrhage, edema, masses, mass effect, or acute\n territorial infarction. The -white matter differentiation is preserved.\n The ventricles and sulci are normal in size and configuration. There is no\n acute fracture. There is partial opacification of the mastoid air cells.\n There is extensive mucosal opacification of the paranasal sinuses, including\n the ethmoid air cells, sphenoid sinuses, and maxillary sinuses. There is\n associated bony sclerosis of the maxillary sinuses indicative of a chronic\n component. An endotracheal tube is partially visualized.\n\n IMPRESSION:\n 1. No acute intracranial process.\n\n 2. Extensive paranasal mucosal opacification with associated bony sclerosis\n indicative of a chronic component.\n\n (Over)\n\n 12:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute intracranial process\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2106-02-09 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1178009, "text": " 12:21 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for obstruction, LLL infiltrate\n Admitting Diagnosis: RENAL FAILURE\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with hepatitis C/low grade B cell lymphoma now with\n cryoglobulinemia with pulmonary involvement, intubated; also concern for\n intestinal obstruction and LLL ?consolidation\n REASON FOR THIS EXAMINATION:\n Please evaluate for obstruction, LLL infiltrate\n CONTRAINDICATIONS for IV CONTRAST:\n Elevated BUN/creatinine - please page if would prefer to do contrast study\n ______________________________________________________________________________\n WET READ: DLrc TUE 2:44 AM\n 1. Diffuse mosaic pattern with areas of groundglass opacification and areas of\n sparing. Bilateral lower lobe airspace consolidation. Overall findings are\n non-specific most likely related to infection, though\n inflammation/hypersensitivity, or components of disease involvement are also\n in the differential.\n 2. Diffuse anasarca. No evidence of obstruction with contrast demonstrated to\n the level of the rectum. Small amount of intrabdominal simple ascites.\n Splenomegaly. Layering high density in the gallbladder either excretion of\n contrast or sludge. Scattered tiny non-obstructing renal\n calculi bilaterally. Diverticulosis. Multiple non- specific lymph nodes in the\n porta hepatis.\n WET READ VERSION #1 DLrc TUE 2:40 AM\n 1. Diffuse mosaic pattern with areas of groundglass opacification and areas of\n sparing. Bilateral lower lobe airspace consolidation. Overall findings are\n non-specific most likely related to infection, though\n inflammation/hypersensitivity, or components of disease involvement are also\n in the differential.\n 2. Diffuse anasarca. No evidence of obstruction with contrast demonstrated to\n the level of the rectum. Small amount of intrabdominal simple ascites.\n Splenomegaly. Layering high density in the gallbladder either excretion of\n contrast or sludge. Diverticulosis. Multiple non-specific lymph nodes in the\n porta hepatis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of hepatitis C and low-grade B-cell lymphoma, now with\n cryoglobulinemia and pulmonary involvement. Concern for pneumonia. Concern\n for intestinal obstruction.\n\n TECHNIQUE: Multidetector helical CT scan of the chest, abdomen and pelvis was\n obtained without the administration of contrast. Coronal and sagittal\n reformations were prepared.\n\n COMPARISON: CT scan dated .\n\n FINDINGS:\n\n CT CHEST: The lungs demonstrate diffuse ground-glass opacities with slightly\n (Over)\n\n 12:21 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for obstruction, LLL infiltrate\n Admitting Diagnosis: RENAL FAILURE\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n more posterior predominance however seen within all lobes. At the bilateral\n bases there are dense consolidations with small pleural effusions. The\n airways appear patent to the segmental level. Hypodensity of blood relatve to\n the cardiac wall suggests anemia.\n\n The patient is intubated. A feeding tube is in place with tip within the\n stomach. A right-sided PICC line and right jugular catheter are in place with\n tip in the mid to low SVC. As compared to the prior examination, pleural\n effusions are decreased in size, however, the extensive consolidation at the\n bases is increased.\n\n CT ABDOMEN: The liver and adrenal glands are normal. The kidneys contain\n multiple nonobstructing stones bilaterally measuring 1-2 mm. Punctate\n calcifications are noted within the pancreas. The spleen is enlarged. The\n gallbladder contains hyperdense material which could represent sludge or\n excretion of contrast from prior CT study. Ascites is present, predominantly\n perihepatic and perisplenic. Several lymph nodes are noted, however, these\n are not pathologically enlarged by CT criteria. No free air is seen. Loops\n of small and large bowel are of normal size and caliber.\n\n CT PELVIS: Distal loops of large bowel and rectum are of normal size and\n caliber. There is extensive sigmoid diverticulosis. The bladder is collapsed\n around a Foley catheter. The uterus appears within normal limits. A rectal\n tube is in place.\n\n There is diffuse anasarca of the soft tissues. No concerning osseous lesion\n is seen.\n\n IMPRESSION:\n 1. Bibasilar consolidations, increased from the prior examination concerning\n for infection.\n 2. Diffuse ground glass opacities, likely pulmonary edema.\n 3. No evidence of bowel obstruction.\n 4. Splenomegaly.\n 5. Multiple nonobstructing renal stones bilaterally.\n 6. Diverticulosis.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179208, "text": " 8:11 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval for pneumothorax\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n Eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension, to assess for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there is further\n improvement in the opacification at the right base. Monitoring and support\n devices remain in place. The subcutaneous gas previously described in the\n region of the lateral aspect of the upper right chest is decreasing.\n Specifically, no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178743, "text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV and B-cell lymphoma who presented from OSH with\n increasing abdominal distension, shortness of breath, and bloody diarrhea.\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: B-cell lymphoma and HCV with shortness of breath.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Lines and tubes are in unchanged position aside\n from a line with a radiopaque tip overlying the carina of uncertain\n significance. The cardiomediastinal silhouette is stable. Diffuse bilateral\n alveolar opacities are not significantly changed nor is a left retrocardiac\n opacity.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177054, "text": " 2:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm ET placement\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV (last VL 22 million)and B-cell lymphoma who presented\n from Hospital for further workup of bloody diarrhea, abdominal\n distension, and BLE purpura.\n REASON FOR THIS EXAMINATION:\n Confirm ET placement\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST RADIOGRAPH:\n\n INDICATION: History of B-cell lymphoma. Status post intubation.\n\n COMPARISON: .\n\n As compared to the previous examination, there is a massive increase in extent\n and severity of the pre-existing bilateral, predominantly apical but also\n basal opacities. Unchanged evidence of a small left pleural effusion.\n\n In the interval, the patient has been intubated. The tip of the tube projects\n 4.2 cm above the carina. The tube could be advanced by approximately 1 cm.\n Normal course of the nasogastric tube, the tip is not included in the film.\n The stomach is minimally overinflated.\n\n No complications, notably no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177101, "text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with HCV and abdominal pain and SOB.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Abdominal pain, shortness of breath, evaluation for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased. Nonetheless, there are extensive bilateral opacities that are\n unchanged in extent in the right upper lung periphery and at the right lung.\n The size of the cardiac silhouette is unchanged. Presence of a small left\n pleural effusion cannot be excluded. No change in position of the nasogastric\n tube and the endotracheal tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176653, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiac or pulm process\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with acute SOB, chest pain.\n REASON FOR THIS EXAMINATION:\n cardiac or pulm process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Shortness of breath, chest pain.\n\n FINDINGS: The heart is mildly enlarged. There are bilateral pleural\n effusions. There are small right greater than left. There is bilateral lower\n lobe volume loss/infiltrate, and pulmonary vascular re-distribution. There is\n right-sided PICC line with tip at the cavoatrial junction.\n\n IMPRESSION: CHF, an underlying infectious infiltrate cannot be excluded.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-01 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1176740, "text": " 12:04 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please give PO contrast. Please evaluate for possible intuss\n Admitting Diagnosis: RENAL FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV and B-cell lymphoma who presented from OSH with\n increasing abdominal distension, shortness of breath, and bloody diarrhea.\n REASON FOR THIS EXAMINATION:\n Please give PO contrast. Please evaluate for possible intussusception\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf MON 3:18 AM\n Moderate bilateral simple effusions cause mild compressive atelectasis.\n Splenomegaly measuring 16 cm. No evidence of intussusseption.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 59-year-old with HCV and B-cell lymphoma with increasing\n abdominal distention, shortness of breath, and bloody diarrhea. Evaluate for\n intussusception.\n\n No prior examinations available for comparison.\n\n TECHNIQUE: Multidetector helical scanning of the abdomen and pelvis was\n performed following the administration of oral and 130 mL of IV Optiray\n contrast. Coronal and sagittal reformats were displayed.\n\n CT OF THE ABDOMEN: There are moderate-sized nonhemorrhagic bilateral pleural\n effusions with associated atelectasis. The liver enhances homogeneously with\n no focal lesions. The spleen is enlarged, consistent with the history of\n lymphoma, though could be related to the patient's underlying liver disease.\n There are multiple portal hilar and periportal lymph nodes measuring up to 10\n mm in short axis, which may be due to the patient's underlying liver disease.\n The gallbladder and pancreas are normal. The adrenal glands are unremarkable.\n The kidneys enhance and excrete contrast symmetrically. There are two\n subcentimeter hypodensities within the left kidney, which are too small to\n further characterize but likely cysts. The intra-abdominal small and large\n bowel loops are normal, with no evidence of small bowel wall thickening or\n intussusception. There is no ascites. The abdominal aorta is of normal\n caliber with moderate atherosclerotic calcification.\n\n CT OF THE PELVIS: There is extensive sigmoid diverticulosis, with sparing of\n the distal sigmoid colon. The rectum is normal. The uterus is not visualized\n and has presumably been removed. There is a Foley catheter and small focus of\n air within the bladder. No pelvic free fluid or lymphadenopathy.\n\n No concerning lytic or sclerotic lesions. There are extensive spondylitic\n changes in the thoracolumbar spine.\n\n IMPRESSION:\n 1. No evidence of intussusception or other acute bowel pathology.\n\n (Over)\n\n 12:04 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Please give PO contrast. Please evaluate for possible intuss\n Admitting Diagnosis: RENAL FAILURE\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Moderate bilateral pleural effusions and atelectasis.\n\n 3. Splenomegaly, which may be related to the patient's lymphoma or\n HCV-related liver disease.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179340, "text": " 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with ARDS\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS.\n\n FINDINGS: In comparison with the study of , there is continued diffuse\n bilateral pulmonary opacifications throughout both lungs. This appears to be\n accentuated by the slightly poor lung volumes. Monitoring and support devices\n remain in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177906, "text": " 2:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with HCV and cryoglobulinemia and respiratory failure.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HCV and cryoglobulinemia and respiratory failure.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Diffuse prominence of interstitial markings\n persists. More focal area of opacification at the left base is slightly less\n prominent than on the previous study, though it still could represent\n pneumonia or hemorrhage. As recommended on the previous study, CT scan would\n be helpful for evaluation of the interstitial prominence.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-01-31 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1176677, "text": " 12:17 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for progression of distension\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with h/o splenomegaly who presents with abdominal distension\n and tenderness\n REASON FOR THIS EXAMINATION:\n Please evaluate for progression of distension\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention.\n\n FINDINGS: There are no old films available for comparison. Contrast is seen\n in loops of bowel on the right likely in ascending colon. There is also some\n fainter contrast probably in the descending colon and sigmoid. The largest\n loop of bowel in the right lower quadrant measures 5.9 cm. Old films would be\n helpful to evaluate for any change.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-06 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1177777, "text": " 8:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: Obstruction\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hx of HCV presents with cryoglobulinemia now with a\n distended abdomen.\n REASON FOR THIS EXAMINATION:\n Obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, \n\n HISTORY: HCV. Distended abdomen.\n\n IMPRESSION: Single frontal view of the supine abdomen shows central\n clustering of minimally aerated bowel loops and moderately distended stomach\n suggesting ascites. There is no evidence of intestinal obstruction.\n Nasogastric tube should be advanced 5 cm to move all the side ports beyond the\n GE junction.\n\n A concurrent semi-erect chest radiograph shows no free subdiaphragmatic gas.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178892, "text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, ETT placement\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 F w/ HCV, NHL cryoglobulinemia s/p plasmapheresis\n REASON FOR THIS EXAMINATION:\n interval change, ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 59-year-old woman with HCV and non-Hodgkin's lymphoma.\n\n FINDINGS: Comparison is made to previous study from .\n\n Lines and tubes are stable. There has been interval change in diffuse\n bilateral airspace opacities throughout both lung fields, worse in the left\n base. Cardiac silhouette is within normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178694, "text": " 6:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: change in infiltrate? PTX?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with severe ARDS possibly influenza with sudden desaturation\n REASON FOR THIS EXAMINATION:\n change in infiltrate? PTX?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ARDS with sudden desaturation.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Endotracheal tube, nasogastric tube, and right\n internal jugular central venous line and right-sided PICC line are in\n unchanged positions. There is no pneumothorax. Multifocal airspace opacities\n are not significantly changed nor is dense retrocardiac opacity.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178548, "text": " 1:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 yo woman with h/o HCV and B-cell lymphoma who presented from OSH with\n increasing abdominal distension, shortness of breath, and bloody diarrhea.\n REASON FOR THIS EXAMINATION:\n Intubated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old female with history of HCV and B-cell lymphoma, now\n with shortness of breath.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP radiograph of the chest was obtained.\n\n FINDINGS: An endotracheal tube is seen with tip approximately 3 cm above the\n carina. Right PICC line and right internal jugular lines are in similar\n positions. An intestinal tube is seen traversing below the diaphragm. There\n are persistent bilateral lower lobe opacities, increased on the right, and new\n bilateral peripheral opacities, probably worsening infection. Heart size is\n normal.\n\n IMPRESSION: Worsening multifocal pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2106-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179486, "text": " 2:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, interval change?\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 F w/ HCV cirrhosis, B cell lymphoma, cryoglobulinemia\n REASON FOR THIS EXAMINATION:\n intubated, interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma with intubation.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Little overall change in the diffuse bilateral\n pulmonary opacifications.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176809, "text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for abnl\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with vasculitis and worsened sob.\n REASON FOR THIS EXAMINATION:\n please assess for abnl\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Vasculitis, worsened shortness of breath. Assessment for\n abnormalities.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing\n parenchymal opacities have moderately increased in extent.\n\n The new occurrence of bilateral pleural effusion cannot be excluded.\n Unchanged retrocardiac atelectasis. The right PICC line is of unchanged\n course.\n\n At the time of dictation, the referring physician, . , was paged for\n notification at 10:57, .\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-16 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1179307, "text": " 4:14 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please evaluate placement of new plasmapheresis line\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with cryoglobulinemia, ARDS, pneumonia, renal failure on\n CVVH, s/p new plasmapheresis line\n REASON FOR THIS EXAMINATION:\n please evaluate placement of new plasmapheresis line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New plasmapheresis line.\n\n FINDINGS: In comparison with the earlier study of this date, the new\n plasmapheresis line has its tip exactly in the same position as the prior one,\n at about the carina. Diffuse bilateral pulmonary opacifications persist.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-16 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1179316, "text": " 6:00 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval L-IJ placement\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 F w/ HCV cirrhosis, B cell lymphoma, cryoglobulinemia\n REASON FOR THIS EXAMINATION:\n eval L-IJ placement\n ______________________________________________________________________________\n WET READ: ENYa TUE 8:17 PM\n New L IJ CVL terminate in the left brachiocephalic vein. No PTX. Unchanged\n support devices. Unchanged marked bilateral hazy opacities.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ placement.\n\n FINDINGS: In comparison with the earlier study, there has been placement of a\n left IJ catheter that extends to the brachiocephalic vein. Otherwise, little\n change.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1176911, "text": " 2:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change.\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with HCV and abdominal pain and SOB.\n REASON FOR THIS EXAMINATION:\n Please assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HCV with abdominal pain and shortness of breath.\n\n FINDINGS: In comparison with the study of , there is little interval\n change. Previously noted bilateral pulmonary opacifications persist, though\n they appear slightly less prominent related to the improved aeration of the\n lungs. There is evidence of left pleural effusion. Right PICC line remains\n in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178013, "text": " 2:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: inverval change\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with HCV and cryoglobulinemia and respiratory failure.\n REASON FOR THIS EXAMINATION:\n inverval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HCV and cryoglobulinemia with respiratory failure.\n\n FINDINGS: In comparison with study of , there is increased opacification\n at both bases consistent with worsening effusion and possible development of\n bilateral consolidations. Some of this appearance could reflect the\n underlying pulmonary vascular congestion and basilar atelectatic changes.\n Monitoring and support devices remain in place. The findings are consistent\n with the areas of bilateral lower lobe airspace consolidation seen on the\n recent CT scan.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-08 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 1177970, "text": " 3:08 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Please evaluate for obstruction\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year-old female with hepatitis C/low grade B cell lymphoma, intubated, with\n distended abdomen, decreased bowel sounds\n REASON FOR THIS EXAMINATION:\n Please evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible obstruction.\n\n FINDINGS: In comparison with study of , the nasogastric tube extends to\n the distal stomach. There is a relative paucity of bowel gas. If this could\n clinically reflect dilatation of fluid-filled proximal bowel, CT would be\n indicated to exclude a possible obstruction.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1179171, "text": " 1:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change.\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hypoxia, tachycardia\n REASON FOR THIS EXAMINATION:\n eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia and tachycardia.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. The degree of opacification at the right base may be\n slightly improved. There is extensive soft tissue gas along the right lateral\n chest wall and base of the right neck of uncertain etiology.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-02-16 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1179216, "text": " 9:10 AM\n PORTABLE ABDOMEN Clip # \n Reason: ? constipation or other intra-abdominal process\n Admitting Diagnosis: RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with several days of no bowel movements, intubated\n REASON FOR THIS EXAMINATION:\n ? constipation or other intra-abdominal process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Several days without bowel movements.\n\n COMPARISONS: Abdominal radiograph , abdominal CT, .\n\n TECHNIQUE: Supine views of the abdomen and pelvis (two radiographs).\n\n FINDINGS: Since the previous examination there is new gaseous distention of\n the stomach. The relative paucity of small bowel gas is unchanged since\n . There is stool in the cecum. Several contrast-filled\n diverticulae are seen in the colon, and contrast from the previous CT is noted\n in the colon and rectum. An NG tube terminates in the stomach. No evidence\n of free intraperitoneal air.\n\n IMPRESSION: New gaseous distention of the stomach; otherwise, no change in\n nonspecific bowel gas pattern with paucity of small bowel gas.\n\n" }, { "category": "Echo", "chartdate": "2106-02-16 00:00:00.000", "description": "Report", "row_id": 92941, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Valvular heart disease.\nHeight: (in) 64\nBP (mm Hg): 85/43\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 09:27\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - poor apical views. Suboptimal image quality -\nbandages, defibrillator pads or electrodes. Suboptimal image quality -\nventilator.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF 70%). The right\nventricular cavity is dilated with borderline normal free wall function. The\naortic valve is not well seen. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion. There is an anterior space which most likely represents\na prominent fat pad.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar, but the technically suboptimal nature of both\nstudies precludes definitive comparison.\n\n\n" }, { "category": "Echo", "chartdate": "2106-02-01 00:00:00.000", "description": "Report", "row_id": 92942, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 195\nBSA (m2): 1.94 m2\nBP (mm Hg): 104/43\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Location corrected. No changes made to findings. WJM\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views. Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The right\nventricular cavity is mildly dilated with borderline normal free wall\nfunction. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is moderate pulmonary artery systolic hypertension.\nThere is mild-moderate tricuspid regurgitation. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Right ventricular cavity enlargement. Mild-moderate tricuspid\nregurgitation. Pulmonary artery systolic hypertension. Normal left ventricular\ncavity size and regional/global systolic function.\nThis constellation of findings is suggestive of an acute pulmonary process\n(e.g., pulmonary embolism, bronchspasm, etc.).\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2106-02-16 00:00:00.000", "description": "Report", "row_id": 257913, "text": "Atrial fibrillation with rapid ventricular response and diffuse ST-T wave\nchanges. Compared to the previous tracing of atrial fibrillation has\nreappeared.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2106-02-22 00:00:00.000", "description": "Report", "row_id": 257907, "text": "Atrial fibrillation. Compared to the previous tracing of the rhythm has\nchanged.\n\n" }, { "category": "ECG", "chartdate": "2106-02-22 00:00:00.000", "description": "Report", "row_id": 257908, "text": "Sinus bradycardia. Non-specific T wave inversions in leads V1-V3. Borderline\nlow voltage in the limb leads. Compared to the previous tracing of \natrial fibrillation with a rapid ventricular response rate is no longer seen\nand non-specific T wave inversions in leads V1-V3 are now present.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2106-02-20 00:00:00.000", "description": "Report", "row_id": 257909, "text": "Atrial fibrillation with a rapid ventricular response. RSR' pattern\nin lead V1 (probable normal variant). Delayed R wave progression.\nBorderline low voltage in the limb leads. Non-specific ST segment changes\nin the inferolateral leads. Compared to the previous tracing of atrial\nfibrillation with a rapid ventricular response rate is now present and diffuse\nnon-specific ST segment changes in the inferolateral leads are seen.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2106-02-19 00:00:00.000", "description": "Report", "row_id": 257910, "text": "Sinus rhythm. Delayed R wave progression. Borderline low voltage in the\nlimb leads. Non-specific ST-T wave changes in leads V1-V3. Compared to the\nprevious tracing of atrial fibrillation is no longer appreciated.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2106-02-18 00:00:00.000", "description": "Report", "row_id": 257911, "text": "Atrial fibrillation. Compared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2106-02-17 00:00:00.000", "description": "Report", "row_id": 257912, "text": "Atrial fibrillation with rapid ventricular response and slowing of the rate as\ncompared with previous tracing of . Diffuse non-specific ST-T wave\nchanges. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2106-01-31 00:00:00.000", "description": "Report", "row_id": 258146, "text": "Atrial fibrillation. Low QRS voltage. Delayed R wave progression. Modest low\namplitude right precordial lead T wave changes. Findings are non-specific.\nSince the previous tracing of same date the ventricular rate is slower and\nST-T wave changes appear decreased.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2106-01-31 00:00:00.000", "description": "Report", "row_id": 258147, "text": "Atrial fibrillation with rapid ventricular response. Low QRS voltage. Diffuse\nST-T wave abnormalities. Findings are non-specific but clinical correlation is\nsuggested. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2106-02-16 00:00:00.000", "description": "Report", "row_id": 258138, "text": "Sinus rhythm and occasional ventricular ectopy. Non-specific ST-T wave\nchanges. Compared to the previous tracing of sinus rhythm has\nappeared.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2106-02-16 00:00:00.000", "description": "Report", "row_id": 258139, "text": "Atrial fibrillation with rapid ventricular response and ventricular\nectopy. Diffuse non-specific ST-T wave changes. Compared to the previous\ntracing of the ventricular response has increased. Ventricular ectopy\nhas appeared. Followup and clinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2106-02-14 00:00:00.000", "description": "Report", "row_id": 258140, "text": "Atrial fibrillation with a borderline ventricular response. Mild non-specific\nST segment abnormalities are likely secondary to rate. Compared to the previous\ntracing the ventricular response has slowed. The other findings are similar.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2106-02-14 00:00:00.000", "description": "Report", "row_id": 258141, "text": "Atrial fibrillation with a rapid ventricular response. Diffuse ST segment\nabnormalities likely secondary to rate. Compared to the previous tracing of no\ndiagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2106-02-12 00:00:00.000", "description": "Report", "row_id": 258142, "text": "Atrial fibrillation with rapid ventricular rate. Diffuse ST segment\nabnormalities likely secondary to rate. Compared to the previous tracing\nof the rhythm is now atrial fibrillation.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2106-02-07 00:00:00.000", "description": "Report", "row_id": 258143, "text": "Sinus bradycardia. Low precordial lead voltage. Compared to the previous\ntracing of the rate has slowed. Sinus rhythm has appeared and\nventricular ectopy is absent. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2106-02-01 00:00:00.000", "description": "Report", "row_id": 258144, "text": "Atrial fibrillation with rapid ventricular response and occasional ventricular\nectopy. Non-specific inferolateral ST-T wave changes. Old tracings were not\navailable for comparison.\n\n" }, { "category": "ECG", "chartdate": "2106-01-31 00:00:00.000", "description": "Report", "row_id": 258145, "text": "Probable junctional rhythm. Low QRS voltage. Delayed R wave progression.\nBorderline prolonged/upper limits of normal QTc interval. Right precordial lead\nT wave changes. Findings are non-specific but clinical correlation is\nsuggested. Since the previous tracing of same date probable junctional rhythm\nhas replaced atrial fibrillation and right precordial lead T wave changes are\nmore prominent.\nTRACING #3\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-03-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1178084, "text": " 11:42 AM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for pulmonary edema or pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with HTN, h/o CHF and flash pulm edema, with SOB and chest\n heaviness, crackles at bases\n REASON FOR THIS EXAMINATION:\n please evaluate for pulmonary edema or pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 1147 HOURS.\n\n HISTORY: Hypertension with history of congestive heart failure/pulmonary\n edema, presenting with shortness of breath and chest heaviness with crackles\n at the bases.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Relative to the most recent prior exam, there has been a dramatic\n improvement in overall volume balance with no significant pulmonary edema\n noted on the current exam. There are low lung volumes which have persisted\n with predominantly linear opacities at both lung bases and laterally in the\n left mid lung more consistent with subsegmental atelectasis. No definite\n focal consolidation is evident. Mild aortic tortuosity is again noted. The\n cardiac silhouette size is difficult to assess due to low lung volumes but is\n grossly stable and presumed mildly enlarged. No definite effusion or\n pneumothorax is seen. Degenerative changes are seen throughout the thoracic\n spine.\n\n IMPRESSION: Marked improvement in the overall volume balance with resolution\n of previously noted pulmonary edema. There are low lung volumes with\n subsegmental atelectasis in both lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-06 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1178134, "text": " 4:15 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with GIST (partial resection ) growing recently, awaiting\n repeat resection, presents with epigastric and b/l upper quadrant abdominal\n pain, not passing gas, no BM x2 days, nausea\n REASON FOR THIS EXAMINATION:\n please evaluate for obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 5:57 PM\n 1. No evidence of bowel obstruction.\n 2. Interval increase of now mild intra-abdominal ascites.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old woman, with partially resected GIST, recently\n recurrence, pending four weeks, repeat resection. Now with epigastric pain\n and bilateral upper quadrant abdominal pain. Assess for obstruction.\n\n COMPARISON: CT torso with contrast on .\n\n TECHNIQUE: MDCT images were acquired from the lung bases to the pubis\n symphysis after administration of IV contrast. No oral contrast was\n administered. Multiplanar reformatted images were obtained for evaluation.\n\n CT ABDOMEN WITH IV CONTRAST: There is mild bibasilar atelectasis but no\n pleural effusions. In the liver, a well-circumscribed 3.2 cm left hepatic\n cyst is unchanged. There is intermediate density fluid around the liver and\n also extending to the mesentery and bilateral paracolic gutters, concerning\n for interval hemorrhage. The previously described rounded GIST mass in the\n right upper quadrant subjacent to the liver now appears to have substantially\n decreased in size with an ill-defined morphology (where previously ovoid with\n well defined margins), measuring 3.7 x 3.5 cm, compared to 7.1 x 6.5 cm in\n .\n\n The spleen, pancreas, gallbladder, and adrenal glands are normal.\n Subcentimeter hypodense lesions in the kidneys are too small to be fully\n characterized. There is no hydronephrosis, hydroureter or evidence of renal\n stone.\n\n Anastomotic suture line is noted in the distal stomach, compatible with the\n documented prior GIST resection. The duodenum, loops of small bowel are\n grossly unremarkable. There is no free air or gross lymphadenopathy in the\n intra-abdominal cavity.\n\n CT PELVIS WITH IV CONTRAST: Moderate amount of intermediately-dense\n (hemorrhagic) fluid pools in the deep pelvis. The colon is normal and patent\n with oral contrast. Midline abdominal surgical soft tissue defect is again\n noted. The urinary bladder is normally distended without focal lesions.\n\n BONE WINDOW: There is no suspicious lytic or sclerotic lesions. Multilevel\n (Over)\n\n 4:15 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: please evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n degenerative changes are moderate-to-significant, with vacuum gas phenomena\n noted in L3-4 and prominent anterior osteophytosis.\n\n IMPRESSION:\n 1. No small-bowel obstruction.\n\n 2. Interval development of mild-to-moderate amount of free hemorrhagic fluid\n in the abdomen, with interval substantial decrease of the known GIST tumor,\n likely represents interval rupture of the GIST tumor. Given the patient is on\n Gleevec, this possibly represents a Gleevec-induced tumoral hemorrhage, which\n have been reported.\n\n Dr. , the attending radiologist, has discussed the findings with the ED\n attending, Dr. , at 6:30 p.m. shortly after the official\n interpretation of the study.\n\n" }, { "category": "Radiology", "chartdate": "2153-03-17 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1179851, "text": " 8:50 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: please evaluate for distended loops, ileus, or obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with GIST tumor resection POD4, now with more pain, some\n abdominal distension\n REASON FOR THIS EXAMINATION:\n please evaluate for distended loops, ileus, or obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN ON \n\n HISTORY: Abdominal pain and bloating after tumor resection.\n\n IMPRESSION: Four views of the abdomen show generalized distension of large\n and small bowel, mostly with gas. There is formed stool in the rectum. There\n is no disproportionate dilatation of the cecum, which one generally sees with\n distal colonic obstruction or of the small bowel. No appreciable\n pneumoperitoneum. Lung bases show more pulmonary edema than present on . All of these findings were discussed by telephone with the house officer\n at the time of this dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-12 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1179123, "text": " 4:27 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ABDOMINAL PAIN\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with CHF for GIST resection\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with congestive heart\n failure before resection of GIST tumor.\n\n PA and lateral upright chest radiographs were reviewed in comparison to\n .\n\n Current study demonstrates interval resolution of pulmonary edema with normal\n appearance of the lungs on the current study. Cardiomediastinal silhouette is\n unremarkable. There is no appreciable pleural effusion and there is no\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1179422, "text": " 1:43 PM\n CHEST (PA & LAT) Clip # \n Reason: urine output low, known CHF, evaluate for signs of fluid ove\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 F w/ hemorrhage from known recurrent GIST tumor, now s/p tumor resection.\n REASON FOR THIS EXAMINATION:\n urine output low, known CHF, evaluate for signs of fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old female with hemorrhagic GIST tumor, now with\n decreased urine output in setting of known CHF. Evaluate for evidence of CHF.\n\n COMPARISON: .\n\n TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.\n\n FINDINGS: Compared to most recent prior, there has been mild interval\n improvement in pulmonary vascular congestion. Heart size is top normal.\n There are low lung volumes. A right internal jugular catheter is seen with\n tip in the right atrium. This could be retracted approximately 5 cm.\n\n IMPRESSION:\n 1. Persistent but improved pulmonary vascular congestion.\n\n 2. Central line with tip in the right atrium. This could be retracted\n approximately 5 cm.\n\n These findings were reported to Dr. by Dr. by telephone\n at 2:20 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2153-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1179317, "text": " 6:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval , PTX\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p GIST w R \n REASON FOR THIS EXAMINATION:\n eval , PTX\n ______________________________________________________________________________\n WET READ: ENYa TUE 8:35 PM\n New R IJ in the lower SVC or cavo-atrial junction. Interval increase of\n bilateral hazy opacities, suggestive of worsening pulmonary edema. No PTX.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:08 P.M. \n\n HISTORY: Right central venous line, rule out pneumothorax.\n\n IMPRESSION:\n AP chest compared to through 28:\n\n Lung volumes are lower, but pulmonary vascular and mediastinal venous\n engorgement and moderate cardiomegaly have progressed. There is new mild\n pulmonary edema. Tip of the new right subclavian line projects over the upper\n right atrium, partially obscured by the spine, but probably below the superior\n cavoatrial junction. An epidural catheter loops over the lower midline but\n cannot be localized on this single frontal view. There is no evidence of\n pneumothorax or appreciable pleural effusion. Small right lung nodules may be\n present projected over the second and third anterior interspaces, significance\n uncertain.\n\n" }, { "category": "Radiology", "chartdate": "2153-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178285, "text": " 2:40 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Evaluate L subclavian CVL placement and pneumothorax\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with new L subclavian CVL\n REASON FOR THIS EXAMINATION:\n Evaluate L subclavian CVL placement and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left subclavian placement.\n\n FINDINGS:\n\n In comparison with the earlier study of this date, there has been placement of\n a left subclavian catheter that extends to the mid portion of the SVC. No\n evidence of pneumothorax. No change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178230, "text": " 10:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for fluid overload, after IR procedure.ON ARRIVAL TO SI\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with history of CHF, has received 4units PRBC's, 4 FFP, s/p\n IR embolization. Recent admit for severe CHF\n REASON FOR THIS EXAMINATION:\n Eval for fluid overload, after IR procedure.ON ARRIVAL TO SICU PLEASE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF with transfusion, to assess for fluid overload.\n\n FINDINGS: In comparison with study of , there is asymmetric prominence of\n predominantly interstitial markings, suggestive of asymmetric elevation of\n pulmonary venous pressure related to the recent transfusion. The possibility\n of supervening pneumonia would be difficult to exclude, especially at the\n right base, where there is silhouetting of the hemidiaphragm and more\n coalescent opacification. Blunting of the right costophrenic angle could\n reflect some degree of pleural fluid.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-03-07 00:00:00.000", "description": "INITAL 2ND ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 1178194, "text": " 5:33 AM\n MESSENERTIC Clip # \n Reason: Please embolize likely bleeding from GIST tumor. Embolize ev\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER VISERAL SEL/SUPERSEL A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with GIST tumor and dropping HCT.\n REASON FOR THIS EXAMINATION:\n Please embolize likely bleeding from GIST tumor. Embolize even if not\n extravasation.\n ______________________________________________________________________________\n FINAL REPORT\n MESENTERIC ANGIOGRAM\n\n HISTORY: 78-year-old woman with GIST tumor and dropping hematocrit. Please\n embolize likely bleeding from GIST tube.\n\n COMPARISON: CT abdomen and pelvis with contrast, .\n\n PROCEDURES:\n 1. Right common femoral artery access.\n 2. Celiac arteriography.\n 3. Subselective angiography of the gastroduodenal artery and its branches.\n 4. Closure of the right common femoral arteriotomy site by manual pressure.\n\n OPERATORS: Dr. (fellow), (fellow) and Dr. \n (attending interventional radiologist), who was present and supervising\n throughout the entire procedure.\n\n MEDICATIONS: Moderate sedation was provided by administering divided doses of\n 100 mcg of fentanyl and 1 mg of Versed throughout the total intraservice time\n of 85 minutes during which the patient's hemodynamic parameters were\n continuously monitored. 1% lidocaine was used for local pain control.\n Estimated blood loss was less than 20 mL.\n\n TECHNIQUE: After discussion of the procedure, including the risks, benefits,\n and alternatives to the procedure with the patient via a translator, written\n informed consent was obtained. The patient was brought to the angiography\n suite and placed supine on the imaging table. The right groin was prepped and\n draped in the usual sterile fashion. A preprocedure timeout and huddle were\n performed per protocol.\n\n Using palpatory and fluoroscopic guidance, a 21-gauge micropuncture needle was\n advanced into the right common femoral artery. A 0.018 wire was advanced into\n the aorta. The needle was exchanged for a 4.5 French micropuncture sheath.\n The wire and inner dilator were removed and exchanged for a 0.035 \n wire. The micropuncture sheath was removed and a 5 French 23 cm Tip\n (Over)\n\n 5:33 AM\n MESSENERTIC Clip # \n Reason: Please embolize likely bleeding from GIST tumor. Embolize ev\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sheath advanced. The sidearm was connected to a heparin saline flush. A\n -1 glide catheter was advanced over the wire. Using a combination of the\n glide and a 0.035 angled Glidewire, the celiac axis was selected and an\n angiogram performed. Next, the Glidewire was removed and a Renegade STC\n microcatheter loaded with a 0.018 Transcend wire advanced into the GDA. A\n selective angiogram was performed. Next, a branch of the GDA was subselected\n and an angiogram performed and subsequently a computed tomography with\n contrast. No extravasation was demonstrated. Given the patient is postop\n with unknown collateral reserve, it was felt that the risks of ischemia from\n prophylactic embolization outweighed untargeted embolization. Wires and\n catheters were removed. The right common femoral arteriotomy site was closed\n via manual pressure for 20 minutes. Sterile dressing was applied. The patient\n tolerated the procedure well and there were no immediate post-procedure\n complications.\n\n FINDINGS:\n 1. Celiac and gastroduodenal and subselective angiograms including CTA\n demonstrated no extravasation. Specifically, using the computed tomography in\n comparison with CT from , no extravasation was seen in likely\n branches involving the GIST tumor.\n 2. Given the increased risk of ischemia postoperatively secondary to altered\n anatomy and in consultation with the surgical team, a decision was made to not\n perform a non-targeted embolization.\n\n IMPRESSION: Celiac, gastroduodenal and subselective gastroduodenal branch\n angiography and computed tomography without evidence for extravasation in the\n region of the GIST.\n\n" }, { "category": "ECG", "chartdate": "2153-03-12 00:00:00.000", "description": "Report", "row_id": 117419, "text": "Atrial fibrillation with a controlled ventricular response. Late R wave\nprogression. ST-T wave abnormalities. Since the previous tracing of \nthere is probably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2153-03-07 00:00:00.000", "description": "Report", "row_id": 117420, "text": "Sinus rhythm. Compared to the previous tracing of there is downsloping\nST segment depression in leads I, II, aVF and V3-V6 with increase in rate and\nT wave inversion in leads V3-V6. These findings are consistent with acute\nanterolateral and apical ischemic process. Rule out myocardial infarction.\nFollowup and clinical correlation are suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2178-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982021, "text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check NGT placement\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p open abd on vent increasing FiO2 requirement and fever s/p return\n from to OR this AM\n REASON FOR THIS EXAMINATION:\n check NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n For NG tube placement.\n\n Tip of NG tube overlies body of stomach. No other change since previous film\n of . Endotracheal tube is 4 cm above carina. Tip of left\n subclavian CV line overlies proximal SVC. There are bilateral pleural\n effusions and associated atelectasis in the lower zones. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-07 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 981616, "text": " 4:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for lobar collapse, worsening RLL opacification\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p open abd on vent increasing FiO2 requirement and fever s/p return\n from to OR this AM\n REASON FOR THIS EXAMINATION:\n eval for lobar collapse, worsening RLL opacification\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Increasing oxygen requirements.\n\n A single AP view of the chest is obtained on at 1657 hours and is\n compared with the radiograph performed the same day at 0820 hours. Tubes and\n lines are unchanged. Low lung volumes persist. Persistent retrocardiac\n density in the left side consistent with airspace disease/atelectasis appears\n to have worsened. Opacity at the right base likely representing linear\n atelectasis is unchanged.\n\n IMPRESSION:\n\n Worsening retrocardiac opacification on the left side is consistent with\n worsening airspace disease/atelectasis at the left base. Unchanged right base\n opacity likely representing atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 982043, "text": " 1:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: acute desat\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p open abd on vent increasing FiO2 requirement and fever s/p return\n from to OR this AM\n REASON FOR THIS EXAMINATION:\n acute desat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old male status post open abdomen; fever and\n desaturation.\n\n COMPARISONS: Chest radiograph dated at 1141 hours.\n\n FINDINGS: A single AP portable view of the chest revealed the endotracheal\n tube to terminate 4 cm above the carina. The left subclavian catheter\n terminates in the proximal superior vena cava. A nasogastric tube terminates\n in the stomach. There is a stable bibasilar hazy opacity, without\n pneumothorax. The cardiac silhouette is stable. There is no pulmonary\n vascular congestion .\n\n IMPRESSIONS:\n\n 1. Stable chest radiograph, with layering moderate pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2178-11-15 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 982533, "text": " 3:20 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast only; r/o infectious process\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p LUQ stab wound, incr WBCs, mild temp\n REASON FOR THIS EXAMINATION:\n IV contrast only; r/o infectious process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post repair of gastric and duodenal injury after stab\n wound with increasing white blood cell count, mild temperature elevation.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: MDCT-acquired contiguous axial images from the lung bases to pubic\n symphysis were obtained following the administration of 130 mL of IV Optiray.\n Nonionic contrast was administered secondary to protocol. Coronal and\n sagittal reconstructions were performed.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Small left pleural effusion\n appears to have increased in size compared to the previous examination. There\n is associated compressive atelectasis within the left lower lobe. Minimal\n right pleural effusion also appears new in the interval.\n\n Liver, spleen, kidneys, adrenal glands, pancreas, gallbladder appear within\n normal limits. Postsurgical changes are seen within the anterior and\n posterior aspects of the body of the stomach as well as at the level of the\n ligament of Treitz, s/p resection of proximal jejunum. A small focal fluid\n collection has developed under the left lobe of the liver and just superior to\n the stomach, and lateral to the spleen measuring approximately 5.5 (AP) x 1.5\n (TV) x 1.6 (CC) cm, new in the interval. Second smaller fluid collection is\n seen just anterior to the anterior suture line within the stomach. Both of\n these small fluid collections likely represent postoperative seromas. Small\n amount of perisplenic hypodensity is also seen, just posterior to the superior\n aspect of the spleen (series 2, image 16) likely representing a trace amount\n of fluid.\n The abdominal wall has been closed in the interval. A small fluid collection\n contained within the left anterior abdominal wall musculature has decreased in\n size, now measuring 2.1 x 1.2 cm. The extent of mesenteric fat stranding has\n decreased in the interval. Small bowel loops otherwise appear unremarkable\n without evidence of obstruction, bowel wall thickening, or evidence of\n contrast extravasation.\n\n Abdominal aorta is normal in caliber. No pathologically enlarged mesenteric\n or retroperitoneal lymph nodes are seen. There is no free air.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: An oval loculated fluid\n collection measuring 4.4 (AP) x 3.1 (TV) x 2.3 (CC) has decreased in size from\n the prior exam, located just anterior to the rectum. This fluid collection\n continues to demonstrate what appears to be a hematocrit level, likely\n (Over)\n\n 3:20 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast only; r/o infectious process\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n representing a resolving hemorrhagic fluid collection. Remaining loops of\n bowel appear within normal limits. Small amount of gas is seen within the\n bladder, likely due to prior instrumentation. The bladder otherwise is\n unremarkable. Seminal vesicles, prostate are within normal limits. No pelvic\n or inguinal lymphadenopathy seen.\n\n Ill defined hypodense area causing expansion of the right gluteus medius and\n minimus muscles has decreased in size from the prior exam. Again this may\n reflect a resolving hematoma, edema, or contusion.\n\n Bone windows demonstrate no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Two small fluid collections surrounding the stomach, one anterior to the\n stomach adjacent to a suture site, and the second located just superior to the\n stomach and inferior to the left lobe of the liver. Both of these fluid\n collections likely represent postoperative seromas and are not amenable to\n image-guided drainage due to their small size.\n 2. Interval decrease in size of loculated hemorrhagic/proteinaceous fluid\n collection within the pelvis.\n 3. Interval decrease in size of ill-defined hypodensity in the right gluteus\n minimus and medius muscles causing muscle expansion. This may represent\n resolving intramuscular hematoma, contusion, or edema.\n 4. Status post closure of the abdominal wall with interval decrease in extent\n of mesenteric stranding. Small bowel loops are unremarkable.\n 5. Slight interval increase in size of small left pleural effusion and new\n right pleural effusion. Continued left lower lobe atelectasis.\n\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2178-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981572, "text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change suggestive of VAP\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd on vent, febrile,\n leukocytosis, increasing sputum production\n REASON FOR THIS EXAMINATION:\n eval for interval change suggestive of VAP\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Febrile, leukocytosis.\n\n Single AP view of the chest is obtained at 08:25 and is compared with\n the prior morning's radiograph. There is respiratory blurring on the film\n which is making this examination suboptimal. The patient remains intubated\n with the tip of the ET tube approximately 4 cm above the carina. Nasogastric\n tube is in place with its tip below the diaphragm and projecting over the\n expected location of the gastric fundus. Low lung volumes are present. Patchy\n opacity in the right base is again seen as is a retrocardiac density on the\n left side and patchy left lower lobe opacity which may represent\n atelectasis/air space disease. No pneumothorax seen.\n\n IMPRESSION:\n\n Low lung volumes with bibasilar lower lung opacities, incompletely evaluated\n due to respiratory blurring and left likely represented atelectasis or\n airspace disease.\n\n" }, { "category": "Radiology", "chartdate": "2178-11-04 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 981201, "text": " 5:26 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Is there evidence of 1) leak from gastric or duodenal repair\n Admitting Diagnosis: S/P STABBING\n Field of view: 38\n ______________________________________________________________________________\n FINAL ADDENDUM\n Findings discussed with Dr. .\n\n\n 5:26 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Is there evidence of 1) leak from gastric or duodenal repair\n Admitting Diagnosis: S/P STABBING\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p ex lap repair of gastric and duodenal injury after\n stab wound (POD 6), s/p takeback for abdominal compartment syndrome (POD 3),\n now with persistent hypotension, volume requirement. Please perform with IV\n and NGT contrast - we are most interested in proximal bowel.\n REASON FOR THIS EXAMINATION:\n Is there evidence of 1) leak from gastric or duodenal repair 2) missed bowel\n injury 3) abscess 4) missed pancreatic injury?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 26-year-old male status post ex-lap repair of gastric and\n duodenal injury after stab wound, postop day 6. Postop day 3 for reoperation\n for abdominal compartment syndrome. Persistent hypotension, volume\n requirement.\n\n COMPARISON: None.\n\n TECHNIQUE: Contrast-enhanced MDCT acquired axial images of the chest,\n abdomen, and pelvis from the thoracic inlet to the pubic symphysis.\n Multiplanar reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lungs demonstrate bilateral\n dependent lower lobe consolidation vs atelectasis, right greater than left.\n Small left pleural effusion is present. Note is made of a tiny air bubble\n within a small focal colleciton of pleural fluid along the left mid lateral\n chest, which may relate to a small traumatic pneumatocele. ET tube and NG tube\n are identified. The heart and great vessels are normal. The thoracic aorta\n maintains a normal contour. No mediastinal, axillary or hilar lymphadenopathy.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: No focal hepatic lesion is\n identified, however streak artifact limits sensitivity. The adrenal glands\n spleen, gallbladder and pancreas are within normal limits. Fluid is seen\n surrounding the head of the pancreas. The kidneys enhance and excrete\n contrast symmetrically.\n\n The abdomen remains open. Pigtail drain via a left subcostal approach\n terminates anterior to the stomach and left lobe of the liver. JP drain is\n seen within the subcutaneous tissues of the mid abdomen. Contrast opacifies\n the small bowel, however yet to reach the cecum and distal ileum. There is a\n tiny focus of high density material along the anterior abdominal wall (series\n 2 image 90), which is of uncertain etiology and may relate to suture material\n although extraluminal contrast cannot be excluded . There is no evidence of\n intraperitoneal extravasation of oral contrast. Suture material is identified\n in the stomach and proximal small bowel.\n\n (Over)\n\n 5:26 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Is there evidence of 1) leak from gastric or duodenal repair\n Admitting Diagnosis: S/P STABBING\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Intermesenteric fat stranding and small amount of free fluid seen within the\n abdomen, however, no evidence of free intra- abdominal air. The abdominal\n aorta maintains a normal contour. The celiac, proximal SMA, are normally\n opacified.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon are\n within normal limits. Bladder is decompressed and contains a Foley with tiny\n bubbles of air. Free fluid with a hematocrit level is seen within the pelvis,\n likely blood. A left fat-containing inguinal hernia is identified.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesion is detected. Note is\n made of diffuse subcutaneous tissue strading and edema. More focal tissue\n asymetry is identified overlying the right illiac bone, which may represent\n contusion, edema, IM hematoma (though atypical).\n\n IMPRESSION:\n 1. Right lower lobe consolidation vs atelctasis. Small left pleural effusion.\n 2. Postoperative changes within the stomach and proximal duodenum. No\n evidence of intrperitoneal extravasation of oral contrast. Extensive\n intermesenteric stranding and small amount of free fluid. Open abominal wall.\n 3. Free fluid within the pelvis with a hematocrit level consistent with\n blood. Slight asymmetry of the muscles overlying the right iliac crest which\n may represent contusion, edema or Intramuscular hematoma.\n 4. Tiny focus of high density material along the anterior abdominal wall\n (series 2 image 90), which is of uncertain etiology and may relate to suture\n material although extraluminal contrast cannot be excluded. Recommend\n correlation with exam and CT can be repeated if indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981240, "text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient after multiple\n operations due to stabbing abdominal wound.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 4 cm above the carina. The left subclavian line tip is in\n mid SVC. The NG tube is in the stomach. Mediastinal drains are demonstrated\n in unchanged positions. Partial atelectasis of right lower lobe is again\n demonstrated accompanied by pleural effusion. Mild vascular engorgement might\n be positional. No pneumothorax is present.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981404, "text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: S/P multiple operations for stabbing through abdomen.\n\n Comparison is made to prior study performed a day earlier.\n\n ET tube is seen in standard position. A subclavian vein catheter tip is in\n the SVC. The NG tube tip is in the stomach. Small right pleural effusion is\n unchanged. The cardiac size is top normal. There are low lung volumes.\n Right lower lobe atelectasis is persistent. There is no pneumothorax.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2178-11-09 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 981747, "text": " 9:03 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: check NGT position.\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with s/p gastric jejunal perforation, complicated by\n compartment syndrome. POD#2 s/p abdominal closure. having regurgitation w/ TFs\n REASON FOR THIS EXAMINATION:\n check NGT position.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post gastric jejunal perforation, postoperative day\n two.\n\n ABDOMEN\n\n The distribution of gas in the abdomen is unremarkable. Multiple opacities\n overlying the left flank are thought to lie outside of the abdomen in\n bandages. No free air is identified on the supine film.\n\n IMPRESSION: Unremarkable bowel gas pattern.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-03 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 980981, "text": " 11:55 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd. Now s/p chest tube\n removal\n REASON FOR THIS EXAMINATION:\n ?PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left chest tube removal, to assess pneumothorax.\n\n In comparison with earlier films of this date, the left chest tube has been\n removed. There is no evidence of significant pneumothorax. However, there is\n some increasing opacification at the right base consistent with pleural fluid\n and underlying atelectasis or pneumonia. The endotracheal tube, nasogastric\n tube and left subclavian catheter remain in position.\n\n IMPRESSION:\n 1. Removal of left chest tube with no pneumothorax.\n 2. Increasing opacification at the right base consistent with pleural\n effusion and either atelectatic change or developing pneumonia.\n\n RLE\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2178-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980838, "text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old man status post stabbing injury.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: Multiple lines and tubes are in\n unchanged position. A coiled line over the left mid abdomen, likely\n represents - drain, given the history of recent abdominal\n surgery. A small/moderate right pleural effusion is new since , and\n tracks into the minor fissure. Atelectasis in both hila and along the\n existing left chest tube is unchanged. There is no pneumothorax.\n\n IMPRESSION: New, small/moderate layering pleural effusion could represent\n fiuld or blood.\n\n" }, { "category": "Radiology", "chartdate": "2178-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981064, "text": " 10:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate NGT placement\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd, s/p new NGT insertion\n REASON FOR THIS EXAMINATION:\n evaluate NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old male status post multiple abdominal operations, with\n new nasogastric tube insertion.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: A nasogastric tube has been replaced in the\n interval and now terminates in the area of the stomach fundus. The appearance\n of the chest is otherwise unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2178-10-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 980472, "text": " 11:31 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p l sl tlc\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n\n REASON FOR THIS EXAMINATION:\n s/p l sl tlc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old man status post stabbing injury.\n\n COMPARISON: AP supine portable chest x-ray dated at 6:40 a.m.\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube remains low lying 2 cm\n above the carina. A left subclavian central venous catheter is in place in\n the interval with the tip at the distal SVC/RA junction. A left chest tube is\n in place, unchanged. There is no pneumothorax on this supine radiograph. The\n pulmonary vasculature is not engorged. Streaky opacity surrounding both hila\n most likely represent atelectasis.\n\n IMPRESSION: Status post left subclavian central venous catheter placement\n with the tip at the distal SVC/RA junction. No pneumothorax on this supine\n radiograph. Left chest tube remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980960, "text": " 8:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval changes\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M intubated interval change RLL ? effusion vs. collapse\n\n REASON FOR THIS EXAMINATION:\n eval interval changes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n CLINICAL INDICATION: 26-year-old male, assess for interval change of the\n right lower lobe. Question effusion versus collapse. Assess for interval\n change.\n\n FINDINGS: and .\n\n FINDINGS: A single portable image of the chest was obtained. There is no\n significant interval change since the prior examination. The supporting lines\n are stable. Persistent right pleural effusion is noted. Persistent right\n basilar atelectasis is present. The cardiomediastinal silhouette is within\n normal limits.\n\n IMPRESSION: Stable examination as above.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980571, "text": " 2:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p or, eval for pulm edema\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n\n REASON FOR THIS EXAMINATION:\n s/p or, eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n HISTORY: Evaluate for pulmonary edema. Patient with history of recent\n stabbing.\n\n FINDINGS: Portable frontal view of the chest is compared with prior study\n . Cardiomediastinal silhouette is stable. Left subclavian central\n venous catheter terminates at the cavoatrial junction. Endotracheal tube\n terminates in the mid thoracic trachea. Orogastric tube is seen in the left\n upper quadrant within the stomach. There is no pleural effusion or\n pneumothorax. A left chest tube is unchanged in position. There is linear\n opacity in the left mid lung surrounding the chest tube which may be related\n to atelectasis. Right perihilar opacity has improved. Bony structures\n unchanged.\n\n IMPRESSION: Improved right perihilar opacity. No other change.\n\n" }, { "category": "Radiology", "chartdate": "2178-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 981063, "text": " 9:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p NGT placement\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 yo M s/p multiple operations for stabbing to abd. Now s/p chest tube\n removal\n REASON FOR THIS EXAMINATION:\n s/p NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old male, status post abdominal surgery. Evaluate\n nasogastric tube placement.\n\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: A nasogastric tube has been replaced in\n the interval and is curled at the level of the lower esophagus, with the tip\n positioned at the thoracic inlet. A left subclavian central venous catheter\n is unchanged in position with the tip at the left brachiocephalic/SVC\n junction. The heart size is normal. A moderately large right pleural\n effusion persists unchanged, with patchy atelectasis at the right lung base,\n and left mid lung.\n\n IMPRESSION: Malpositioned nasogastric tube as described above. A followup\n chest x-ray one hour earlier confirms repositioning within the stomach fundus.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 1614705, "text": "Nursing Progress Note 07:00-15:00\n(Continued)\nl Work is involved, assisting with identification of this pt, security called to keep pt safe.\n\nPlan: Maintain acceptable BPs, HR, and fluid status. Monitor sepsis/temp. Acquire additional information re: past medical history, home meds, ETOH use, this particular hospitalizing event. Support pt and family-only allow immediate family members to visit.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 1614706, "text": "Respiratory Care\n\n Pt continues on full ventilatory support. No changes made today. B/S CTA Sx'd scant thin white. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 1614707, "text": "T/SIVCU NSG note addendum\n1530>>\n\nplease see previous note.\nplease refer to careview for specific data.\nSocial service consult note in OMR\n\nEVENTS this afternoon: temperature resolving with additioanl tylenol\n tachycardia persisting\n sedation changes ongoing\n resolving metabolic acidosis\n **recent desaturations requiring increase in oxygen support. positive patient ID made\n\nNEURO- in light of new information regarding patient's PMH/substance abuse, fentanyl dose increased to 150mcg/hour(no significant cahnge in heart rate noted). Also, ativan dosing initiated with prn doses provided while awaiting arrival of infusion. Propofol weaned. (No significant change in heart rate noted in repsonse to these cahnges; blood presure level slightly decreased post ativan dosing.\nPatient continues to respond to voice, MAE's, follows commands, and nods head to answer yes/no questions regarding pain.\n\nCVS- NST withpout ectopy.\n acceptable blood pressure ranges with transient but consistent hypotensive response to stimualtion: coughing or suctioning.\n CVP 12>>6. IVF infusing @ 125cc/hour with fluid boluses of 1 liter L/R x 3 this shift to manage ongoing metabolic acidosis(assessed by lactate/base deficit values).\n\nRESP- Stable oxygenation and saturation ranges throughout the shift until ~ 1745 when saturation noted to drift into 93 then 88 range. No secretions obtained by suctioing although lung coarse and diminished bilaterally with faint wheezing apprecviated. CXR reported as unchanged from previous per ICU resident.\nPEEP and fio2 increased(see careview) with improvement in saturations; ABG revealed decrease in PaO2 to 72 range on increased O2 support settings.\nBladder pressure measured serially to assess for abdominal compartment syndrome: 20..13..21 with firm distended abdomen. Surgical and ICU teams aware.\nlactate levels improving; base deficit corrected to zero.\n\nID- temperature responding to antipyretic; currently 101.3 with repeat tylenol dose provided. Heart rate noted to be decreasing.\nContinues on fluconazole and antibiotics x3. Abdominal incision assessed by surgical team: s/s oozing but incision approximated with staples intact.\n\nRENAL- hourly output with slight increase to 60-70cc.\n electrolytes repleted.\n\nHEME- hct stable\n\nSKIN- warm, slightly moist; no diaphoresis post tylenol doses.\n palpable peripheral pulses; compression boots and sc heparin in use.\n\nSOCIAL- as noted in above note.\n\nASSESS: 28 yo male s/p stabbing with surgical repair to gastric and duodenal enterotomies. Post-op significant for ongoing fluid requirements, acidosis, fever and tachycardia, and acute desaturation.\nPMH significant for psychiatric disorders and poly substance abuse; possible withdrawal situation.\n\nPLAN- continue with current POC with close monitoring for abdominal compartment syndrome and increased respiratory failure/ARDS. Follow fever trend and treat with tylenol. Sedation a\n" }, { "category": "Nursing/other", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 1614708, "text": "T/SIVCU NSG note addendum\n(Continued)\nnd analgesia for pain and withdrawal management. Follow with DMH case manager for additional patient history/meds/information. Contnmue with family contact and support.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-31 00:00:00.000", "description": "Report", "row_id": 1614709, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds dim throughout suct sm loose clear. ABGs slowly improving but has significant oxygen deficit despite multiple vent adjustment. Pt transported to and from OR without incident. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-31 00:00:00.000", "description": "Report", "row_id": 1614710, "text": "T/SICU Nursing Progress Note\nEvents: Pt. bladder pressures kept rising, increased difficulty ventilating patient and decreasing urine output. Pt brought back to OR by trauma team for abdominal washout and abdomen left open and pt returned to T/SICU.\nReview of systems:\nNeuro: Sedated with fentanyl and ativan. Pt. requiring high doses to remain in synch with ventilator and to be able to tolerate turns. When lightened, opens eyes and follows simple commands, nods to questions. Pt. wrists restrained for safety.\nCVS: tachycardic. Before OR up to 130's, after OR 100-120, sinus. No ectopy. L radial art line initially correlated with nbp but now nbp > than art line. MAP 60-75. Has received several fluid boluses. Peripheral pulses present\nRESP: Pt with ARDS picture requiring high peep and fio2 to maintain abg. Multiple changes made to maximize oxygenation/ventilation. Current settings a/c 25 X 400 60% 18 peep, abg 100/45/7.30/-3. Very diminished breath sounds in lower lobes, coarse upper lung sounds. Minimal secretions. L sided chest tube to 20cm wall suction with serosanginous drainage. CXR done post op which show small lungs with very high diphragm.\nRENAL: LR @ 125cc/hr. Lytes repleted per sliding scales. Weight up 10kg from estimated preop weight. Pt with obvious edema. Urine output 1000cc since midnight.\nGI:Abdomen now open with ioban drape in place, L sided jp to bulb suction, lies in lesser sac. R sided jp to wall suction draining serosanginous drainage. NG in place with bilious drainage. Tube to not be manipulated. Pt on protonix for prophylaxis. Abdomen very tense and protruburant. We are continuing to follow bladder pressures (using 50cc, leveled at mid hip with patient flat). Last pressure 18.\nHeme: hct 30, on sq heparin and venodynes for prophylaxis. INR 1.6.\nID: on fluconozole, kefzol, cipro for antibiotic coverage. WBC 21. Temp to 101. Two blood cultures and urine sent to lab\nSKIN: Large abdominal dressing over open abdomen, small superficial lac on back from another stab wound.\nLINES: Has L radial art line, L subclavial triple lumen, three large bore peripheral ivs.\nSOCIAL: mom and dad called for OR permission and to report findings postop. Pt in privacy alert bed due to unknown circumstances of his injury.\nA: unfortunte 26 year old man s/p penetrating abdominal injury from stab wound now with abdominal compartment syndrome, ARDS picture.\nP: Continue careful hemodynamic monitoring, ventilation per ARDS protocol, full sedation till pt stabilizes.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-31 00:00:00.000", "description": "Report", "row_id": 1614711, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 400 x 25 12P 60%. Decreased PEEP from 18 to 15 to 12. Current ABG: 7.43/39/145/27. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-31 00:00:00.000", "description": "Report", "row_id": 1614712, "text": "0700-1900\nROS:\n\nNEURO: Sedated on Fentanyl/Ativan, waking up occasionally throughout day-MAEs with good equal strength, and even folowing commands at times. PERRLA 3mm/brisk. Impaired cough/gag. Fentanyl increased this am and pt appears comfortable per VS.\n\nCV: Received 25gms of Albumin x1 this am. Vasopressin also started at 1.2 units/hr (to remain at continious infusion rate) CVP 14-17. HR 80's-120, no ectopy. ABP initially much lower than cuff, appearing to correlate some what at times this afternoon. NIBP 90's-130's systolic. ABP 70's-100's systolic. Hct trending down slightly to 26(29)-?dilutional, repeat pending.\n\nRESP: Continues on vent. support-400 x 25 x 12, on 60% has been successfully tolerating weaning thus far per ABGS. No secretions. Lungs dimished in all fields, O2 sats 95-100%. Chest tube to 20cm wall , serous output, No fluctuation/leak noted. No crepidus. Dsg C/I.\n\nGI: Abd remains distended, some improvement from this am, becoming softer, hypo BS heard at 12 but not at 1600 check. NPO. to , MD has not been mainipulated/flushed, and cont. to drain sm amt bilious drainage.\n\nGU: Bladder pressures 18-23. LR at 125cc/hr. U/O has improved since initiating vasopressin. Foley draining clear yellow urine at 20-100cc/hr. Calcium repleted twice today and repeat lytes pending. Fluid balance +3L so far today.\n\nID: T-max 102, tylenol PR/ice packs provided, temp down to 100.1. WBC also down slightly, now 20. Fluconazole/Cipro continue.\n\nSKIN: Open abd-dsg C/I. JP #1 draining amts serosang. drainage. JP#2 to wall draining mod amts serodang. Staples to LUQ and back clean/intact. Skin at pressure sites/backside intact. Multipodus boots placed.\n\nSOCIAL: Privacy Alert bed. PD spoke with PD about coming up to see pt, RN informed them pt was unable to take part in questioning at this time due to condition. Police will f/u at another time. sister's into visit this afternoon and ICU consent obtained from -sister. informed this RN that an unidentified person came to her home last night looking for pt and a friend, however pt's family didnt answer door and didnt see person at door. Family is pleased with pt's progress, questions/behavior have been appropriate.\n\nPOC: Continue to wean vent settings as tolerated\n monitor Abd wound/bladder pressures\n sedation/pain management\n replete lytes PRN\n update/support family PRN-maintain Privacy alert\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-01 00:00:00.000", "description": "Report", "row_id": 1614713, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Pt remains with open abd. ABGs cont to improve as well as pt; able to wean FIO2 overnoc. Would not wean PEEP any lower since it is required to counteract tense abdomen and it is not causing any additional hemodynamic embarassment at present. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 1614704, "text": "Nursing Progress Note 07:00-15:00\n26 yo male s/p stabbing x2: LUQ abdomen and upper left back. No further information known of event. Had surgical repair of stomach and duodenum, and left CT placed. Tox screen ETOH: 207.\n\nSee careview for specific data.\n\nNeuro: Pt wakes to stimulation/voice, responds to questions about pain by nodding/mouthing \"yes\" or \"no\". Follows commands, calm and cooperative but requires restraints for protection to prevent him from pulling his tubes. He reaches for the tubes when restraints removed and his orientation is difficult to assess d/t ET tube and sedation. Pt has brisk, reactive, equal pupils.\n\nPain: Fentanyl gtt 50mcg/kg/hr as well as propofol 50mcg/kg/min for sedation for most of day with good response. Occasional 50mcg Fentanyl boluses required for pain/repositioning. Recently changed to Ativan IVP + Fentanyl gtt for comfort. Response to new medication regime unknown.\n\nCV: Low BP at times, Sinus Tachycardia. NBP and ABP equivocal. CV . EBL 600cc, given 3 units PRBCs in OR. Given periodic fluid boluses throughout the day to maintain adequate BPs and improve metabolic acidosis. Hypovolemia and questionable third spacing in abdomen.\n\nResp: Lung sounds coarse in upper lobes bilaterally, diminished in lower lobes. Left lung is more diminished than right. O2 sat >95% on 50% FiO2 vent. Left CT to 20cm continuous suction draining small amount of serosanguinous fluid. No leaking, very little fluctuation.\n\nSKIN: Both wounds sutured, abdominal stab wound with intact dsd, back stab wound open to air with no drainage. Large abdominal dsd has moderate serosanguinous drainage. Remote scar noted on left upper back. No other skin issues.\n\nGI: Abdomen soft during AM but more firm during afternoon, distended. NPO with NGT which is not to be repositioned/flushed per TSICU team-they request to do it if there are issues.\n\nGU: Adequate UO draining from foley: opaque yellow with some sediment ?d/t propofol. Bladder pressures 20 down to 13 in afternoon.\n\nENDO: BS maintained by RISS.\n\nID: Pt is febrile up to 103.3, HR to 140's-given Tylenol PR with HR decreasing. Tetanus IM injection given in left deltoid. Pt on Flagyl, Cispro, Cefazolin, and awaiting ID to approve Flux order. Some of bowel contents suspected to be in abdomen, watching for sepsis/signs of infection.\n\nLines: PIVs x3, Arterial line in left wrist, and CVL placed today. Sharp, all WNL & intact.\n\nSocial: Pt identified in afternoon. According to mother, police called her about the stabbing which happened near pt's home . Mother and father live in and son lived in in a group housing unit run by the Department of Mental Health at one point because of his mental illness (bipolar and ADD)-now lives in an apt in . Mention of previous/ongoing altercation with another man (unknown relationship or if this person was involved in the stabbing). Pt's DOB is and name is (still identified as EU Critical ). \n" }, { "category": "Radiology", "chartdate": "2178-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980698, "text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung infiltrates\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n\n REASON FOR THIS EXAMINATION:\n lung infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 26-year-old man with stabbing wound. Evaluate lung infiltrates.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been no interval change. The endotracheal tube, left-sided central\n venous catheter, feeding tube, and left-sided chest tube are stable. There is\n again seen parenchymal opacity within the suprahilar region identified at the\n left chest tube, stable. No pneumothoraces are seen.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2178-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980422, "text": " 6:15 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess location of ETT, chest tube and r/o PTX\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n REASON FOR THIS EXAMINATION:\n assess location of ETT, chest tube and r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Replacement of malpositioned chest endotracheal tube.\n\n FINDINGS: In comparison with earlier films of this date, the endotracheal\n tube has been pulled back to about 2 cm above the carina. The nasogastric\n tube extends to the distal stomach. A left chest tube is in place and there\n is no definite evidence of pneumothorax.\n\n There is an area of increased opacification in the left perihilar region. It\n is unclear whether this could be related to the insertion of the chest tube or\n possibly represent a focal area of atelectasis or developing pneumonia.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2178-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980414, "text": " 2:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx? tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n REASON FOR THIS EXAMINATION:\n ptx? tube placement?\n ______________________________________________________________________________\n WET READ: KLMn FRI 2:22 AM\n Right mainstem intubation. Please pull back ~3cm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25-year-old man with stabbing. Preop for an exploratory\n laparotomy.\n\n COMPARISON: None.\n\n AP SUPINE CHEST: An endotracheal tube extends into the right mainstem\n bronchus and should be pulled back at least 3 cm. Lung volumes are quite low.\n There is no evidence of consolidation. The cardiac and mediastinal contours\n are difficult to assess but are likely within normal limits given technique\n and extremely low volumes. No definite pneumothoraces or pleural effusions\n are seen. There are no displaced rib fractures.\n\n IMPRESSION: Right mainstem intubation. Please pull back roughly 3 cm.\n\n Findings were discussed with Dr. at the time of the study.\n\n" }, { "category": "Radiology", "chartdate": "2178-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 980538, "text": " 6:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? iuncrease in pnx\n Admitting Diagnosis: S/P STABBING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man with stabbing\n\n REASON FOR THIS EXAMINATION:\n ? iuncrease in pnx\n ______________________________________________________________________________\n WET READ: DXAe FRI 9:36 PM\n No pneumothorax. Streaky perihilar opacities both hila may represent\n pneumonia or atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax.\n\n Single portable radiograph of the chest is submitted. The left lateral\n hemithorax is excluded. ET tube is 1 cm. above the carina. The remaining\n visualized portions of the support lines are unchanged compared with the chest\n radiograph obtained six hours prior. No pneumothorax is identified. Trachea\n is midline. Increased airspace opacities involving the bilateral lungs,\n particularly in the right hilar region and along the course of the left-sided\n chest tube, remain similar in appearance. The lung volumes are low.\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-07 00:00:00.000", "description": "Report", "row_id": 1614745, "text": "Nursing Progress Note\n(Continued)\n units coverage. Potassium and calcium gluconate repleted.\n\nSocial: Pt's family called today for anesthesia & surgical consent (spoke to anesthesia, MD, and RNs), very pleasant and appreciative. Plan to visit tomorrow.\n\nPlan: Ensure that pt is sedated and comfortable while paralyzed: note vital sign changes which may be indicators of pain/awareness. Titrate Cisatracurium appropriately. Stop tube feeds if lowering head of bed. Rotate ET tube back to left side of mouth tomorrow to allow healing time on right side. Start antibiotics (still waiting from pharmacy).\n" }, { "category": "Nursing/other", "chartdate": "2178-11-08 00:00:00.000", "description": "Report", "row_id": 1614746, "text": "Resp Care\nPt remains intubated on full vent support. Adjustments made to vent settings accordingly, based on ABG results. Fio2 now weaned to 70%, PEEP remains at 10. SpO2= 96%. BS coarse bilaterally and diminished at lung bases. Pt suctioned for small amounts of thick white secretions. Paralytic turned off, sedation increased.. pt tolerating well at this time. Pt continues to become agitated when stimulated with suctioning and other nursing care, but recoving and calming down within seconds. See CareVue for details and specifics.\nPlan: Wean O2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-08 00:00:00.000", "description": "Report", "row_id": 1614747, "text": "Nursing Progress Note, 1900-0730\nPlease refer to careview for specifics.\n\nSHIFT EVENTS: Pt receive fluid boluses x2 for reacurring tachycardia, pan cultured for rectal tmax of 105.3, cisatracurium d/c'd, midaz increased for heavy sedation, aline clotted off/self d/c'd.\n\nROS:\n\nRESP: A/C 450x24, FiO2 70%, peep 10, SpO2 92-98%, pt overbreaths vent 1-2 breaths per . Most recent ABG taken at midnight while on 90% FiO2, 7.44/37/114/26/0. LS coarse bilaterally w/ diminished bases. Copious amts of oral secretions, scant amt of clear thick secretions sxned via ETT. Sputum specimen sent for culturing. Most recent CXR reveals increasing consolidation to RLL, ? pneumonia. Pulm hygiene performed per protocol.\n\nCVS: ST, no ectopy noted. HR 128-149, NIBP 110-130/44-65. Aline clotted off & d/c'd. Pt x2 with 1.5L of LR total for continual tachycardia/labile blood pressure. Tachycardia did not resolve following fluid boluses. Tmax 105.3 rectal. Pt received PO & PR tylenol, cooling blanket/ice packs applied to groin and armpits, cold bath given with minimal effect. Pt pan cultured. Receiving zosyn & vanco for anbx coverage for ? of pna. Pt remains febrile, Tmin 103.8 oral. ? neuroleptic malginant hyperthermia; Cisatracurium and reglan d/c'd as they may be a contributing factor to continual fever. Hct 33.7, WBC 53.2- significant increase in 24 hrs, yesterdays white count 26. LSC CVL for access. + pedal pulses. Venodynes and SC heparin for DVT prophylaxis.\n\nNEURO: Pt heavily sedated on 17mg/hr of midaz and 500mcg/hr of fentanyl. Pt opens eyes spontaneously, however unable to track or follow commands. GCS 10 (e4v1m5), pt withdraws/grimaces to sternal rub, moves all extremities purposefully and with equal strength, gag/cough intact. PERRLA.\n\nGI/GU: firmly distended, hypoactive BS, no BM, currently NPO, draining moderate amts of bilious output- 340 cc since midnight. Fascia closed, retention sutures in place. Moderate amt of s/s drainage, wet to dry dsg changed, + granulation noted. Bladder pressure 17. FS 139-153, sm amt insulin required per RISS. Foley patent, draining light amber urine. UOP 30-125cc/hr. Diamox given for correction of metabolic alkalosis. D5 1/2 NS w/ 20 KCL at 75 cc/hr. BUN 6, creatinine 1.1, Na 133, K 4.1, Ca 8.1, Mg 2.0, Phos 3.9. Lytes repleted as necessary.\n\nSOCIAL: No contact from family overnoc.\n\nPOC: Wean vent settings as appropriate, cont pulm hygiene, waiting for sputum culture results, cont anbx for ? pneumonia, hemodynamics/temperature, ? attempt to place new aline, maintain SBP > 90, bld cultures pnding, cont to keep pt heavily sedated for protection of airway and abdomen, cont w/ pain mgmt, GI status, cont skin care/dsg changes to abdomen, I/Os, replete lytes as required, cont to provide pt with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-08 00:00:00.000", "description": "Report", "row_id": 1614748, "text": "Respiratory Care\nPt had eso-balloon placed on 15cm showed ex.pair-peso -4.4, plat pair-peso = 6.2. On 23cm of peep ex.pair-peso= 0, plat pair-peso= 13.7, Pt had decreased BP on 23cm. Peep set 21cm ex.pair-peso= -2, plat = 11.5. Please see chart for graphs.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-08 00:00:00.000", "description": "Report", "row_id": 1614749, "text": "NPN \nEVENTS: >right axillary aline placed this am without difficulty. >Precedex started in attempt to wean high dose midazolam and fentanyl patient had been consistantly tachycardic but was maintainting an adequate blood pressure, became hypotensive shortly after aline placement (? caused by precedex initiation?) and IVF bolus was given and phenylephrine drip was started to maintain MAP of 60. currently remains on 0.5 mcg/kg/ phenylephrine.\n >this afternoon esophageal balloon was dropped to measure transthoracic pressures and maximize ventilor support with increased PEEP ~ PEEP increased to 21 after respiratory therapy got measurements (see RT note for details). patient transiently became hypotensive with PEEP increase and phenylephrine drip was increased temporarily ~ drip was quickly able to be weaned back to 0.5mcg/kg/\n >? Malignant hyperthermia vs NMS (as cause of temps of 105 over night, tachycardia, etc) ~ started on dantrolene sodium this evening, (at 1730), although most symptoms had resolved when dantrolene was given\n\nROS: see carevue for details\n\nNEURO: remains sedated on precedex (0.4mcg/kg/hr), fentanyl (200mcg/hr) and midazolam (8mg/hr). moves all extremities with stimulation > very strong. purposeful movement towards ETT when aroused. perla , briskly reactive > disconjugate gaze off & on.\n\nCV: initially tachycardic into 130s this morning with precedex initiation HR down and currently with HR 60-80s, SR, occasionally brady down to 57-59. as above, phenylephrine drip titrated to maintain MAP above 60 with good effect. CVP ~12. +pp, subq heparin as ordered.\n\nRESP: orally intubated and vented on settings as charted in carevue > PEEP increased per esophageal balloon numbers, abg pending ~ ls clear, dim at bases > suctioned for minimal clear secretions. O2 sat currently 97-98%. VAP bundle per protocol\n\nGI: abdomen firmly distended > hypoactive bowel sounds > tf started via this am ~ residuals acceptable thus far. no BM yet, digital exam - stool. protonix as ordered. bladder pressures 12\n\nGU: amber colored urine out via foley catheter. catheter seems to be positional. afternoon lytes pending.\n\nENDO: RISS for coverage if needed ~ no coverage needed today\n\nID: tmax today 103.5 > tylenol & motrin given, ETOH bath given frequently, ICE packs to groin & axilla, multiple cool baths given and now temp currently 98.0. vanco & zosyn as ordered. multiple blood, urine and sputum cultures negative.\n\nSKIN: intact aside from abdomen which has midline incision wwith wet > dry dressing changed . tissue pink/red moist > stay sutures intact.\n\nSOCIAL: no family contact today\n\nPLAN: wean vent if tolerated > follow esophageal balloon numbers as guide for weaning PEEP. maintain normothemic. titrate phenylephrine drip to maintain MAP of 60. turn & reposition frequently to prevent skin breakdown. ? if necessary to continue dantrolene since symptoms seem to have resolved. follow lab values and treat as indicated. monitor\n" }, { "category": "Nursing/other", "chartdate": "2178-11-08 00:00:00.000", "description": "Report", "row_id": 1614750, "text": "NPN \n(Continued)\n& support as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-09 00:00:00.000", "description": "Report", "row_id": 1614751, "text": "Resp Care\nPt remains intubated on full vent support. Vent changes made according to ABG's and SpO2. Rate weaned to 18, FiO2 weaned to 50%. BS mostly clear and diminished bilaterally with slight exp wheezing in RLL. Prn Albuterol given. Suctioning for scant amounts of thick white secretions. Last ABG shows slight metabolic alkalosis with PaO2=66, Spo2=92%. Follow up ABG pending, Spo2 currently 100% on FIO2 50%. PEEP remains at 21. Eso. balloon remains in place, TPP still -2. See CareVue for details and specifics.\nPlan: Slow wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2178-11-13 00:00:00.000", "description": "Report", "row_id": 1614771, "text": "NPN, 1900-0700\nneuro: AAO x ; calm and cooperatvie all noc w/ precedex gtt. Fentanyl gtt weaned by 50%; pt tol well w/ pain. No focal deficits; PERRLA\n\nCV: NSR, no VEA; MAP 70-90. Pulses palpable throughout; moderate anasarca. Pboots, sq heparin DVT rpophy.\n\nPulm: weaned to NC w/ sats 98-100%. Strong cough, productive thick tan secretions. BS essentially CTA, bases.\n\nGI: sl firm, tender to palp; hypoactive BS. +flatus, no stool. Pt d/c'd last eve; NPO. VAC over open inciosn; intact and clean, draining scant s/s.\n\nGU: F/C urine clear yellow, adequate OP. remains +4 liter for LOS.\n\nSkin: no pressure areas; skin grossly intact. A-line d/c'd leaking, bleeding; site clean w/o hematoma.\n\nEndo: RISS, adequate coverage.\n\nID: Tmax 99.8po; cont on mult antibx. WBC remains 23\n\nPsychosocila: no family contact .\n\nP: cont fentanyl wean; d/c precedex. ? PCA dilaudid. OOB today. Social Service Consult today. ? start po liquids as tol.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-13 00:00:00.000", "description": "Report", "row_id": 1614772, "text": "Nursing Progress Note\nEvents: precedex and fentanyl gtts shut off\n all antibiotics dc'd\n TPN dc'd\n started on po diet\n called out to floor\n\nSee carevue for specific details:\n\nSkin: abdominal dressing intact with wound vac.\n\nNeuro: alert/oriented X 3, MAE's,follows commands.sometimes a little anxious,on the call bell throughout the day.easily reassured.\n\nCV: hr 80's-100's,SR-ST,no ectopy noted. low grade temp.SBP increasing throughout afternoon.120's-190s'-5mg IV lopressor given with good effect.heparin SC,p boots on. fluids KVO'd,LEFt SC cvl.\n\nResp: RA all day. sats 95-100%,RR 24-28.productive cough-white/thick,small amt.LS clear bilat,dim at bases at times.\n\nGI: softy distended around wound vac site.hypoactive BS,no BM.positive flatus.pt asked for bedpan many times today-pt has not had a BM yet today.Pt started on clear liquid and advanced to full liquid diet. pt's appetite still poor,but attempted to eat. no c/o N/V. TPN stopped today.\n\nGU: foley cath draining clear,yellow, and adequate amt of urine an hour.\n\nPain: fentanyl weaned off today,replaced with fentanyl patch.pt also on methadone.pt has no c/o pain.\n\nSocial: social work and psych in to see pt today. social work called mother and father. pt had a nice visit with his parents.\n\nPlan: transfer orders written-waiting for telemetry bed\n encourage po's\n use prn meds to keep pt from getting HTN\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-05 00:00:00.000", "description": "Report", "row_id": 1614735, "text": "T/SICU NSG NOTE\n0700>>1900\n\nEVENTS: Continues with intermittent anxiety/agitation with activities.\n Arterial line d/c'd: not working; unable to place new one.\n Desaturation to 90 this afternoon; slow resolution.\n Urine output low: maintenance IV started\n amber with clots & sediment\n To start tube feeds tonight.\n\nNEURO- sedated with higher doses fentanyl; boluses required with activites, espescially turning,suctioning, mouth care. Patient does not nod head to questions today; moves extremities purposefully and with normal strength: focused attempts to pull ETT. Ativan 2mg ivp every 2-4 hours. Haldol dosing discontinued. Strong cough/gag.\\\n\nCVS- continues to spike heart rate to 150-180 with extreme agitation, but less episodes today. NSR-NST 90 120. CVP- single numbers.\n\nto be continued\n" }, { "category": "Nursing/other", "chartdate": "2178-11-05 00:00:00.000", "description": "Report", "row_id": 1614736, "text": "Respiratory Care\nPt remains intubated on psv/cpap, with ATC. Suctioned mod amts of white secrections.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-05 00:00:00.000", "description": "Report", "row_id": 1614737, "text": "nsg note continued:\n\nCVS: blood pressure maintained greater than 100/systolic until recently- now drifting into 90/range with MAP's in 50's. IVF continues at 75cc per hour. Fluid bolus x1(250cc) today for low urine output. No albumin this shift..per ICU team.\n..unable to place arterial line; central line wnl but positional and at times difficult to draw blood.\n..cortisol stimulation test repeated today- pending.\n\nRENAL- sub-optimal urine output some hours this shift: maintainence fluid started and fluid blous x1 as noted...output improved to 40-50cc per hour now. Urine is amber colored and notable for some clots and sediment.\n\nRESP- remains on PSV/CPAP 5/5 with 40% fio2. Breath sound are clear>coarse with diminished bases: R>L. Secretions are scant to small amounts of thick white to light tan sputum.\nOne episode of desturation with slow resolution following an episode of intense agitation. Now saturations greater than 95%.\n\nID- temp max- 101.2; no tylenol required this shift. No new culture results; no antibiotics. WBC continues to climb: 28(26, 20)\n\nENDO- no coverage required.\n\nHEME- stable, no issues\n\nGU- to start tube feeding today with replete. PPI continues. Reglan and erythromycin therapy initiated to assist in bowel emptying/motility. Abd remains open and distended. Drainage from JPs x2 is reduced today. Abd dressing was changed by trauma team and mesh support was tightened again.\n\nSKIN- intact, compression boots and multipodus boots in use. sc heparin continues. warm skin with palpable peripheral pulses.\nSmall right lip corner ulceration presists; ETT not rotated.\n\nSOCIAL- call from Mom this am for update; no other contact this shift.\n\nA/P: continues with intermittent agitation episodes assoicated with coughing & pain. Patient continues to require fentanyl infusion at 350mcg/hour with bolus doses(50-100mcg) provided with activities of suctioning/turning/mouth care. Ativan 2mg ivp also provided eery 2 to 4 hours prn.\n less temperature variation this shift.\n low urine output requiring IVF support\n nutritional support initiated\n daily dsg changes, tightening of mesh, and monitoring for surgical closure.\n continue all other interventions/plans\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-06 00:00:00.000", "description": "Report", "row_id": 1614738, "text": "Resp Care\nPt remains intubated on PSV. No vent changes made this shift. BS slightly coarse bilaterally, exp wheezing heard at times. Pt ordered for Albuterol MDI prn, given X2. Pt 'd for moderate amounts of thick white secretions. PT continues to become very agitated with any intervention. See CareVue for details and specifics.\nPlan: Maintain vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-06 00:00:00.000", "description": "Report", "row_id": 1614739, "text": "Nursing Progress Note 7pm-7am\n\nROS: See carevue for exact data\n\nIssues overnoc: Adequate sedation, risk for self extubation.\n\nN: Pt with frequent periods of severe agitation. Pt sitting up in bed, forcefully reaching up for ETT. Requiring person assist to hold pt down. Ativan frequently through the noc. Dr. aware of agitation. Pt currently on 400-450 mcg fentanyl an hour. Suggested to MD possibility of implementing another medication, ? pt developing tolerance for drug. Pt will intermitently follow commands, MAE's. Able to nod yes and no to questions asked by RN. Bilat wrist restraints and mitts.\nCV: BP stable 100-120's systolically. HR 90's SR, frequent episodes of burst tachycardia with any stimulation to the patient. When relaxed HR does come down. Palp pulses, venodynnes on. CVP d/c'd overnoc due to inadequate read. Pt with left subclavian line. Pt has no arterial line\nResp: Pt on PSV ventilation 5/5. LS coarse to clear, suctioned for yellow thick secretions. O2 sats 97-99%, occas will dip to 94% but with poor wave form. Pleth currently on pts toe. Resp slightly dropped overenoc but pt still remains with same minute ventilations. Pt has no art line Dr. aware. No gas warranted by MD.\nGi: Pt remains with open belly. Distended, soft, hypoactive BS. Pt with OGT, tube feeds initiated last noc. Titrate to order. No BM yet.\nGu: U/o adeq, some small occasional clots noted in catheter.\nSkin: Open transparent drsg . Pt with 2 jps #2 to suction, #1 to bulb suction. Some staples to back and below left breast from s/p stabbing. Old CT site intact.\nLytes: K being repleted, pt will need calcium\nHem: Hct stable\nID: Pt cont with temperatures, wbc starting to come down.Endo: Bld sugars wnl.\nPlan: Better pain, sedation regimen while pt intubated. Wrist restraints to be continued. Monitor pain control. Plan to continue to close abdomen daily. Provide support, cont with current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-06 00:00:00.000", "description": "Report", "row_id": 1614740, "text": "Respiratory care\nPt remains intubated on cpap/psv , Plan to continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-06 00:00:00.000", "description": "Report", "row_id": 1614741, "text": "Nursing Progress Note: 0700-1900\n\nNeuro: Pt. received sedated on 400mcg/hour Fentanyl, still very agitated, putting legs over edge of bed,HR and BP high. Pt. given multiple boluses of Fentanyl without helping and was then given 4mg Ativan which calmed pt. down. After discussion with team, pt. was started on Versed gtt as well. Fentanyl now at 350mcg/hour and Versed at 4mg/hour which works. Pt. still requires boluses when being stimulated. He MAE (very strong), has not followed any commands, ? whether pt. has nodded head in response to questions. He does not seem to make eye contact.\n\nCV: HR 90s-100s when not agitated (up to 150s when he is), NBP 90s-130s/40s-50s (higher when agitated). Pt. is quite edematous. L SC TLC is patent and WNL.\n\nResp: RR teens-30s, 02 sats high 90s. Pt. on CPAP+PS 40%/. Pt. suctioned occasionally for scan amounts of thick,white sputum. Lungs are clear to all lobes.\n\nGI: BSX4, no BM on shift. Tube feeds of Replete with fiber at 60cc/hour (goal 75cc/hour) and are tolerated well. Abdomen open, surgical team changed dressing today, no obvious signs of infection. JP drain to wall suction and draining brown liquid (500cc for shift). One drain removed this morning.\n\nGU: UO was around 30-40cc/hour today aso Lasix gtt started at 1700 (to be titrated to UO- needs clarification).\n\nEndo: No coverage required.\n\nSkin: Dressing to open abdomen is to suction (not wound vac), dressings to back and side are dry and intact.\n\nSocial: Priest and cousin in to see patient.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-07 00:00:00.000", "description": "Report", "row_id": 1614742, "text": "NPN, 1900-0730\nPlease refer to careview for specifics.\n\nNo significant events this shift.\n\nROS:\n\nRESP: CPAP + PS, , FiO2 40%, TV 400. SpO2 96-100%, occasionally dips to 94% when pt requires sxning. RR 12-23. LS coarse bilaterally. Moderate amt thick clear/whitish secretions sxned via ETT or with oropharyngeal sxning. Cough/gag intact.\n\nCVS: ST, no ectopy noted. HR 104-134, when anxious/agitated HR will increase as high as 180s. NIBP 98-124/38-61, MAP 53-73. Tmax 102.5, pt given 650mg tylenol x2, pt receiving for erythromycin for anbx covered. Pt pan cultured on , bld cultures pnding. Hct stable- 27.3, WBC 26.2. LSC CVL for access. + pedal pulses. Heparin and venodynes for DVT prophylaxis.\n\nNEURO: Pt receiving midaz and fentanyl gtt for sedation/pain control, however pt easily agitated/anxious when stimulated, therefore requires occasional boluses of midaz, especially prior to turning pt. Midaz is currently infusing at 6mg/hr and fentanyl 400mcg/hr. Pt arouses to voice/noxious stimuli, GCS (e4v1m5-6), moves all extremities purposefully and with equal strength, pt follows commands inconsistently, pt did appear alert at midnight- asked if he was having discomfort and nodded yes. PERRLA, gag/cough intact.\n\nGI/GU: open and firmly distended, vac dsg in place, JP x1 to continuous wall , draining moderate to lg amts serosanguinous drainage- 350cc total this shift. Bladder pressure 15. Replete w/ fiber at 30cc/hr, residuals have been high: 75-190cc, therefore unable to titrate tube feeds to goal of 75cc/hr. FS 104-134, no insulin required per RISS. Foley patent, c/y/u noted. Lasix gtt set at 4mg/hr to maintain adequate uop- approx 200cc/hr. BUN 7, creatinine 1.0, Na 137, K 3.9, Ca 7.3, Mg 2.3, Phos 2.8. Lytes repleted according to sliding scales. D5 1/4NS infusing at 75cc/hr.\n\nSOCIAL: No contact from family overnoc.\n\nPOC: Wean vent settings, ? extubate, pulm toileting, hemodynamics, cont to titrate midaz as appropriate for proper sedation, cont w/ pain mgmt, cont to GI status, advance TF according to residuals, titrate lasix gtt for adequate uop- amt of uop not specified, replete lytes as ordered, cont to provide pt with emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-12 00:00:00.000", "description": "Report", "row_id": 1614768, "text": "NPN 1900-0700\n\n Pt became dangerously agitated at . Requiring extra doses both fentanyl and versed to decrease agitation to managable level. Dr at bedside. Pt very purposefully trying to kick staff and pull out tubes. After calming somewhat at 2100 pt again at very dangerously agitated and requiring more sedation. Eventually Ho spoke with attending who wants to utilize propofol gtt to maintain safety/sedation. At 50mcg/kg/ pt quiet x 4hrs. Midazolam gtt finished early am and left off at present to assess level of sedation without it, given one PRN dose.\n\nResp- Unchanged. copious amts oral secretions with agitation, small to mod amt thick yellow ETT secretions.ABGs wnl.\n\nCV- SR-ST, adeq BP. HTN when agitated. Afebrile. WBCs^23. HCT stable. Calcium repleted. Lasix given with 2L+ in 3 hours. Cont to diursis well overnight. K 4.0.\nSkin w/d. dressing changed, tissue pink with some small tan areas.\n\nGI/GU- TF increased, residuals remain less than 200cc. 2 large loose stools this shift. Foley patent with adeq UO.\n\nPlan- ?trach and PEG vs extubation. Wean sedation if tolerated.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-12 00:00:00.000", "description": "Report", "row_id": 1614769, "text": "Resp Care\nPt weaned and extubated this afternoon to 100% cool aerosol face tent. Prior to extubation many vent changes were made throughout the shift due to aggitation. Pt weaned to just before extuabtion with adequate abg and rsbi. Pt has strong periodically productive cough of thick tan/yellow secretions. Pt had audible cuff leak prior to extuabtion and no stridor post. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-12 00:00:00.000", "description": "Report", "row_id": 1614770, "text": "**TSICU NURSING NOTE 7A-7P**\n--please see carevue for exact data--\n\nEVENTS: pt @ 1600, currently on 40%FiO2 face tent\n wound vac placed on abdomen.\n\nROS:\n\nNEURO: pt A&Ox3. following commands. MAE's, equal strength, purposeful movements. PERRLA 3mm/3mm, brisk. +cough/gag. propofol discontinued for extubation. pt currently on Fentanyl @400mcg/hr & Precedex @ .7mcg/kg/hr for pain control. PLan to wean as tolerated.\n\nCV: NSR-ST. no ectopy. HR 90-120s. ABP 110-130s/60-80s. sharp waveform. PRN Lopressor ordered to control HR&BP. extremities warm. +pp. TLC LSC/WNL. R axillary A-line/WNL. compression sleeves, multipodus boots, SC heparin for prophylaxis.\n\nRESP: pt @ approx 1600. currently on face tent, 40%FiO2. tolerating well. RR 20-low 30s. SaO2 96-100%. LS clear bilaterally w/diminished bases. strong productive cough. C&DB taught & encouraged.\n\nGI: SS , currently clamped. TF, Replete w/fiber @ goal of 80cc/hr. TF off during extubation & currently to . TPN infusing, plan to d/c tpn tomorrow. +BS. +BM x1, pt placed on bedpan. firm/distended. wound vac placed w/small amts s/s drainage, wound bed pink, top of incision with visable omentum, white sponge placed over dehised portion. dressing dry&intact. PPI for prophylaxis.\n\nGU: Foley, adequate amts yellow/clr urine.\n\nENDO: RISS, no coverage needed during shift.\n\nID: Tmax 100.7. prn tyelenol given, fan on & cool cloth applied to forehead. Vanco, zosyn & flagyl ordered, but plan to discontinue tomorrow. WBC's trending down\n\nSOCIAL: no family contact.\n\nPLAN: cont to monitor hemodynamic & respiratory status. cont to control pain. encourage C&DB. teach & encourage use of IS. discontinue TPN and antibiotics tomorrow . cont to support pt.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614763, "text": "T/SICU Nursing Progress Note\nTube feedings to be at trophic 10cc/hr and not advanced for now per ho .\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614764, "text": "NURSING NOTE 7AM-7PM\n\nSEE CAREVUE FOR EXACT DATA\n\nISSUES OF TODAY: PT APPEARED COMFORTABLE THIS A.M. ON CURRENT SEDATIVE LEVELS. PT ON FENTANYL, MIDAZOLAM, PRECEDEX, CLONIDINE PATCH. PT DOING WELL WOULD REQUIRE AN OCCASIONAL EXTRA IVP OF MIDAZOLAM AND FENTANYL TO HELP ASSIST WITH ANY STIMULATION TO PT DUE TO HIS HIGH AGITATION LEVEL. PT THIS AFTERNOON NOT SETTLING DOWN AFTER NOON CARE DESPITE EXTRA DOSE IVP MEDS. MD CALLED TO THE ROOM. TOTAL OF 4 RN AT PT'S BEDSIDE KEEPING PT SAFE AND FROM SELF EXTUBATION. AT CURRENT TIME PT HYPERDYNAMIC, BP 180-190'S SYSTOLICALLY WITH HR IN THE 130'S-150'S. PTS O2 SAT DROPPED AT TIME TO LOW 80'S. PT ON AC CONTROL PEEP INCREASED FROM 10-->12 WITH INCREASE IN O2.PT HAD XRAY PRIOR TO EPISODE BUT DUE TO EPISODE DR. WANTED REPEAT TO MAKE SURE NO OTHER CHANGES. PER ATTENDING PT TO BE RESTARTED ON PROPOFOL. ATTENDING AWARE OF INCREASED CK'S WHEN ON PROPOFOL PRIOR. PROPOFOL STARTED AT 20 MCG/KG/HR ALONG WITH FENTANYL, MIDAZOLAM, PRECEDEX, CLONIDINE PATCH. NO MEDS MD OR THAT NEED TO BE D/C'D CURRENTLY. PER TEAM CONTINUE ON SAME DOSAGES, NO NEED TO D/C ANY OTHER MED CURRENTLY. PLAN TO KEEP ON PROPOFOL UNTIL METHADONE STARTED THEN WEAN OFF PROPOFOL ALL TOGETHER. PT DID SETTLE DOWN, HEMODYNAMICS BACK TO BASELINE.\n\nROS: SEE CAREVUE FOR EXACT DATA\n\nN: PT ON MULTIPLE AGENTS FOR SEDATION/PAIN CONTROL. TO START METHADONE TODAY. ONCE METHADONE STARTED, PROPOFOL TO BE WEANED off COMPLETELY PER DR. . PROPOFOL USED MOM TO HELP PT SETTLE DOWN AND TO OXYGENATE PROPERLY. MAE'S WITH GOOD EQUAL STRENGTH. INCONSISTENTLY FOLLOWS COMMANDS. INITIALLY AFTER START OF PROPOFOL EYES BILAT DEVIATING OUTWARDS AND UP. DR. AWARE AND STATED THAT PT HAS BEEN LIKE THIS BEFORE OTHER PROPOFOL INFUSIONS. PT ABLE TO NOD YES AND NO TO PAIN AT TIMES. APPEARS COMFORTABLE, WHEN NOT STIMULATED PT ABLE TO SLEEP.\n\nCV: BP STABLE 100'S SYSTOLICALLY. HR 70'S SR. NO ECTOPY NOTED. BOOTS ON, SQ HEPARIN TID. PALP PULSES. NO MAINTENANCE FLUIDS, JUST KVO NS. PT TO START METHADONE, PRE-EKG REQUIRED PRIOR TO DOSE TO FOLLOW QTC. PT CONT WITH RIGHT AXILLART ALINE. CORRELATING WITH NBP FOLLOWING ART LINE PRESSURES. PT 'S LEFT SUBCLAVIAN SITE WNL, INTACT.\n\nRESP: PEEP DOWN TO 10 TODAY UNTIL SMALL SETBACK AND RECRUITMENT BREATH NEEDED WITH ISSUES THIS AFTERNOON. PT REMAINS ON CMV 500 X 16 WITH NOW PEEP 12. GAS'S REMAIN STABLE AND WNL. SUCTIONING THICK WHITE SECRETIONS FROM LUNGS. PT WITH LOTS OF ORAL SECRETIONS (NO TUBE FEED NOTED). O2 SATS 98-100% PT IS BREATHING OVER THE VENT. MOUTH CARE AS TOLERATED. SPOKE WITH TEAM TODAY RE: TRACHE/EXT PLANS. WILL REEVAL IN FOLLOWING DAYS PER TEAM. TUBE RETAPED TODAY, NOT REPOSITIONED DUE TO ULCER IN CORNER OF MOUTH. THRUSH NOTED TO TONGUE REQUESTED ORDER FOR TEAM FOR NYSTATIN.\n\nGI:TF STOPPED THIS A.M. DUE TO HIGH RESIDUALS PER ORDER >100 CC. PT WITH RESIDUALS TO 140'S. RECHECKED AT NOON AND SAME OUTPUTS REMAIN. PT TO START NARCAN PO TO HELP REVERSE ANY NARCOTIC ILEUS AND TO HELP\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614765, "text": "(Continued)\nINITIATE MOTILITY. PT GIVEN SUPPOSITORY AGAIN THIS AFTERNOON EFFECTS STILL PENDING. PT WITH OGT TO LEFT NARE FOR FEEDS, AND IS ON TPN DAILY NOW.\n\nGU: U/O ADEQ, NO ISSUE, CLR YELLOW URINE.\n\nSKIN: PT WITH STRAPS, OPEN BELLY WOUND WITH RETENTION SUTURES TO EACH SIDE OF . W--> D DRSG . TISSUE PINK, GRANULATING, SM AMT OF SEROUS SANG DRAINAGE. REST OF SKIN OTHERWISE INTACT. OLD STAB WOUND SITES OPEN TO AIR.\n\nID: TMAX 101.3, CULT ONLY IF GREATER THAN 101.5 PER DR. . PT CONT ON VANCO, FLAGYL, ZOSYN. DANTROLENE D/C'D CULTURES NEG. WBC TRENDING DOWN.\n\nHEM: STABLE LOW 20'S TEAM AWARE NO NEED FOR TRANSFUSION AT PRESENT TIME.\n\nENDO: NO INSULIN REQ'D\n\nPLAN: MONITOR NEURO STATUS\n TO START METHADONE, AND WEAN FROM PROPOFOL, TO EVENTUALLY START WEANING ALL OTHER SEDATIVE MEDS IN HOPES TO EXTUBATE\n CONTINUE WRIST RESTRAINTS FOR SAFETY.\n CONT VENT WEAN AS TOLERATED FOLLOWING ABG'S\n MONITOR GI STATUS, RESIDUALS, RESTART TF ONCE LESS THAN 100 CC, CONT TO PT DAILY.\n DRSG AS ORDERED.\n MONITOR TEMPS, CULTURE IF RE-SPIKE, ?COURSE OF ANBX IF STILL ALL CULT NEG. CONT CURRENT PLAN OF CARE, MONITOR PROVIDE SUPPORT.\n ? TRACHE AND PEG IN FUTURE\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614766, "text": "Respiratory Care\n\n\n Pt continues on full ventilatory support. Pt had episode this afternoon of acute desaturation. Very awake and dyschnronous. FI02 up and PEEP up Pt sedated and FI02 weaned. B/S sl coarse. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-12 00:00:00.000", "description": "Report", "row_id": 1614767, "text": "Respiratory Care:\nPatient remains intubated and on fentanyl and propofol for sedation. He appears slightly restless but is synchronous with vent. He is on A/C of 500 by 16, +10 PEEP and 40%. RSBI held at this time due to high peep level. Awaiting team rounds for desired changes as none are noted in POE. BS=bilat, suctioned for minimal secretions. No albuterol needed this shift. Plan to continue with supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614732, "text": "T/SICU NSG NOTE\n(Continued)\n.\n\nASSESS: 26 yo male s/p stabing with repair to gastric and duodenal sites. ICU course complicated by abdominal compartment syndrome requiring return to OR to open & rexplore abdomen. Patient has required ventilation support and sedation due to open abdomen; today he is tolerating PSV. Narcotic infusion & PRN dosing with anti anxietals continues due to patient's history of substance abuse and known pysch disorder.\n\nPLAN- assess daily for ability to close abdomen; possible vac dressing if fascia can be closed. Attempt to wean & extubate when abdomen is more secure. Consider nutritional support. Continue sedation/pain management. Moniotr hemodynamics and support with albumin & vadoactive agents per ICU team if urine output becomes inadequate. Follow temp, maintain normothermia; reculture as needed. Provide reorietation and reassurance prn.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-05 00:00:00.000", "description": "Report", "row_id": 1614733, "text": "Resp Care,\nPt. remains on IPS ATC on. VT 400's RR 15. Suctioned white sputum. RSBI 32 this am. Maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-05 00:00:00.000", "description": "Report", "row_id": 1614734, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems:\nNeuro:Pt remains on fentanyl gtt. With any stimulation especially turning, suctioning pt gets quite agitated, arches back and attempts to extubate himself. Pt. also given doses of ativan and haldol without much effect. Fentanyl gtt increased X 2 in 50 mcg/hr amounts. Currently on 400mcg/hr and at present pt appears comfortable when undisturbed. Difficult to titrate sedation to adequate levels without impairing respiratory effort. Pt. also on zyprexa (disintegrating tab). At times pt nods to questions and will follow simple commands inconsistently.\nCVS: at rest heart rate 90-115, with stimulation heart rate can go as high as 180! BP 88-160/70-80. CVP 9-12, peripheral pulses present\nRESP: remains orally intubated on psv 5/peep 5 40% with adequate oxygenation/ventilation (co2 slightly elevated to 54). Suctioned for thick white secretions. CXR done this am.\nRENAL: fluids are kvo'd. Urine output adquate, weight down to 86.3kg. Lytes wnl.\nGI: ng in place draining bilious liquid. On protonix. Abdomen remains open with two jps in place. L sided jp to bulb suction, R sided to wall suction. patch in place with transparent dressing. Abdomen slightly soft but distended. Pt receiving no nutrition. Absent bowel sounds.\nHeme: hct down slightly to 27, on venodynes and sq heparin.\nID: temp to 102.4, wbc up to 28, blood cultures X 2, urine sputum sent, on no antibiotics.\nskin: open abdomen as described above. L sided chest tube site with dsd, back laceration with two staples open to air.\nLines: L sc triple lumen and R radial art line in place\nA: 26 year old man with penetrating abdominal trauma with open abdomen, agitation, fevers and high wbc.\nP: follow cultures. Consider other sedation methods to achieve better levels. ??ID consult to assess for other causes of temp.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-09 00:00:00.000", "description": "Report", "row_id": 1614754, "text": "Resp Care\nPt remains intubated on CMV and high level of peep. ABG's as noted able to wean peep slowly today. Esophageal balloon remains inplace, no measurements done. Plan to continue to wean vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614755, "text": "Respiratory Care:\nPatient remains intubated and sedated with PEEP lowered to 17 last shift and good oxygenation on abgs. BS remain coarse. He received one albuterol MDI this am for apparent air trapping on waveforms. He has been suctioned by RN app Q1-2 hours for small-med amounts of pale secretions. No RSBI done due to high PEEP level. Plan for continuos monitoring and weaning as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614726, "text": "NPN 1200-1900\n\n Pt had brochoscopy at 1300 and LSC multilumen site rewired.\nBlood and BAL sent for cx.\n\n Pt currently on 300mcg/h fentanyl and 3. Pt had recieved 4mg ativan and 150mcg of fentanyl during bronch at Dr request. Post procedure pt very sedate and hypotensive. Opened eyes to pain and occ stimuli, little other response. Repositioned with little effect on pt LOC or VS. Fent decreased to 100mcg and later increased as pt more responsive. Prior to procedure when stimulated he became very agitated and resisted care with HR as high as 180s and SBP 170s. Presently when stimulated pulls at gown and grabs onto staff, opens eyes to voice. Settles when undisturbed, however did pull out despite restraints, surgery aware.\n\nResp- AC 400x22x40% PEEP 5. Alkolosis on ABG. Lungs clear with diminished bases. Able to tolerate L side this afternoon. Bronch showed some secertions L>R. BAL sent.\n\nCV- SR-ST 80-180s with SBP from 70-170s. Very labile VS which correlate with LOC and nursing/medical interventions. At time SBP 70s with MAP 57-61 the CVP was 17-20 and HR in 80-90s. Decreased fent gtt for a while and VS improved. IVF TKO, CA repleted, tubing changed with new line. CPKs decreasing, in 8000s. BG wnl.\n\nGI/GU- Abd open, very distended, JP x 2 with intact transparent dressing. Hypo BS. As mentioned pt removed , surgery not wanting to replace it at this time. Foley patent with UO>30cc/h.\n\nSocial- No contact from family.\n\nPlan- Maintain minimal amt sedation needed for safety and pain control. Replete lytes as needed. Follow up on cultures. Monitor resp status for high risk PNA.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614727, "text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice. PERRLA (3mm bilat; briskly reactive). Pt squeezed RN's hands and moved toes to command inconsistently. Moves all extremities to nailbed pressure. Pt lifts/holds BUE and moves BLE in bed. Pt agitated with activity/turning/repositioning/suctioning; attempts to pull at ETT and sit up in bed at times. Bilateral wrist restraints on for safety. Bed alarm on; monitored closely by RN. Fentanyl gtt @ 300mcg/hr. Haldol and lorazepam IV given for agitation with +effect. Pt bolused with 30mcg fentanyl x2 when agitated. +gag/cough/corneal reflexes. Tmax 101.5 (Dr. aware). Tylenol 650mg PR given with +effect. At 0200, pt's temp 97.7 PO. Fan on. HR 90s-low 100s when asleep/calm (NSR/sinus tach). HR increased to 120-180s when agitated; Dr. aware; HR decreased to 90-110s after Haldol/lorazepam/fentanyl given. ABP 80s-160s/50s-80s. When asleep, SBP decreased to 80-low 100s. CVP 7-14. Pt with trace pedal and BUE edema. DP/PT pulses palpable. Weight: 83.6kg (down 1.1kg from yesterday). Multipodus boot alternated between RLE and LLE q3-4hrs. Venodyne boots on BLE. Potassium and calcium repleted. AM labs pending. Lungs coarse; clear/diminished at times. Pt suctioned down ETT for small amount thin, white secretions. Suctioned orally for moderate amount of thick, white secretions. No change in vent setting. CMV: 40%, Vt 400 x 22, PEEP 5. ABG showed metabolic alkalosis. O2 sat >/= 96%. Pt with strong cough. Mouth care done per VAP prevention protocol. HOB >/= 30 degrees. Old left chest tube site with dsg clean, dry, intact. No crepitus noted. Pt tolerated laying on left and right side. Abdomen open; hypoactive bowel sounds. placed by primary team, but CXR showed that was coiled. replaced by Dr. and another CXR ordered to evaluate placement. Per Dr. , placed to low continuous suction; large amount green, bilious drainage (see CareVue for total output). No bowel movement this shift. FS q6hr; BS 71-97. Foley intact with clear, yellow urine. UO 35-100cc/hr. Abdominal transparent dsg intact; small amount serosang drainage. JP #1 to bulb suction with small amount serosanguinous output. JP #2 to medium wall suction with large amount serosang output (see CareVue for total output). Staples on LUQ of abdomen and on back clean, dry, intact. No pressure sores noted. Pt turned and repositioned q2-3hrs to maintain skin integrity. No calls from family members overnight.\n : Monitor VS, I's and O's, labs. AM labs pending. Replete lytes per sliding scale. Monitor neuro and respiratory status. Wean vent setting as tolerated. Continue fentanyl gtt for pain/sedation; wean as tolerated. Haldol and lorazepam for agitation. Monitor temp; follow up cultures. Monitor abdominal dsg and drainage. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614728, "text": "Resp Care Note:\n\nPt cont intub as per Carevue. Lung sounds dim @ bases; suct sm th tan sput. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614729, "text": "Resp. Care Note\nPt received intubated and vented on AC settings per resp flowsheet. Pt changed to PSV during rounds with settings . TV 400 range, MV essent. unchanged. ABG 7.40/45/158/29/2. Cont current settings, pt needs to return to OR for abd. closure, no plans to extubate until then.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614730, "text": "BRIEF NURSING NOTE 1600-1900\nPT 1.5 BOTTLES OF -CAT FOR CT SCAN OF ABD, TORSO. TO CT SCAN AT 1730. RESULTS PENDING. UPON RETURN, PT DANGEROUSLY AGITATED SITTING UP IN BED AND RECEIVED 300 MCG BOLUS OF FENTANYL PLUS 2.5 MG HALDOL ALL IV. DURING CT SCAN, PT 2 MG IV ATIVAN WITH GOOD SEDATION.\n\nPRESENTLY SEDATED ON 300 MCG/HR OF FENTANYL. SUCTIONED FOR MOD AMTS OF THICK TAN /WHITE SPUTUM.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-04 00:00:00.000", "description": "Report", "row_id": 1614731, "text": "T/SICU NSG NOTE\n0700>>1530\n\nEVENTS: temp spike to 102.9(cultures -pending)\n hypotension: fluid bolus and albumin infusion\n intermittent agitation/anxiety: ativan & haldol with effect\n abdominal dressing changed\n abdominla CT done\n corticostimulation test\n\nNEURO- fentanyl infusion continues @ 250-300mcg per hour for pain management with effect at rest; transient discomfort noted with turning & coughing activitites. PRN dosing with ativan and haldol for persistent & intermittent agitation & anxiety with turning and coughing activites. Patient remains purposeful with upper extremities movements: attempts to self extubate. He remains minimally responsive when calm/sedate but will open eyes. He does not respond briskly to commands but will follow with persistent encouragement. Patietn contiues to have dramatic heart rate response to noxious stimulation- see careview flowsheet.\n\nCVS- NSR..NST without ectopy; rate varies with level of anxiety/agitation/discomfort. Blood pressure has less dramatic response than heart rate. Blood pressure drifts into 70-90/systolic range following prn medications for agitation/anxiety treatment. Patient received fluid bolus(500cc) and 25grams of albumin to support intravascular volume. CVP remains . IVF remains at kvo rate.\n\nRENAL- adequate hourly urine output. Goal is for negative daily fluid balance if possible. ICU team will tolerate lower systolic blood pressure as long as urine outpur continues to be adequate(30cc/hour). Currently, fluid status is negative.\n..serum potassium repleted with 40meg kcl\n..serum calcium repleted with 4 grams calcium gluconate.\n\nRESP- ventilation mode changed to CPAP/PS at 5/5 with 40% fio2. ABG's remain within acceptable range. Breath sounds remain and diminished at bases. Secretions are small amounts of thick white sputum; oral secretion production hjas decreasewd; glycopyrolate therapy is finished(last 2 doses not given). Cough is strong.\nOral ulcer at right lip corner; ett not rotated.\n\nID- temp spike to 102.9; tylenol and fan...temp to 100.6; cultures pending from . No antibiotics at this time. WBC is elevated: 26(20).\n\nGI- bilious gastric draainge in mod-large amounts.\n PPI contiues\n NPO\n abdomen remains open with abdominal dressing changed by trauma team at bedside under sterile technigue; wound edges were brought closer together but edema presistes and fascia ias not able to be closed at this time per team. Abdominal CT was done- pending.\n\nENDO- no coverage required.\n\nSKIN- generally intact: see above notation on lip ulcer and abdomin remains open with transparent dressing. JP drains x2 to abdominal wound with mod-large amount s/s drainage. Previous CT site with dry dsg. Stab wound sites with staples: D&I.\nSkin remains warm and moist; compression boots and sc heparin continue. Multipodus boot in use.\n\nSOCIAL- parents visiting today; excited to see patietn with his eyes open and trying to speak. Condition update and plan of care provided\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614756, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: on max dose precedex (0.7 mcg/kg/hr). Fentanyl increased over shift as when pt awake is quite difficult to control and prevent from self extubation. Currently on 500mcg fentanyl/hr. Continues on dantrolene for ??malignant hyperthermia tx. Pt. follows commands at intervals, mouths words.\nCVS: when quiet hr 70-80, bp 95-100. When agitated heart rate as high as 150's, bp 140/60. CVP 12-20, peripheral pulses present\nRESP: remains orally intubated on a/c 18 X 500, 50%, 17 peep. ABGs within acceptable limits. Suctioned for thick white secretions.\nRENAL: calcium repleted. Pt. was 2L negative yesterday. Weight today 81.8kg. Urine output 60-180cc/hr. Fluids at kvo\nGI: Abdomen firm with hypoactive bowel sounds. NG with bilious output. Pt. on protonix for prophylaxis. No stool, +flatus. Receiving no nutrition at present. Had issues with reguritation of tube feeds into mouth with prior attempt at feeding.\nENDO: ssri, no insulin needed\nID: wbc 29, temp to 101. Was cultured at 1pm last. Continues on vancomycin, flagyl and zosyn. Cultures have been negative to date.\nMRSA screen sent\nSKIN: Belly with open skin. Moist to dry dressings being done tid. Held in place with straps. Wound is beefy red with small amount of serosanginous drainage.\nIV: has l sc triple lumen and R axillary art line.\nsocial: no calls from family tonight.\nA: s/p penetrating abdominal traums with persistent fevers, high wbc but negative cultures\nPersistent agitation requiring large doses of sedation\nInadequate nutritional status.\nP: ??IR for ng advancement to start feedings. Continue sedation as needed. Follow cultures and adjust antibiotics as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614757, "text": "T/SICU Nursing Progress Note addendum\nHeme: 2am hct 22, clot sent to blood bank. Pt. with venodynes and sq heparin for prophylaxis.\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614758, "text": "T/SIUC NSG NOTE\n0700>>1900\n\nEVENTS: PEEP weaned to 12cm\n Versed drip restarted for increasing agitation.\n TPN & tube feedings started.\n More awake today.\n\nNEURO- persistent intermittent restlessness/ agitation/ anxiety/ discomfort...required restart of versed infusion AND continues to require boluses of versed and fentanyl pre activities. Patient remains on dexamethasone @ .7mcg/kg/hour with overall improved sense of calm & cooperation. Patient with eyes open much of afternoon; improved focusing on speaker; nodding head to answer questions; imnteracting with parents somewhat during their visit. Versed 2mg>>3mg per hour; fentanyl weaned to 400mcg/hour.\nDantrolene therapy continues; patient noted to be less rigid; CPK's down; temp down; vitals more steady.\n**clonidine patch therapy initiated today.\n\nCVS- heart rate and blood pressure elevate with stimulation/discomfort but to less intense degree than previously AND settle more quickly. Vitals remain within an acceptable range with HR now 70-80's; no ectopy.\nBladder p[ressure to 18() this evening; to be repeated this evening and reported to ICU/surgical teams if more elevated.\n\nRESP- tolerated wean of peep to 12cm; saturations remain 100%; abg on 15cm peep: in acceptable range. Breath sound remain clear with diminished bases. Secretions are clear and moderately thick with increase in amount noted this afternoon. Cough is strong & effective in loosening secretions.\nVAP care per protocol.\n\nRENAL- adequate hourly urine output. Minimal fluid intake; slight negative fluid balance today. Electrolytes repleted.\n\nGI- remains firm/distended; PPI.\n adjusted by surgical team. clamped with residuals of 60cc after 5 hours>> tube feedings started. Back flow continues from vent port whenever patient in flat position of whenever coughing.\nTPN therapy initiated today.\n\nID- tmax 100.8. Continues on antibiotics.\n wound is pink & moist with serous draiange in moderate amount; wet to dry dressing tid continues.\n\nENDO- no coverage required\n\nSKIN- intact but for abdominal incision.\n compression boots and sc heparin; multipodus boots in use. Positioned side to side every 2-3 hours.\n\nSOCIAL- parents visited this afternoon; update provided by ICU RN and resident. Possibility of neuroleptic malignant syndrome & malignant HTN explained.\n\nASSESS- 26 yo s/p stb incident with penetrating gatric and bowel injuries. Post-op course complicated by abdominal compartment syndrome requiring opening od abdominal incision, high temps, elevated wbc without positive cultures,labile hemodynamics, elevated CPK levels and muscle rigidity...possible differential diagnoses: NMS and Malignant htn. ICU course also comlpicated by respiratory failure and significant supplemental oxygen support required. Dantrolene threaoy assessed as effective.\n..patient also with high analgesic & sedation requirements.\n\nPLAN- continue with current plan of care.\n wean fentanyl as tolerated\n advance tube feeds as tolera\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614759, "text": "T/SIUC NSG NOTE\n(Continued)\n.\n wean peep in am as tolerated; ? PSV\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-10 00:00:00.000", "description": "Report", "row_id": 1614760, "text": "Resp Care\nPt remains intubated on CMV, able to wean peep. Abg's as noted with good oxygenation. Plan to continue to wean as tolerated and manage sedation.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614761, "text": "Respiratory Care:\nPatient continues on A/C mode of 500 by 16, 40% and +10. BS are bilat, coarse. Suctioned frequently for small amounts of thick whitish sputum. RSBI held due to high PEEP level. Plan to continue weaning as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 1614762, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: sedated with precedex, fentanyl, midazolam and clonidine patch. Still startles with suctioning, mouth care but settles much faster and less agitation observed when not disturbed. Nods at times to questions, follows commands inconsistently. Distant gaze when eyes open. Restrained with wrist restraints and mitts to prevent self extubation. Continues on dantrolene for ??neuroleptic malignant syndrome.\nCVS: sinus rhythm 70's at rest, up to 115 with stimulation. BP 95-130. CVP13-25. Peripheral pulses present.\nRESP: on a/c 16X500 40% 10 peep with excellent abg. Suctioned for thick white secretions. Mouth care per vap protocol. Breath sounds decreased in bases.\nRENAL: weight today 81.5kg, urine output 60-150cc/hr. Lytes repleted per orders.\nGI: receiving tube feeds per ng tube of fs replete with fiber, initiated at 10cc/hr, currently at 30cc/hr. Held for 2 hours because of high residual (140cc). Belly firm, distended with hypoactive bowel sounds. On protonix. Bladder pressure remains at 18mmhg. On starter tpn.\nENDO:ssri, last bs 125\nID: wbc down to 20 (29), continues on vancomycin, flagyl, and zosyn. T max 101. Cultures still negative at present. Last cultures 10/8 at 1pm.\nHEME: hct 21, on sq heparin, venodynes.\nSKIN: continue tid wet to dry dressings to open abdominal wound. Wound is pink with serosanginous drainage, held in place with straps. Staples removed from L upper quadrant stab wound site, draining small amount of sanginous drainage. Other skin intact. ??mouth with white coating so pt may be developing thrush.\nLINES: L subclavian triple lumen, R axillary art line in place, also with 20 g angio r lower arm\nSOCIAL: no contact with family tonight\nA: lungs much improved oxygenation, ventilation. Agitation better controlled on current medications. WBC on the downswing.\nP: continue to advance tube feedings as tolerated. Wean peep as tolerated. Continue careful hemodynamic monitoring. If pt spikes, reculture again.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-01 00:00:00.000", "description": "Report", "row_id": 1614716, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 400 x 22 10P 40%. Current ABG: 7.44/50/116/35. Decreased PEEP from 12 to 10. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-02 00:00:00.000", "description": "Report", "row_id": 1614717, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. ABGs cont to improve and stable overnoc; no vent changes required. Would not decrease PEEP since abd remains tense. Cont mech vent and PEEP.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-02 00:00:00.000", "description": "Report", "row_id": 1614718, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: sedated with fentanyl and ativan, responds to name called. With stimulation has exaggerated response with very tense arms and legs requiring boluses of fentanyl. Also receiving iv haldo (2.5 mg q 4hours) which has allowed a decrease in fentanyl and ativan overall. When undisturbed, pt appears very comfortable. Pt. at times will follow simple commands. PERRLA.\nCVS: at rest heart rate 80-110, BP 90-120 systolic. Art line dampened and very positional with bleeding at site (catheter appears to be kinked). CVP 5-11, peripheral pulses present. With stimulation heart rate to 140-150 and BP to 170-180.\nRESP: no changes in ventilation made overnight. Currently on a/c 22X400, 40% 10 peep. Suctioned for thick yellow secretions. Decreased breath sounds in bases. Pt. with L pleural tube with serous drainage, no leak noted. Last abg 178/41/7.51 +9. Mouth care per VAP protocol.\nRENAL: pt autodiuresing. Was 3500cc negative yesterday despite a 500cc fluid bolus late in day for decreasing BP. PO4 low again this am. Potassium and calcium repleted. Pt. with metabolic alkalosis (BE +9). Weight today 90.5kg. Cr 1.0. Sodium has corrected from 130 yesterday am to 141 this morning.\nGI: ng in L nare remains in place with bilious output. Belly open with patch in place, much softer than yesterday. Bladder pressure 17mmHg. Iodoban dressing in place. R sided JP to wall suction draining serosanginous drainage. L sided JP to bulb suction with small amount of serous drainage. On protonix. Liver enzymes elevated this am as is CPK (!).\nENDO:ssri\nHeme: hct again down to 21.3 this am. Sq heparin and venodynes in place.\nID: remains febrile to 102.6po despite cooling methods of cool bath, fan and tylenol. On cipro, flagyl, and fluconozole. All cultures pending. WBC 18\nSKIN: open abdomen, stab wound on l abdomen with staples. Also has small stab wound on back which is open to air, no drainage. Other skin intact. Multipodus being alternated between feet.\nLINES: All peripheral ivs removed, pt with Lsc triple lumen and L radial art line (which is described above).\nSocial: no calls or visits from family tonight.\nA: Autodiuresis. Metabolic alkalosis secondary to ??gi losses. Elevated CPK due to ?? Persistent fevers due to ??.\nP: replete K and PO4 as ordered. Continue sedation of ativan, fentanyl with prn haldol. ??begin nutrition. Rewire/replace art line. Follow cultures and adjust antibiotics as indicated. Follow CPK's.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-02 00:00:00.000", "description": "Report", "row_id": 1614719, "text": "Resp Care\nPt remains intubated. Current vent settings: A/C 400 x 22 8P 40%. Decreased PEEP from 10 to 8. Pt tolerating well. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-02 00:00:00.000", "description": "Report", "row_id": 1614720, "text": "NPN: Review of Systems\nNeuro: Sedated w/ 2mg/hr Ativan and 250mcg/hr fentanyl. 100mcg Fentanyl boluses w/ turning d/t Pt tense and resists movement. Opens eyes w/ stimulation. Brief episode approx 1840 during which Pt coughing/ pulling himself up/ agitated. HR up to 130s. Suctioned by respiratory therapist for small amt of secretions. Bolused w/ 100mcg fentanyl and 2.5mg haldol. Pt appears calm/ HR 115 w/ MAP 60s. Periodically follows commands: showed 2 fingers when asked and nodded occasionally to questions. PERRL. (+) cough and gag reflex. MAES. Soft wrist restraints on d/t purposeful hand movement to ETT.\n\nResp:ABG on AC Fio2 40%, 22X400, and 8 PEEP, which was decreased from 10cm PEEP= 7.41/45/114 and 30/+2. Sa02=100%. PEEP has since been decreased to 5cm and Sao2=99%. Pt not breathing over the vent. BS decreased at bases bilaterally.Pleural CT to 20cm suction. Draining small amts of serous fluid.\n\nCV: SR/ST. HR 80s-105. no ectopy. K=3.9->20meq KCl infusing. PO4=2.1-> 15mmmol sodium phosphate infusing over 6hrs. MAP 60s-80s. Left radial arterial line removed d/t dampening and unable to draw from line. New right radial arterial line placed. Fling present and arterial line approx 20-30 points higher than NBP. Following NBP. Skin warm/dry. DP pulses palpable bilaterally. Tmax=102.5-> PR tylenol given w/ drop in temp to 101. WBC=18.8k from 17.6K. Blood and sputum cultures from pending. Antibiotics discontinued. Temp at 1600=102.3. Pt w/o rigors. CPK= from .\n\nGI: to suction. output=350cc green fluid since 8am. Abdominal transparent dressing intact. Abdomen is open. Distended but according to Dr. < taut than previous exam. Serosanguinous drainage from JP #2 which is to suction. JP#1 w/ small amt of serous fluid. Fingerstick glucose=86-105-> no insulin coverage per sliding scale.\n\nGU: Clear yellow urine via foley. UO=1470 8am-1800. HCT=21.3 this morning-> 2 units PRBCs given for volume. F/U HCT=29.1. BUN/Cr=7/0.9. Pt currently (-) approx 1L.\n\nSkin: Chest/abdominal dressings intact. Upper back laceration staples intact/ no drainage and edges well approximated. No pressure wounds present.\n\nSocial: Mother and father in by bedside. Updated on plan of care. Asking appropriate questions. Calm/cooperative. They also spoke w/ SW.\n\nA: Calm/ comfortable apearing most of shift w/ one episode of agitation which responded to haldol and fentanyl. Hemodynamics have been stable. Steady autodiuresing. ? etiology of temp.\n\nP: Reculture if fever persists 24hrs after antibiotics stopped. F/U w/ culture results. 25% albumin when available to aid in diuresing. Electtrolyte repletion as ordered. Check QTc Cont. family support. Monitor as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614721, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse dim bases; suct mod th white sput. ABGs stable on present vent settings; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614722, "text": "Nursing Progress Note\nSee Careview for specific data\n\nSignificant Events: Albumin administered. wgt 84.7 kg, brisk UO, repleted lytes.\n\nNeuro: sedate, unable to assess orientation. Arouses to voice, does not follow commands, purposeful movement of all extremities, stiff/strong extremities. At 04:00 assessment, pupils brisk, equal, reactive, but has disconjugate gaze. 2.5mg Haldol for anxiety during repositioning- still requires soft arm restraints.\n\nPain: no c/o pain at rest, but vitals and agitation indicate pain during repositioning-given 100mcg fentanyl IVP with good relief. 250mcg Fentanyl gtt and Ativan 2mg gtt providing adequate comfort as evidenced by vitals and nonverbal cues.\n\nCV: ABP & NBP equivocal. SBP 140's except during periods of sleep when SBP dropped to 90's/100's. ST, no ectopy. HR quickly increases to 140's during agitation/repositioning but resolves quickly when pt quiets down. Adequate perfusion: brisk cap refill, easily palpable pedal pulses. Heparin and pneumo boots for DVT prophylaxis. HCT 29.1, CVP 4-10.\n\nResp: O2 sat 95-100% on 40% FiO2, 10 PEEP, no breaths over the vent. Clear in upper lobes, diminished in lower lobes bilaterally. for thick, white secretions about every hour when coughing.\n\nLytes: repleted 40mEq K+ and 3gm calcium gluconate\n\nSkin: 2 stab wounds, both open to air with no drainage: left upper back, LUQ abdomen. Large abdominal incision open with transparent dsg, no leaking/drainage.\n\nGI: NPO, NG tube to suction-do not manipulate per TSICU team request. NG tube draining large bilious drainage. Abdomen soft & distended, no BS, no BM.\n\nGU: Brisk UO throughout shift, clear, yellow urine draining through foley.\n\nID: Febrile throughout shift: Tmax 103.4- given Tylenol PR, ice packs, fan in room, cool facecloths, minimal relief, no diaphoresis. WBC count continues to increase, antibiotics removed.\n\nSocial: Family visited during day, no calls overnight.\n\nPlan: Monitor HR and BP closely for rapid changes. Monitor UO and fluid status. Monitor disconjugate gaze, temp, and lytes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614723, "text": "Correction\nCorrection: Pt on 5 PEEP throughout shift.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614724, "text": "T-SICU NPN\nS/P STabbing with Open Abdomen\n\nS/ Intubated. Sedated\nO/ See flowsheet for details.\n Neuro: Fentanyl increased from 250mcg/hr to 400 after total of 200 mcg boluses for guarding and writhing with stimuli, ie: ett suctioning or repositioning. MAE purposefully; strongly reaches for ETT. Does not follow commands.\n Cardiovascular: ST to 170 with stimuli, BP with tachycardia. CVP 4 After Increased fentanyl, HR and BP down. CVP down to 0mm Hg SBP 88 Given 25% albumin with BP to 130/66, HR 109, CVP backto 4 mm Hg\n REspiratory: SaO2 down to 84% while with lt side down + fremetus and dimness. FIO2 increased transiently. CXR done. No acute Lt sided process noted. Rt consolidation present. Copious thick oral secretions, same type suctioned from ETT. T max 101.7, down to 100.6 after pulmonary toilet and several turns. Now on Rt side So2 100%\n GI / GU: ABdomen remains firm with absent BS. NG lg amouts bileous drainage, JPS with serosanginous. Abdomen still open with occlusive transparent dressing, No leaking from dressing. U/O down.\n Endo / ID: BG normal Last cultures on . All negative. ON no antibiotics. Proph: on heparin sc, pneumoboots, PPI, alternating foot splints Skin: Intact, no redness on back . Lt posterior wounds not visualized\nA: Hyptotention and tachycardia secondary to Pain and hypovolemia\n Probable pneumonia secondary to intubation and aspiration of oral secretions.\nP: Albumin prn for hypotention with low CVP. Maintain comfort with fentanyl, may need to increase dosage further.\nBronch later today, Rigorous pulmonary hygiene. Keep pts head turned to side at all times to facilitate drainage of oral secretions. Will start glyco later to decrease secretion production\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-03 00:00:00.000", "description": "Report", "row_id": 1614725, "text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp flowsheet. Pt with desats to 80's this morning while turned to L side. CXR done and no new process noted on L. Sats improved when turned to R although CXR with R sided process. Bronch for BAL done. Secretions mostly white. Periods of agitation. cont vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-01 00:00:00.000", "description": "Report", "row_id": 1614714, "text": "T/SICU Nursing Progress Note\nS:\nO: Review of systems\nNeuro: sedated with ativan 3 mg/hr, fentanyl 450mcg/hr. Still wakes with stimulation such as turning, suctioning and at times even at rest. Pulls arms up and pulls torso off bed with suctioning. When lightened, follows commands and nods.\nCVS: continues on vasopressin at low dose. Heart rate 80-100, sinus. BP 98-130/50-70, cvp 8-11, peripheral pulses present\nRESP: abgs much improved on lower fio2 and lower peep. Currently on a/c 22 X 400, 40% 12 peep. Coarse breath sounds in upper lobes, decreased in lower lobes. Suctioned for scant amount of thick yellow secretions. L sided chest tube with no fluctuation/leak and serous drainage, no crepitus. CXR done this am.\nRENAL: LR @ 125/hr, weight up to 95.6 kg this am (preop estimate 80). Urine output 30-100cc/hr. Obviously edematous. Lytes repleted except for phosphate (awaiting order).\nGI: belly remains open. R sided JP draining large amount of serosanginous drainage, L side JP with small amount of serous drainage. NG to wall suction with bilious drainage. On protonix.\nENDO: ssri\nID: on fluconozole, flagyl, cipro, wbc 17 this am. Temp to 102.7 po, blood cultures X 2 and sputum sent to lab. Pt. persistently febrile despite tylenol, cool bath and fan.\nHeme: hct continues to drop, currently 21.1. On sq heparin and venodynes.\nskin: belly open with ioban dressing, small area on back from superficial stab wound. Other skin intact\nSocial: no calls from family\nLines: L sc triple lumen and l radial art line, two peripheral ivs in place\nA: Respiratory status much improved, persistently febrile\nP: dc vasopressin, hep lock fluids, ??start haldol, replete Phosphate, continue to monitor hct.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-01 00:00:00.000", "description": "Report", "row_id": 1614715, "text": "NPN \nROS: see carevue for details\n\nNEURO:patient remains lightly sedated on ativan and fentanyl drips. haldol and zyprexa given as ordered with good effect and ability to wean down ativan and fentanyl a bit throughout day. +csm. follows commands. opens eyes to voice. PERLA , reactive.\n\nCV: HR 90s-120s, SR. no ectopy noted. BP stable. hyperdynamic at times tachy into 120s and hypertensive ~140s-160s systolic but settled with decreased stimulation\n\nRESP: LS clear, coarse in uppers at times > dim at bases. suctioned for small amounts of thick yellow/white sputum. ABG with slight compensated metabolic alkalosis. PEEP decreased to 10. mouth care per VAP protocol.\n\nGI: to suction with bilious output. abd. remains open, absent bowel sounds. protonix as ordered.\n\nGU: autodiuresing, large amounts clear yellow urine out. afternoon electrolytes pending.\n\nFEN: IVF kvo'd this morning. Ca++ repleted. banana bag infusing.\n\nENDO: IRSS for coverage if needed.\n\nID: ciprofloxacin and flagyl as ordered. conts. with temps, tmax 101.9 today\n\nSKIN: abdomen open, transparent dressing intact with 2 JPs to suction. stab wound x2 with staples OTA. back side intact.\n\nSOCIAL: mom called today for update. she will visit tomorrow.\n\nplan: cont. to wean vent as tolerated. replete electrolytes as indicated. ? diuresis. return to OR sometime this week to close ABD. monitor & support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-09 00:00:00.000", "description": "Report", "row_id": 1614752, "text": "T-SICU NPN\nS/P Stab wound /X-Lap with Repairs Facia closure \nSee carevue for details.\nS- Intubated and sedated\nO- Neuro: MAE strongly, occ follows commands. Midaz now at 6mg/hr. Fentanyl and Dex drips unchanged.Bolus with 50 fentanyl and 2 midaz prior to turning with good effect.\nCV- Remains on NEO, no changes made SR and normotensive Tmax 102.8 Started on for potential c=diff coverage\nResp-FI02 down to 50% Still on PEEP21. Ve Lpm\nGI/GU- hypoactive BS, belly firm. consistently regurgitating bilious TF, feeds d/c and NG to lcs. I/O= minimally negative thus far today. +++ since admission. Skin intact\nA- Afebrile from 4pm until this am. Better controlled with present sedation regieme tonight\nP- Begin stool softeners and TF when tol pos without regurgitation.\nFollow cultures and fevers, Ween PEEP as tol. Reassess sedation needs at rounds. Wean neo as tol\n\n" }, { "category": "Nursing/other", "chartdate": "2178-11-07 00:00:00.000", "description": "Report", "row_id": 1614743, "text": "Resp Care\nPt remains intubated on PSV 5/5. No vent changes made this shift. BS coarse bilaterally and diminished at lung bases. Pt suctioned for moderate amounts of thick white secretions. Morning RSBI=34.8. See CareVue for details and specifics.\nPlan: Maintain Vent support.\n" }, { "category": "Nursing/other", "chartdate": "2178-11-07 00:00:00.000", "description": "Report", "row_id": 1614744, "text": "Nursing Progress Note\nSee Careview for specific data.\n\nSignificant Events: Albumin given. Pt brought to OR for approximation of faschia (skin still open) after mesh was found to be ripped. Pt paralyzed before procedure, returned from OR with tachycardia and HTN- was paralyzed with Cisatracurium Besylate without adequate sedation/pain coverage. pt with Midazolam and Fentanyl to provide pt with comfort. Tachycardia to 160's, T max 104.1: fan on, cold wet facecloths, and Tylenol PR with relief: temperature continues to drop. Tube feeds stopped because residuals greater than 250cc. Arterial line placed in left axilla.\n\nNeuro: Pt sedated with midazolam and paralyzed with Cisatracurium. TOF present before paralytic at 40watts. 0 thumb twitches at .12mcg/hour, titrated down to .10mcg/hr. Pt unresponsive to stimuli/pain but occasionally winces. Before paralyzing , pt followed commands inconsistently, opened eyes spontaneously.\n\nCV: Tachycardia, SBP high initially when returned from OR-given Fentanyl and Midazolam boluses until pt's vitals indicated comfort. CVP not being recorded, ABP placed today, WNL. No ectopy. Albumin administered twice today (25% 25gm each time). Heparin, P boots for DVT prophylaxis.\n\nResp: Lung sounds clear to coarse bilaterally in upper lobes, diminished in lower lobes. Suctioned through mouth for thick moderate, white secretions, suctioned through ET tube for scant thin clear secretions. CXR twice today, suspected pneumonia-antibiotics to begin tonight. O2 sats currently 95-100% on 60% FiO2, increased from 40% FiO2 d/t low saturation. ET tube in place-rotated to right mouth today (right corner of mouth still has small ulcer), had been on left side for several days.\n\nGI: Pt tolerating tube feeds (Replete with fiber full strength) up to 50cc/hr this AM with bilious/undigested residuals 150cc. Tube feeds turned off during procedure in OR, resumed upon return to TSICU (residual=100cc). Pt noted to have tube feeds in mouth and nose after repositioning, suctioned, tube feeds stopped d/t residuals >250cc. Absent BS, no BM, bowel regime planned to start today but held d/t procedure and Tylenol PR administration. Attemped PEG placement in OR but unable to place d/t large intestine status. Reglan and Erythromycin started today.\n\nGU: Lasix started at 4mg/hr, turned down to 3mg/hr then discontinued. Had brisk yellow UO in AM, changed to amber with sediment, now draining minimal amber UO through foley. Bladder pressure: 13.\n\nID: CXR done twice today, suspected pneumonia: to start on antibiotics tonight (Vanco and Zosyn). WBCs up to 26, Febrile.\n\nSKIN: back intact with exception of small stab wound on left upper shoulder which is sutured and open to air- no drainage. Sutures can be removed. Abdomen has dsd in place, some serosanguinous drainage noted on dsdf placed in OR. Stab wound in LUQ covered by dsd, still has sutures (can be removed). CT site on left anterior chest is open to air, WNL.\n\nEndo: Pt on RISS, received 2\n" }, { "category": "Nursing/other", "chartdate": "2178-11-09 00:00:00.000", "description": "Report", "row_id": 1614753, "text": "NPN \nROS: see caervue for details\n\nNEURO: patient more awake today > remains sedated on precedex and fentanyl drips. following commands inconsistantly, opens eyes to voice > moves all extremities with good strength. fentanyl for wtih good effect. PERLA3-4, briskly reactive. becomes agitated at times very purposeful towards ETT, settles with 100mcg bolus of fenatnyl\n\nCV: HR 70/80s, SR. occassionally tachycardic into 120s-130s with agitation, but has been self limiting and settles fairly well. BP stable NEO gtt weaned of this am. +pp. subq hep as ordered.\n\nRESP: orally intubated and vented on settings as charted in carevue. ABGs improving. LS clear, dim at bases. secretions per ETT. O2 sat 99-100%\n\nGI: to suction. per Dr. tube is not in stomach and feeds should not be started until further notice. firmly distended , +hypoactive bowel sounds. no bm.\n\nGU: adequate urine out via foley catheter. Ca++ repleted as indicated. PM lytes pending\n\nENDO: no coverage necessary via riss.\n\nID: tmax this am, currently 98.4. cont. on vanco, zosyn and flagyl\n\nSKIN: midline abdominal wound with w>d dressing . granulating in and looks good. no odor/drainage noted.\n\nSOCIAL: no family contact\n\nPLAN: wean PEEP as tolerated. cont. sedation as indicated. turn & reposistion frequently. cont. abx as ordered. follow up with trauma team regarding position and start feeds when appropriate. monitor & support as indicated.\n" }, { "category": "Echo", "chartdate": "2178-10-31 00:00:00.000", "description": "Report", "row_id": 83661, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 59\nWeight (lb): 188\nBSA (m2): 1.80 m2\nBP (mm Hg): 102/40\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 14:10\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: If clinically indicated, a cardiac MR is recommended.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%) There is no\nventricular septal defect. The right ventricular cavity is moderately dilated.\nThere is mild global right ventricular free wall hypokinesis. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Dilated right ventricle with mild global systolic dysfunction.\nPreserved global and regional left ventricular systolic function. No\nintracardiac shunt seen on this limited study. Pulmonary disease (vascular,\nparenchymal, etc.) or left-to-right shunt should be investigated given right\nventricular enlargement.\n\nIf clinically indicated, a cardiac MR () is recommended for\nquantitative assessment of right ventricular volumes and function, and to\nevaluated for shunting.\n\n\n" }, { "category": "ECG", "chartdate": "2178-11-11 00:00:00.000", "description": "Report", "row_id": 220657, "text": "Sinus rhythm. No diagnostic abnormality.\n\n" }, { "category": "ECG", "chartdate": "2178-10-30 00:00:00.000", "description": "Report", "row_id": 220658, "text": "Sinus tachycardia. Otherwise, normal tracing. No previous tracing available\nfor comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2151-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804510, "text": " 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: swan position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ chf s/p swan placment\n REASON FOR THIS EXAMINATION:\n swan position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swan-Ganz catheter positioning.\n\n VIEWS: Single upright AP view compared with AP view from approximately 3 hours\n earlier, the same day.\n\n FINDINGS: The Swan-Ganz catheter has been withdrawn slightly and the tip now\n lies in satisfactory position within the right pulmonary artery. Again noted\n is a left sided ICD device with leads in appropriate positions. There is no\n pneumothorax identified. The remainder of the chest appears stable from 3\n hours earlier.\n\n IMPRESSION: Satisfactory placement of Swan-Ganz catheter. Otherwise, no\n changes in the appearance of the chest from 3 hours earlier.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804444, "text": " 9:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swann position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ischemic cardiomyopathy, s/p incarcarated ventral hernia\n repair\n REASON FOR THIS EXAMINATION:\n eval swann position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ischemic cardiomyopathy, incarcerated ventral hernia, evaluate\n Swan position.\n\n VIEWS: Single semi-upright AP view compared with PA and lateral view from\n .\n\n FINDINGS: There has been interval placement of a Swan-Ganz catheter with the\n tip suboptimally located within an interlobar segment of the descending right\n pulmonary artery. The left-sided ICD device is again noted with leads in\n stable and satisfactory positions. No pneumothorax is identified. Low lung\n volumes are present bilaterally. There has been interval improvement in the\n bilateral, diffuse interstitial opacities consistent with improving pulmonary\n edema. The cardiac and mediastinal contours remain stable. No pleural\n effusions are identified.\n\n IMPRESSION:\n\n 1) Slightly distal location of the tip of the Swan-Ganz catheter within an\n interlobar segment of the descending right pulmonary artery.\n\n 2) Interval improvement in mild interstitial pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-11-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 804227, "text": " 7:47 AM\n CHEST (PA & LAT) Clip # \n Reason: Pt with ascites, hx chf, eval for chf, pulm edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with CHF, CRI s/p BiV ICD\n REASON FOR THIS EXAMINATION:\n Pt with ascites, hx chf, eval for chf, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive heart failure, chronic renal insufficiency, ascites.\n Evaluate for pulmonary edema.\n\n VIEWS: Standard PA & left lateral view, compared with supine AP view from\n .\n\n FINDINGS: Again noted is an ICD with leads in stable and satisfactory\n positions. There is slight left ventricular prominence with slight upper zone\n redistribution, however, no evidence of overt pulmonary edema. There is\n discoid atelectasis at the bases bilaterally. No pleural effusions are\n identified. There has been interval removal of an NG tube. Osseous structures\n reveal degenerative changes throughout the thoracic spine. Otherwise, the soft\n tissues are unremarkable.\n\n IMPRESSION:\n 1) Stable left ventricular prominence with slight upper zone redistribution\n without evidence of frank pulmonary edema.\n 2) Minimal bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804495, "text": " 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swann ganz placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ vtach\n REASON FOR THIS EXAMINATION:\n eval swann ganz placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P Swan-Ganz catheter placement. Check position.\n\n Comparison is made to study of same day at 10:01 hours.\n\n FINDINGS: A Swan-Ganz catheter is again seen with its tip in an interlobar\n segment of the right main pulmonary artery, not significantly changed in\n position. No pneumothorax seen. There is stable appearance to mild upper\n zone vascular redistribution and mild interstitial opacities consistent with\n edema. Minor left basilar atelectasis is unchanged. No pleural effusions. No\n focal areas of consolidation.\n\n IMPRESSION:\n\n 1) No significant change to position of Swan-Ganz catheter with tip in\n interlobar segment of right main pulmonary artery.\n 2) Persistent mild interstitial edema.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-01 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 805013, "text": " 2:03 PM\n DUPLEX DOPP ABD/PEL; RETROPERITONEAL US Clip # \n Reason: screen for AAA and renal artery stenosis (please with indice\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with class IV CHF as pre-op eval for heart transplant\n REASON FOR THIS EXAMINATION:\n screen for AAA and renal artery stenosis (please with indices)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Class 4 CHF preoperative evaluation for heart transplant.\n\n ABDOMINAL ULTRASOUND, COMPLETE: There is a large amount of ascites. The\n liver is unremarkable, without focal or textural abnormalities. There is no\n biliary duct dilatation. The gallbladder is not visualized. There is a right\n pleural effusion. The right and left kidneys are unremarkable measuring 10\n and 9.7 cm respectively. Resistive indeces in the right kidney are measured\n at .8. Resistive indeces in the left kidney are measured between .74 and .76.\n The visualized portions of the aorta are of normal caliber. The pancreas and\n spleen are not imaged.\n\n IMPRESSION:\n\n 1) Large amount of ascites and right pleural effusion. No evidence of aortic\n aneurysm. Unremarkable kidneys with resistive indeces from .74 to .8, as\n described above.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804838, "text": " 8:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Line in correct place?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ chf s/p central line placement.\n REASON FOR THIS EXAMINATION:\n Line in correct place?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: CHF. Central line placed. Check position.\n\n FINDINGS: The new right IJ central line tip is well positioned in the mid SVC.\n It replaces the previous Swan catheter. The heart again shows slight left\n ventricular enlargement. Some slight upper zone redistribution is noted,\n improved since the prior study. Some minor atelectatic changes are again noted\n at the right base and to a lesser extent at the left base. The ICD pacemaker\n with 4 electrodes remains in unchanged position.\n\n IMPRESSION: 1) Satisfactory placement of new right IJ central line. 2)\n Slightly improved left heart failure. 3) Improved bibasilar atelectases.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 804686, "text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swann placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ chf s/p swan placement - swann not wedging\n REASON FOR THIS EXAMINATION:\n eval swann placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 07:42:\n\n INDICATION: Check Swan placement.\n\n COMPARISON: \n\n FINDINGS: The ICD device and Swan-Ganz catheter remain in place. The tip of\n the Swan is seen in the proximal right pulmonary artery. The pulmonary\n vasculature appears slightly more prominent than that seen previously\n suggesting an element of fluid overload. No effusions are noted and there are\n no new infiltrates. No pneumothorax.\n\n IMPRESSION:\n\n Swan-Ganz catheter remains in satisfactory position. Features of fluid\n overload.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 805147, "text": " 4:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ chf s/p central line placement.\n\n REASON FOR THIS EXAMINATION:\n check ett position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central line placement and ETT placement.\n\n VIEWS: Supine AP view compared with semi-erect AP view from .\n\n FINDINGS: An ETT is seen with tip approximately 3 cm from the carina, in\n satisfactory position. The Swan-Ganz is noted in satisfactory position with\n the tip in the right pulmonary artery. An NG tube is seen with the tip in the\n mid stomach. An ICD device is again noted with leads in stable positions.\n There has been interval placement of epicardial pacing leads. No definite\n pneumothorax is identified although the right apex is excluded from the study.\n There is continued bibasilar atelectasis. The cardiac and mediastinal contours\n are normal. The pulmonary vascularity is within normal limits given the supine\n positioning of the patient.\n\n IMPRESSION: 1) Satisfactory placement of all lines and tubes. 2) Persistent\n bibasilar atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-30 00:00:00.000", "description": "CAROTID LMTD/ DPP", "row_id": 804942, "text": " 2:27 PM\n CAROTID LMTD/ DPP Clip # \n Reason: carotid stenosis - pre-op evaluation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with history of end stage cardiomyopathy, being worked up for\n possible heart transplant.\n REASON FOR THIS EXAMINATION:\n carotid stenosis - pre-op evaluation\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE:\n\n REASON: Patient undergoing heart transplant, evaluate.\n\n FINDINGS: Limited duplex evaluation was performed of the left carotid artery.\n There was an IV in the right neck so that did not allow evaluation of the\n carotid artery on that side.\n\n On the left no plaque was identified. The peak systolic velocities are 69,\n 85, 99 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.8. This\n is consistent with no stenosis.\n\n There is antegrade flow in the left vertebral artery.\n\n IMPRESSION: No evidence of stenosis in the left carotid artery. The right\n carotid artery was not visualized due to IV line.\n\n" }, { "category": "Radiology", "chartdate": "2151-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 805204, "text": " 9:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's d/c'd\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo male w/ chf s/p central line placement.\n\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's d/c'd\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Central line placement, evaluate for pneumothorax after chest\n tubes discontinued.\n\n VIEWS: Semi-erect AP view compared with supine AP view from .\n\n FINDINGS: There has been interval removal of the endotracheal tube, Swan-Ganz\n catheter, and nasogastric tube. The right interval jugular vascular sheath\n remains in stable and satisfactory position. The cardiac and mediastinal\n contours remain stable. There is persistent left lower lobe\n atelectasis/consolidation with small left pleural effusion. There has been\n interval increase in bilateral diffuse interstitial opacities, likely\n consistent with mild left ventricular heart failure. A curvilinear lucency is\n noted at the lateral aspect of the right middle lung field as well as two\n vertical linear lucencies noted at the right lung base, which likely\n represent skin folds.\n\n IMPRESSION:\n 1. Interval development of mild left ventricular heart failure.\n 2. Persistent left lower lobe atelectasis with small left pleural effusion.\n 3. Curvilinear lucency over the right middle lung field likely representing a\n skin fold. Followup examinations are recommended to exclude the presence of a\n pneumothorax.\n\n\n" }, { "category": "ECG", "chartdate": "2151-12-02 00:00:00.000", "description": "Report", "row_id": 112446, "text": "Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\nof the paced rate has slowed. There is atrial sensed and ventricular\npaced rhythm which now has a right bundle-branch block morphology, as recorded\non but different from that of . Question lead position.\nClinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2151-11-25 00:00:00.000", "description": "Report", "row_id": 112447, "text": "Regular ventricular pacing. Pacemaker rhythm - no further analysis. Since the\nprevious tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2151-11-24 00:00:00.000", "description": "Report", "row_id": 112448, "text": "Sinus rhythm with ventricular pacing, rate 93. Since the previous tracing\nof positional changes are noted over the mid-precordium.\n\n" }, { "category": "ECG", "chartdate": "2151-11-23 00:00:00.000", "description": "Report", "row_id": 112449, "text": "Atrial sensed - ventricular paced rhythm\nCompared to previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2151-12-03 00:00:00.000", "description": "Report", "row_id": 112442, "text": "Atrial sensed-ventricular paced rhythm.\n\n" }, { "category": "ECG", "chartdate": "2151-12-03 00:00:00.000", "description": "Report", "row_id": 112443, "text": "Supraventricular tachycardia, probable atrial fibrillation\nIntraventricular conduction defect\nPoor R wave progression - probable normal variant\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rate\n\n" }, { "category": "ECG", "chartdate": "2151-12-04 00:00:00.000", "description": "Report", "row_id": 112444, "text": "Atrial sensed-ventricular paced rhythm.\n\n" }, { "category": "ECG", "chartdate": "2151-12-04 00:00:00.000", "description": "Report", "row_id": 112445, "text": "Atrial sensed-ventricular paced rhythm.\n\n" }, { "category": "Nursing/other", "chartdate": "2151-11-26 00:00:00.000", "description": "Report", "row_id": 1407253, "text": "CCU progress note 7a-5p\nNEURO: A+Ox3, very pleasant. MAE. OOB to BCS and CHAIR today. ambulates well w/ assist of 1. no c/o of pain or discomfort.\n\nRESP: LS clear, coarse to bases. room air. sats >99%. No SOBOE.\n\nCARDIAC: VPACED 80s-100s. MAPS 60-70s. RIJ PA line - PAD 28 CVP 15 CO 6.7 CI 3.87 SVR 693. PA sats 74% this pm. HCT stable this afternoon at 30. sacral + pitting edema. MILRINONE 0.375mcg/k/min. On Toprol XL 50mg qd + Lisinopril 5mg QD.\n\nGI/GU: foley patent. changed lasix IV to PO 100mg . diuresing well. abd firm/distended - ascites. abd binder on. midline incision intact - steri-strips intact. taking PO meals well. FLUID RESTRICT <1500cc/day.\nENDO: FS QID - sliding scale with humalog insulin for FS >200.\n\nPLAN: con't milrinone and cardiac meds. monitor hemodynamics and cardiac calcs w/ SVR/PVR. document STANDING SCALE WEIGHTS DAILY in kg. FLUID RESTRIC <1500cc/day. FS QID. check PM lytes (pnd). PA line to be changed in am. continue diuresis. ?epicardial LV lead placement on monday per EP/Dr . emotional support for pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-27 00:00:00.000", "description": "Report", "row_id": 1407254, "text": "ccu npn 7p-7a\nS:\"I feel good, thank you.\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 80-90'S vpaced, no vea noted. K+ 3.8 repleted with 40meq PO KCL. am pnd. BP ranges via non-invasive cuff 90-100's/50-60's. IV Milrinone conts at 0.375mcg/kg/min. CO/CI 6.7/3.87 SVR 681 PVR 251. PA 60-70/23-26 CVP 15-16. WEDGE 18-20 via RIJ swan.\n\nResp: Sats 98-100% on room air, lungs clear/coarse with fine dependent rales only. Given 100mg po Lasix at 2200 as ordered with fair response. Neg. 1464cc at MN.\n\nGI;GU; Taking po's on 1500cc FR. Foley to drainage with clear, yellow urine u/o 30-80cc/hour. Large soft, golden stool via bedpan, quiac neg. Colace held.\n\nEndo; Glucose 204, given 1 unit Humalog at 2200, am pnd.\n\nNeuro; Pt. A/A/O X3, pleasant and cooperative, MAE, assisting with turning and repositioning. Slept well without sleeping . Bedrest maintained overnight.\n\nA; Hemodynamically stable on Milrinone dose, diuresis.\n\nP: Cont to monitor hemodynamics, maintain Milrinone as ordered, cont with diuresis. Follow up with am labs. Cont with w/u for heart transplant. Comfort and emotional support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2151-11-25 00:00:00.000", "description": "Report", "row_id": 1407250, "text": "CCU NPN 2300-0700\nO: afeb.\nHR 88-90's Vpaced. rare PVC.\nBP 93-107/50s. PAP 60's/24-29. W 28. CVP 18-22.\nmilrinone at .375mcq/k/min.\nu/o 50-60/hr. negagive 1.7L for . PM lasix dose held. negative 200cc in AM.\nLS clear sats 99% on RA.\nFS 162-137.\n\nAM HCT 25.9 from 30.2 ordered to transfuse 1 unit PC's.\nright groin cath site D/I. pulses intact.\nRIJ swan site D/I/clean.\n\nA/O x3. denies pain, SOB. concerned about FS and asking for check. ate toast and juice in eve.\n\nA: HCT down again- to be transfused. resume lasix in AM. ? OOB as tol. today. SS humulog QID. contin. milrinone gtt.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-25 00:00:00.000", "description": "Report", "row_id": 1407251, "text": "CCU progress note 7a-7p\nNEURO: A+Ox3. MAE. OOB to chair w/ minimal assistance x 4hrs. requested to walk with walker today but has PA line. very pleasant and cooperative. family in to visit this afternoon.\n\nCARDIAC: VPACED 80-120s today. MAPs 70-80s. Increased Toprol XL to 50mg qd. Zestril remains at 2.5mg. RIJ PA line - PAD 23 from 28 post diuresis. CO 6.3. See careview for cardiac calcs q4h. Remains on Milrinone 0.375mcg/k/min. HCT decreased to 25 this am - given 1u PRBCs - pm labs pnd. R fem site D+I.\n\nRESP: LS clear, dim. Sats 99-100% on room air. no sob.\n\nGI/GU: foley patent. good u/o. diruesed w/ total of 100mg IV lasix today (ordered ). abd firm/distended ->ascites. abd sutures - recent ventral hernia repair - wearning abdominal binder. daily large soft golden stools on bedpan. FS QID - on QID sliding scale humalog insulin dose.\n\nPLAN: con't to monitor VS/hemodynamics/cardiac calcs. keep pt comfortable. monitor for bleeding ?unknown why HCT dropping past 2 days - guiac all stools. monitor FS. con't cardiac meds/diuresis.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-26 00:00:00.000", "description": "Report", "row_id": 1407252, "text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\ncv- Tele: V paced not ectopy- HR 84-89- B/P 91-108/47-57- MAPs 62-74- R IJ PA line- CXR showed line down too far- Pulled back by HO- PAS 65-72- PAD 22-27- CVP 12-15- CO 5.5 CI 3.18 SVR 756- con't on milrinone gtt @ .375mcq/kg/min- Hct @ 2200 29.5- K 4.2- Mg 3.0\nR fem site D&I.\n\nresp- lung sounds coarse- resp even, non-labored- SpO2 on Rm air 97-99%.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\ngi- abd firm & distended- (+) ascites- abd incision (ventral hernia repair)- wearing abd binder- no BM this shift.\n\ngu- foley draining clear yellow colored urine qs- lasix 100mg IV given @ - diuresed fairly well- (-) 500cc since 12am.\n\nA- decompensated ischemic cardiomyopathy- diuresing from milrinone gtt & lasix.\n\nP- monitor hemodynamic- offer emotional support to Pt & family- keep them updated on plan of care\n\n" }, { "category": "Nursing/other", "chartdate": "2151-12-02 00:00:00.000", "description": "Report", "row_id": 1407261, "text": "v paced w occas. pvc's. K+ tx'd as indicated. hemodynamically stable on low dose milrinone & lasix. see flow sheet for filling pressures,svo2,ci's.minimal lower extremity edema noted. + abdominal fluid wave.extubated w/o incident.bs decreased bilat. w occas. rhonchi that clear w coughing. lt. upper chest incisions c & d,steri's intact.lt. chestt tube draining thin sero sang. medicated w mso4 for c/o incisional pain esp. w activity w good relief per pt.plan wean levo,cont. milrinone,monotor for worsening failure,transfer to f2,continue transplant work up.\n" }, { "category": "Nursing/other", "chartdate": "2151-12-03 00:00:00.000", "description": "Report", "row_id": 1407262, "text": "Neuro: pt alert and oriented following commands.\nResp: breath sounds clear, o2 sats 99% on 2l np\nChest tube patent draining small amount of serous sang. drainage\nC/V: heart rate itially in the low 90's up to 110 when pt spikeing fever. hemodynmically stable. pa pressure up slightly to hig 70's ? need for diuresis. Wedge presur 21. Levo weaned off but restarted for Bp in the high 80's when fever was >101. Lytes treated as ordered.\nGI: tolerating liquids advance diet this am.\nGU: urine output adequate\nID: Temp up to 101.7 ho aware pt pancultured except for sputum and treated with tylenolx2.\nSkin: Incision clean and dry no draiange.\nPain: pt c/o incision pain difficult to move treated wqith morphine 4mg sc with good effect.\nPlan: wean levo as tolerated, transfer back to ccu service ? remove chest tubes later today medicate for pain as needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-12-03 00:00:00.000", "description": "Report", "row_id": 1407263, "text": "focus: status update.\npt changed primary team back to ccu milrinone cut in half. and to be d/c tomorrow 0900. pa line and a line d/c levo off. pt to be transfered to 2 as soon as a bed is available.\n" }, { "category": "Nursing/other", "chartdate": "2151-12-04 00:00:00.000", "description": "Report", "row_id": 1407264, "text": "Neuro: pt alert oriented following commands.\nResp: o2 sats 100% on 2l np. pt coughing and raising small amounts.\nC/V: pt on 0.187mcg of milrinone to be d/c'd at 0900. blood pressure stable. pt has DDD pacer presently a sensed vpaced. with occasional pvc's\nGI: tolerating diet well.'\nGU: Good urine output.\nSKin: Incision clean and dry no drainage.\nPlan: transfer to floor this am when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2151-12-04 00:00:00.000", "description": "Report", "row_id": 1407265, "text": "S/P LEAD PLACEMENT\nS: \" YES I'M DOING FINE\"\nO: CARDIAC: A SENSED V PACED 80-90'S WITH FREQUENT PVC'S. RECEIVED 20 MEQ KCL PO AND 400 MG MAG X1. SBP 90'S AFTER RECEIVING XL LOPRESSOR. DSGS D+I. PALP PP. OOB TO CHAIR WITH ASSIST OF 2 UNSTEADY OF FEET. PT TO SEE HIM THIS AFTERNOON.\n RESP: BS DIMINISHED BIBASILAR, RR TEENS, C+R SMALL AMOUNTS OF THICK GREEN SPUTUM, IS 750ML WITH ENCOURAGEMENT. O2 SATS ON 2 L NP >97%.\n NEURO: A+O, PLEASANT, CALM, MAE, GRASPS EQUAL ,UNSTEADY ON FEET.\n GI: EXCELLENT APPETITE, REINFORCED FLUID RESTRICTION. + BOWEL SOUNDS , NO STOOL PRESENTLY .\n GU: ADEQUATE UO\n PAIN: DENIES PAIN - HOWEVER NOTED GRIMACING WITH MOVEMENT AND COUGHING REINFORCED IMPORTANCE OF THOSE --- MEDICATED WITH TYLENOL WITH CODIENE 1 TAB WITH GOOD EFFECT.\n ENDO: RECIEVED 120 MG NATEGLINIDE @ 11AM DUE TO GLUCOSE 272. GLUCOSE @ 1500 186. TO BE RECHECKED @ 1700.\n SOCIAL: FAMILY INTO VISIT AND UPDATED.\nA: STABLE POST LEAD PLACEMENT\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, DSGS,PP, RESP STATUS-PULM TOILET, NEURO STATUS, I+O, LABS. TRANSPLANT WORKUP AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-23 00:00:00.000", "description": "Report", "row_id": 1407246, "text": "ccu nursing admit note\nS:\"I'm doing fine, but my blood sugars have been low.\"\n\nO: Please see carevue for VS and objective data. Arrived from cath lab A/A/0X3, pleasant and cooperative. Conversing with RN. Cath lab report with SVG to LAD and LIMA to LAD patent. Swan-ganz placed in cath lab via RIJ with PA 70-80/25-30, CVP 22 WEDGE 30-31. CO/CI 4.46/2.55, started on IV Milrinone with bolus and dose at 0.375mcg/kg/min with CO/CI 6.7/3.83. VSS and Pt. was transferred to CCU for further management. Please see ICU admit note for details of Pmhx.\n\nRight groin D/I with DSD, no palp. hematoma, distal pulses intact. Hct drop to 26.9 from 30.3 after groin bleed in cath lab with angioseal. CCU team notified, clot sent to blood bank awaiting cross match for one unit.\n\nCVS; Hemodynamically stable with HR 70-80's vpaced rare PVC noted, K+4.6, BP ranges via non-invasive cuff 100-112/50-60 with MAPs 68-75. Milrinone conts at 0.375mcg/kg/min with CO/CI 6.7/3.87 SVR 728. PAP 70's/27-30 CVP 15-16. WEDGE 28. Pt. painfree, CPK neg.\n\nResp; Pt. on room air with sats 97-100%, Lungs coarse with fine bibasilar rales. RR 18-21. Diuresised with 80mg IV Lasix at with excellent response as per flow.\n\nGI;GU; Initially with condom cath, foley to drainage placed with clear, yellow urine, diuresised >1500cc to Lasix as above. Appetite good, ate and juice. Abdomen with ascities. Bowel sounds active, no stool.\n\nEndo; Blood sugar on arrival to CCU 24-28, Pt. asymptomatic, treated with total of 2 amps D50, cranberry juice with sugar with blood sugars trending up 160-180's. CCU team aware.\n\nA; hemodynamically stable with good response to Milrinone and IV lasix, Hct drop after angioseal groin bleed in cath lab\n\nP; Cont to monitor hemodynamics, cont Milrinone, follow CO/CI. Monitor PAP, diuresis as needed. Transfuse one unit when ready in blood bank.\nAssess groin. Follow blood sugars closely. to consult. Follow up with labs. Comfort and emotional support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2151-11-24 00:00:00.000", "description": "Report", "row_id": 1407247, "text": "CCU NPN 2300-0700\nS: \" I think I need my sugar checked \"\nO: afeb.\nno CP/ SOB/palps.\nHR 81-89v paced. no VEA. BP 92-113/40-57. milrinone at .375mcq/k/min.\nPAP 59-73/22-27. CVP 11-17, wedge 25. MVO2 71%. C.O. 6.5/3.75/751.\n\nLS clear to diminished bases. sats 100% on RA.\n\nu/o 150-400cc/hr. negative 1.2L for and currently neg. 500cc\n\n12am labs CK 22, K+ 4.3, HCT 26,\n\nTransfused 1 UPRBC completed at 0500. post HCT pnd at 0600.\n\nendo: 12am FS 154. pt. asking for FS at 0400: 109. given glass of OJ. 0600pnd. denies dizziness/lt. headedness/diaphoresis.\n\nneuro: A/Ox3. coop.\nright groin C/I. pulses 2+. extrem. warm/dry. MAE.\n\nA: improved hemodynamics on milrinone.\n good diuresis from lasix\n FS stable.\nP: follow lytes, PAP's, HCT. ? dangle or OOB today.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-24 00:00:00.000", "description": "Report", "row_id": 1407248, "text": "CCU progress note 7a-3p\nNEURO: A+Ox3. pleasant cooperative. no c/o. MAE. some soreness at RIJ PA site. daughters and wife in to visit this afternoon.\n\nID: tmax 99.3 oral. no abx. no spikes.\n\nCARDIAC: VPACED 80-90s. +pulses. R fem site D+I. HCT 30.2. RIJ PA line PAD 26 CVP 17 PCWP 21 CO 5.5/3.18/640. MAPS 60s. MILRINONE @ 0.375 mcg/k/min. Started back on Toprol XL 25mg qd + Zestril 2.5mg QD. to be started on epoetin /tu/th.\n\nRESP: LS clear, rales to bases. Lasix 80mg PO given this morning, to be given an extra dose Lasix IV this afternoon then a standing dose lasix IV tonite. On room air sats >99%.\n\nGI/GU: foley patent. good u/o. fair diuresis from 80mg po lasix this morning, to be given additional this afternoon and standing dose tonite. abd firm/distended - ascites, abd binder in place from ventral hernia repair. large golden semi-formed stool this afternoon. on colace. taking po meals well. ENDO: FS QID. humalog sliding scale per clinic. delicate diabetic. pt was hypoglycemic for a few days post oral .\n\n\nPLAN: monitor cardiac calcs/hemodynamics. con't milrinone. con't diuresis. keep pt comfortable, informed. con't po cardiac meds. Daily standing scale weights.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-24 00:00:00.000", "description": "Report", "row_id": 1407249, "text": "CCu NPN \nPt resting comfortably in bed without complaint.\nCV: HR 80-90's V-paced, had one 5 min period with HR to 120 V-paced. Team aware, slowed spontaneously, BP unchanged, pt asymptomatic. BP consistantly 90's/50 with MAP 66. PAP 60's/24-28, PCWP 28, CVP 18, CO/CI 5.4/3.12, SVR 652, mixed venous sat 69%. Cont on Milrinone at .375ug/kg/min. No ankle edema, (+)acites. Crackles at bases bilaterally, no SOB. Peripheral pulses palpable. No bleeding or hematoma at R groin. Neg 1500 for day , neg 2800 LOS.\n\nResp; sats 98-99% on RA. No distress.\n\nEndo: BS 105, no humalog ins given.\n\nNeuro: A&Ox3, no complaints.\n\nGI: ate sm amt at dinner, no stool.\n\nSoc: wife and daughters in this eve.\n\nA/P: Diuresing well with lasix, neg for day, though little change in PAD, PCWP. Cont to diurese and follow #'s. Cont on Milrinone. Check lytes this eve. Follow BS's qid.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-11-28 00:00:00.000", "description": "Report", "row_id": 1407257, "text": "CCU Nursing Progress Note 7am-7pm\nS: I am very well, thank you\n\nO: ID -T max 97.9 po\n\nCV - HR 77-88 v paced with no vea. BP 113-99/52-57. Cont on Milrinone .375mcgs/kg/min. PAD's 27-30, CVP 16-20, PCWP 27 down to 22 with diuresis (100mg po lasix). Experiencing difficulty wedging PA cath. c.o. 4.6-4.9 SVR 887-996. PVR 261 up to 571. No weight loss today.\n\nResp - cont on RA with sats 98-100%. Rales l base only\n\nGU - as above, 100mg po lasix given at 1130 with u/o from 60 up to 130cc/hr clear amber urine.\n\nGI - Good appetite, no stool + BS\n\nActivity - OOB to chair for most of day, tolerated well\n\nEndo - Recd 1u Humulog for bs 219 before lunch\n\nA: Pad's unchanged with lasix, but SVR and PVR up\n\nP: Cont keep 1 liter neg i/o for day, Monitor weights and lung sounds for change, cont milrinone as ordered, OOB as tolerated\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-11-29 00:00:00.000", "description": "Report", "row_id": 1407258, "text": "ccu npn 7p-7a\nS:\"I'm doing just fine.\"\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with HR 80'S V-PACED,, rare PVC noted K+ 4.2. BP ranges via 86-111/40-50 MAP 57-70, IV Milrinone at 0.375mcg/kg/min, PA 60-70/23-28 CVP 16-20, unable to wedge, CCU team notified, see strips in chart. CO/CI 7.0/4.0 SVR 686.\n\nResp: Sats 97-99% on room air, Lungs with fine bibasilar rales. RR 18-22. Given 100mg po Lasix as ordered at 2100 with moderate effect. I/O neg. 825cc at MN.\n\nGI;GU; Taking po's, NPO after MN. Foley to drainage with clear, yellow urine, u/o 40-190cc/hour.\n\nEndo; sugar 181, NPO after MN, Humalog dc'd, to start Nateglinide when taking po as recommendations\n\nID: afebrile\n\nNeuro; Pt. A/A/Ox3, pleasant and cooperative, MAE, bedrest this shift, slept well at intervals.\n\nA: Hemodynamically stable on IV Milrinone and gentle duiresis.\n\nP: Cont to monitor hemodynamics, cont Milrinone and diuresis as ordered, follow up with am labs. NPO after MN for possible intervention of pacemaker. Hold Nateglinide until taking po. Comfort and emotional support to Pt. and family\n" }, { "category": "Nursing/other", "chartdate": "2151-11-30 00:00:00.000", "description": "Report", "row_id": 1407259, "text": "NEURO: A&O X3.\nRESP: O2 SATS 97-98% ON RM. AIR. BS CLEAR WITH COARSE BS AT BASES. RR\n 17-23.\nCARDIAC: HR 81-93 VP, NO ECTOPY. BP 92-105/47-61. MILRINONE CONT. AT\n .375MCG/KG. RIJ SWAN D/C'D, CHANGED OVER WIRE TO RIJ TRIPLE\n LUMEN CATH. CXR DONE TO CONFIRM PLACEMENT. POST-TX HCT 32.6,\n MG 2.0, K 3.9->TREATED WITH KCL 20MEQ PO X1.\nGI: ABD. DISTENDED WITH ASCITES. BS+. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING QS CLEAR YELLOW URINE.\nID: T(MAX)99.2(PO).\nENDO: BS 198.\nAM LABS PENDING.\nPLAN: CALLED OUT TO FLOOR--AWAITING BED.\n PROCEDURE TO RELACE PACING WIRE ON WEDNESDAY.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-30 00:00:00.000", "description": "Report", "row_id": 1407260, "text": "CCU Progress Note:\n\nsee nursing transfer note- Pt con't on milrinone gtt @ .375mcq/kg/min- Wt today 55 Kg- u/o good- (-) 2L since 12am- ultrasound done this afternoon- needs urine for C&S and 24hr urine collection for protein & creatinine- quiac stools X3- need tuberulin protein injection today- NPO after 12am for fixing pacing lead.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2151-12-04 00:00:00.000", "description": "Report", "row_id": 1407266, "text": "S/P LEAD PLACEMENT\n1800 LISINOPRIL HELD DUE TO SBP 91-89. 2 RN AWARE THAT IT WAS NOT GIVEN AND WHEN SBP > 90 TO GIVE LISINOPRIL.\n" }, { "category": "Nursing/other", "chartdate": "2151-11-27 00:00:00.000", "description": "Report", "row_id": 1407255, "text": "CCU Nursing Progress Note 7am-7pm\nS: I'm feeling well, thank you\n\nO: Afebrile\n\nHR 75-82 V paced with no VEA. BP 98-105/50. Cont on Milrinone .375mcgs/kg., as well as metoprolol XL 50mg and Lisinopril 5 qd.\nPAD's 26-28, CVP's 15-18, PCPW 22-18. Co has decreased this shift to 5.5 at 12noon and 4.7 at 5pm. SVR 770-800. HO aware and is to discuss with fellow. Pt is comfortable and in no distress.\n\nResp - on RA with O2 sat 97-98% with some base rales audible. No additional diuresis today, but is on standing po dose of lasix 100mg po bid.\n\nu/o post po lasix was @360cc. u/o decreased through shift to 40-100cc/hr.\n\nGI - good appetite, no stool. Colace held\n\nActivity - OOB x2hrs to chair with 2 nurse assist. Pt tolerated activity well. Turning self in bed\n\nEndo - no coverage for ss today, bs before lunch 194 and before dinner 119.\n\nSocial - family vss throughout most of day, and is aware of pt status\n\nA: Sl worsening c.o, but asymptomatic\n\nP: Cont monitor hemodynamics, and diuretic effect, monitor ls and u/o., cont monitor sugars, activity as pt tolerates. cont support pt and family\n" }, { "category": "Nursing/other", "chartdate": "2151-11-28 00:00:00.000", "description": "Report", "row_id": 1407256, "text": "ccu npn 7p-7a\nS\"I'm doing just perfect, thank you.\"\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with HR 70-80'S vpaced with rare PVC, K+ 4.8. BP ranges via non-invasive cuff 90-110/40-50. PA 60-70/25-28\nCVP 18-20, WEDGE 20-22. CO/CI 5.9-4.8/3.4-2.7 SVR 624-883 PVR 285-367 on same dose Milrinone at 0.375mcg/kg/min. MV sat 71-64. CCU team aware. Pt. denies CP, SOB or discomfort.\n\nResp; Remains on room air with sats 96-99%, lungs clear with fine bibasilar rales. RR 16-22. Able to lay flat in bed. Eve dose of po Lasix held per team with I/O neg. 1 Liter at MN.\n\nGI;GU; Pos taken, 1500cc FR maintained. Foley to drainage with clear yellow urine, u/o 40-60cc/hour. Soft golden stool via bedpan, quaic neg.\n\nEndo; blood sugars remain wnl.\n\nID; afebrile\n\nNeuro; Pt. A/A/OX3, very pleasant and cooperative. MAE, assisting with care. Family in to visit. Slept well most of night.\n\nA; Hemodynamically stable, slight decrease in CO/CI despite no change in Milrinone, further diuresis held with I/O neg. 1L.\n\nP: Cont to monitor hemodynamics, maintain Milrinone. Team to hold am lasix until assessment of I/Os, may need with PA pressures increasing.\nFollow up with am labs. Comfort and emotional support to Pt. and family\n" } ]

[ { "category": "Radiology", "chartdate": "2152-10-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1039824, "text": " 5:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement, PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with resp distress, PEA arrest from OSH\n REASON FOR THIS EXAMINATION:\n eval for tube placement, PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 1731 HOURS.\n\n HISTORY: Respiratory distress and PEA arrest; transfer from outside hospital.\n\n COMPARISON: None.\n\n FINDINGS: Endotracheal and nasogastric tubes are satisfactorily in place.\n Large tumors identified both within the right infrahilar region and the left\n apex. There is also increased density noted in the left lung base. There is\n a tortuous atherosclerotic aorta. The cardiac silhouette is difficult to\n accurately assess, but is likely at least borderline enlarged. No definite\n effusion is identified. There is no underlying pneumothorax. Degenerative\n changes are noted in otherwise osteopenic spine.\n\n IMPRESSION: Large opacities likely tumors within the right infrahilar and\n left apical regions as above. There may be a consolidative infiltrate at the\n left lung base. It may be pneumonia versus aspiration.\n\n" }, { "category": "Physician ", "chartdate": "2152-10-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 639630, "text": "Chief Complaint: respiratory failure pneumonia and lung cancer\n HPI:\n 78yoF w/ a h/o stage IV lung CA w/ CNS metastasis presents s/p\n respiratory arrest for which she was intubated; noted to have a Large L\n sided infiltrate. At rehab was in respiratory distress (VS at that\n time were BP 84/40, HR 148, O2 91% 3L), was tachypneic and had thick\n secretions, she had bradycardia and rec'd epi and atropine and\n underwent CPR for unknown time. On presentation to ED had good pulses\n and a HR of 80s. Per the family and the patient's oncology fellow she\n has stage IV lung cancer with mets to the brain, s/p TBI and 6 cycles\n of pemetrexed which she finished about 6 weeks ago. Decline in\n functional status since then and a recent hospitalization for fall /\n weakness and UTI. She has been debilitated and in rehab with no plans\n for further palliative chemotherapy. She had been having shortness of\n breath, progressively worsening x 2 weeks, stable cough x yars,\n orthopnea x a few days and 24 hours during which she needed to sit in a\n chair to breath comfortably. No other complaints of anything per her\n family.\n .\n In the ED she rec'd 2L NS, cefepime and vancomycin. No pressors in ED,\n triple lumen femoral line placed. HR 61, BP 158/70 RR 18, 99% on\n vent.\n .\n Patient is intubated and unable to provide a ROS history.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n Diovan 160mg po daily\n Lasix 20mg po daily\n Paxil\n Vicodin\n Ambien\n colace\n Advair 50/250\n MVI daily\n Prilosec 20mg daily\n Folate\n Spiriva\n Tylenol\n Past medical history:\n Family history:\n Social History:\n Stage IV lung cancer w/ known mets to the brain\n SIADH\n HTN\n COPD- emphysema\n TB at age 25\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: living in rehab. 55pk year history of smoking\n Review of systems:\n Flowsheet Data as of 09:21 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 96 (96 - 96) bpm\n BP: 91/43(133) {91/43(133) - 91/43(133)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 96%\n Total In:\n 5,000 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,000 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 46 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n Ve: 6.5 L/min\n Physical Examination\n Vitals: Tm 99.8 Tc: 97.1 BP: 93/41 HR: 96 O2 sat on AC 350 x 20,\n PEEP 5, FiO2 100%\n GEN: intubated, somewhat sedated but tracks w/ eyes and follows\n commands\n HEENT: EOMI, PERRL 3 -> 2mm, sclera anicteric, no epistaxis or\n rhinorrhea, MMM, OP Clear\n NECK: JVP not elevated at 30 degrees\n COR: RRR, no M/G/R, normal S1 S2\n PULM: diffuse ronchi throughout lung fields bilaterally symmetric\n anteriorly and laterally\n ABD: Soft, NT, ND, +BS, no HSM, no masses\n EXT: + bilat low ext edema to mid shins bilaterally symmetric\n NEURO: PERRL, moving all 4 ext, EOMI, follows commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:0.9 mmol/L\n Imaging: CXR - my read: large R lower lung field well\n circumscribed mass with RML infiltrate and large multifocal L lung\n infiltrates.\n ECG: atrial fibrillation although could possibly be MAT at a rate of\n 157, normal axis and normal intervals. Normal RW progression, no Q\n waves. 1mm ST depressions in V3-V5, upward sloping in V3 and\n horizontal in V4-V5. No chamber enlargement. On tele now in sinus.\n Assessment and Plan\n Assesment: 78 yoF w/ a h/o metastatic lung Ca w/ mets to the brain\n presents w/ respiratory failure requiring intubation in field likely\n secondary to pneumonia as well as PEA-brady arrest in field w/\n restoration of pulse.\n .\n Plan:\n # RESPIRATORY FAILURE: copious sputum production per EMS upon initial\n intubation, was in respiratory distress initially with increased RR.\n She has known lung cancer and significant multifocal infiltrates on CXR\n especially of L lung field. In addition she has a leukocytosis and was\n transiently hypotensive- her hypotension responded well to 2L of NS and\n she never rec'd any vasopressor medications.\n -given stage IV lung cancer as well as degree of pneumonia and code in\n field with CPR / Epi / atropine she likely has a very poor prognosis\n -continue treatment with vancomycin and cefepime for now but discuss\n with family code status, prior to intubation was a full code however\n family discussing possibly making patient CMO.\n -will add tobra per ID until cultures come back, ideally would also do\n a mini-BAL versus a bronch\n -f/u blood and sputum cultures\n -send u/a and urine culture\n -send urine legionella\n -obtain outside records for more thorough past medical history\n especially oncologic history\n -in addition the patient has HTN and is on lasix, so may be for reasons\n of diastolic vs. systolic dysfunction- would obtain an echo, again if\n this is consistent w/ goals of care as when BP is stabilized may\n benefit from diuresis.\n .\n # Hypotension: likely related to pneumonia / pneumo-sepsis.\n -IV fluids to CVP goal of , may be difficult w/ femoral line\n -send MVO2, resend lactate\n -add vasopressors (levophed then vasopressin) for MAP < 65 w/ CVP > 8\n -as above send cultures and treat empirically for nosocomial pneumonia\n .\n # PEA arrest: per EMS bradycardia in field for which she underwent CPR\n and one round of epi and atropine and then regained pulse. She was\n bradycardic post intubation and PEA could be due to vagal / peri\n intubation medications versus hypoxia.\n -trend lactate\n -given normal Cr and mental status unlikely very significant period of\n PEA if at all\n .\n # FEN: PPI, NPO for now, electrolyte sliding scales\n .\n # Access: Femoral line in , need to resite to IJ in a.m. for\n infection reasons if family does not decide to make patient CMO.\n .\n # PPx: sc heparin tid, PPI daily\n .\n # Code: FULL CODE, will readdress w/ family\n .\n # Dispo: ICU\n .\n # Comm: , grandson\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:39 PM\n Multi Lumen - 08:40 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2152-10-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 639631, "text": "Chief Complaint: PEA arrest / respiratory arrest\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78-year-old woman with stage IV lung cancer was found in distress at\n today (84/44 148 91% on 3L). EMS arrived -->\n intubated --> bradycardic --> atropine / epi / short episode of CPR (by\n report; we do not have documentation available). In ED: good pulses,\n HR 80s. BP 80s --> 2L saline. Cefepime, vancomycin. 99% on A/C 350 x\n 20 P5 100%.\n She has had progressive decline over the past weeks, admitted to the\n hospital and then to a nursing home. Over the last few days has had\n worsening orthopnea, and over the last day sleeping in a chair.\n History is somewhat limited because her care is usually at . Our team has called her oncology coverage and discussed\n the case.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, Language barrier,\n intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n please see resident note (reviewed)\n Past medical history:\n Family history:\n Social History:\n Stage IV lung cancer w/ known mets to the brain (cell type unknown)\n - diagnosed \n - s/p XRT and palliative chemo (pemetrexed)\n - with progression (finished last cycle ~6 weeks ago)\n SIADH\n HTN\n COPD\n TB at age 25\n - treatment unknown\n Occupation:\n Drugs:\n Tobacco: 55 pack-years\n Alcohol:\n Other: currently at \n Review of systems:\n Flowsheet Data as of 09:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 96 (96 - 96) bpm\n BP: 91/43(133) {91/43(133) - 91/43(133)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 96%\n Total In:\n 5,000 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,000 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 46 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:0.9 mmol/L\n Fluid analysis / Other labs: Labs reviewed in OMR. Particularly notable\n for WBC 15, no bands, lactate 3.1 --> 0.7, HCO3 42, UA with 11-20 wbc\n Imaging: CXR: \" Large opacities likely tumors within the right\n infrahilar and left apical regions as above. There may be a\n consolidative infiltrate at the left lung base. It may be pneumonia\n versus aspiration. \"\n ECG: EKG: MAT vs AFib\n Assessment and Plan\n 78-year-old woman s/p apparent brady (vs. PEA) arrest in the field that\n appears to have been related to a respiratory decompensation. Her\n background history is most notable for stage IV lung cancer (probably\n non-small cell) and a report of COPD.\n Her family is here and we we will meet with them to review goals of\n care. In the interim, will treat for healthcare-associated pneumonia\n (covering MRSA, GNRs, and atypicals). Will treat for hypotension with\n volume resuscitation as needed, and use pressors if needed (not needed\n so far). After family meeting, if pursuing aggressive care, will\n perform bronchoscopy, place arterial line, and order echocardiogram.\n Other issues as per the ICU team note of Dr. from tonight.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:39 PM\n Multi Lumen - 08:40 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n Addendum\n 22:00\n Dr. and I met with patient\ns husband, son, and daughter-in-law.\n They state clearly that Ms. would not want to pursue\n invasive or life-sustaining therapy at this point, since her cancer is\n progressive and incurable. They wish to pursue comfort-focused care,\n including extubation. They understand that we cannot predict how long\n she will survive, or how she will do off of the ventilator. We will\n therefore proceed with extubation and comfort-focused care.\n 25 minutes\n" }, { "category": "Physician ", "chartdate": "2152-10-09 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 639632, "text": "Chief Complaint: PEA arrest / respiratory arrest\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78-year-old woman with stage IV lung cancer was found in distress at\n today (84/44 148 91% on 3L). EMS arrived -->\n intubated --> bradycardic --> atropine / epi / short episode of CPR (by\n report; we do not have documentation available). In ED: good pulses,\n HR 80s. BP 80s --> 2L saline. Cefepime, vancomycin. 99% on A/C 350 x\n 20 P5 100%.\n She has had progressive decline over the past weeks, admitted to the\n hospital and then to a nursing home. Over the last few days has had\n worsening orthopnea, and over the last day sleeping in a chair.\n History is somewhat limited because her care is usually at . Our team has called her oncology coverage and discussed\n the case.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Encephalopathy, Language barrier,\n intubated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Other medications:\n please see resident note (reviewed)\n Past medical history:\n Family history:\n Social History:\n Stage IV lung cancer w/ known mets to the brain (cell type unknown)\n - diagnosed \n - s/p XRT and palliative chemo (pemetrexed)\n - with progression (finished last cycle ~6 weeks ago)\n SIADH\n HTN\n COPD\n TB at age 25\n - treatment unknown\n Occupation:\n Drugs:\n Tobacco: 55 pack-years\n Alcohol:\n Other: currently at \n Review of systems:\n Flowsheet Data as of 09:40 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 96 (96 - 96) bpm\n BP: 91/43(133) {91/43(133) - 91/43(133)} mmHg\n RR: 15 (15 - 15) insp/min\n SpO2: 96%\n Total In:\n 5,000 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,000 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 46 cmH2O\n Plateau: 28 cmH2O\n SpO2: 96%\n ABG: ////\n Ve: 6.5 L/min\n Physical Examination\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:0.9 mmol/L\n Fluid analysis / Other labs: Labs reviewed in OMR. Particularly notable\n for WBC 15, no bands, lactate 3.1 --> 0.7, HCO3 42, UA with 11-20 wbc\n Imaging: CXR: \" Large opacities likely tumors within the right\n infrahilar and left apical regions as above. There may be a\n consolidative infiltrate at the left lung base. It may be pneumonia\n versus aspiration. \"\n ECG: EKG: MAT vs AFib\n Assessment and Plan\n 78-year-old woman s/p apparent brady (vs. PEA) arrest in the field that\n appears to have been related to a respiratory decompensation. Her\n background history is most notable for stage IV lung cancer (probably\n non-small cell) and a report of COPD.\n Her family is here and we we will meet with them to review goals of\n care. In the interim, will treat for healthcare-associated pneumonia\n (covering MRSA, GNRs, and atypicals). Will treat for hypotension with\n volume resuscitation as needed, and use pressors if needed (not needed\n so far). After family meeting, if pursuing aggressive care, will\n perform bronchoscopy, place arterial line, and order echocardiogram.\n Other issues as per the ICU team note of Dr. from tonight.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 08:39 PM\n Multi Lumen - 08:40 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n Addendum\n 22:00\n Dr. and I met with patient\ns husband, son, and daughter-in-law.\n They state clearly that Ms. would not want to pursue\n invasive or life-sustaining therapy at this point, since her cancer is\n progressive and incurable. They wish to pursue comfort-focused care,\n including extubation. They understand that we cannot predict how long\n she will survive, or how she will do off of the ventilator. We will\n therefore proceed with extubation and comfort-focused care.\n 25 minutes\n ------ Protected Section ------\n Addendum\n 22:30\n Supervised extubation. Some clinically apparent dyspnea after\n morphine. Patient\ns family in to see her. Discussed that I suspect\n she will pass away very soon. Family is going home at this point.\n 20 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 22:30 ------\n" }, { "category": "Nursing", "chartdate": "2152-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639633, "text": "PMH: Lung CA w/ mets to brain.\n 78yr F from w/ resp failure from , intubated in route to\n ED. R femoral line places, 4L NS given in ED for hypotension,\n antibiotics started.\n On arrival to MICU, family mtg held, pt did not want to continue care\n and was made CMO. Extubated and morphine gtt started. Pt expired \n @ 2235.\n" }, { "category": "Nursing", "chartdate": "2152-10-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639635, "text": "78-year-old woman s/p apparent brady (vs. PEA) arrest in the field that\n appears to have been related to a respiratory decompensation. Her\n background history is most notable for stage IV lung cancer (probably\n non-small cell) and a report of COPD.\n 78yr F from w/ resp failure from , intubated in route to\n ED. R femoral line places, 4L NS given in ED for hypotension,\n antibiotics started.\n On arrival to MICU, family mtg held, pt did not want to continue care\n and was made CMO. Extubated and morphine gtt started. Pt expired \n @ 2235.\n" } ]

[ { "category": "Radiology", "chartdate": "2139-03-30 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1177954, "text": " 11:55 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p line placement R subclavian\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with hypotension post open chole\n REASON FOR THIS EXAMINATION:\n s/p line placement R subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right subclavian line placement.\n\n FINDINGS: In comparison with the earlier study of this date, the pulmonary\n vascular congestion is less prominent. There has been placement of a right\n subclavian PICC line that extends to the lower portion of the SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-03-27 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1177646, "text": " 5:16 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHOLECYSTITIS\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cholecystitis\n REASON FOR THIS EXAMINATION:\n Preop\n ______________________________________________________________________________\n WET READ: JBRe FRI 5:57 PM\n Small left effusion and left basilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 67-year-old male with history of cholecystitis, preop\n chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. There has\n been interval removal of the previously seen left PICC line. Opacification\n over the left costophrenic angle and inferior lateral left hemithorax may\n relate to overlying soft tissue and external artifact. However, a trace\n effusion, although not seen on the lateral view cannot be excluded, neither\n can atelectasis. The right lung is clear. The cardiac silhouette is top\n normal.\n\n" }, { "category": "Radiology", "chartdate": "2139-04-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178359, "text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pseudomonas pna\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with Pseudomonas pneumonia.\n\n Portable AP chest radiograph was reviewed in comparison to \n radiographs.\n\n The right internal jugular line tip is at the level of mid SVC. The feeding\n tube tip is not included in the field of view but on the prior study\n demonstrated it to be in the stomach. Bibasal opacities appear to be\n unchanged since the most recent prior radiograph. There is no interval\n increase in pleural effusion. There is no evidence of pulmonary edema but\n mild degree of vascular engorgement is still present, although improved since\n the prior radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177842, "text": " 12:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with increased oxygen requirement\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:19 P.M. ON \n\n HISTORY: Increasing oxygen requirement. Possible pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n New interstitial abnormality at the lung bases and probable right pleural\n effusion are explained by cardiac decompensation. Heart shadow and\n mediastinal vascular caliber are also increased. Nevertheless, there is\n greater opacification in the right lower lung, which makes it difficult to\n exclude pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178046, "text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo M s/p elective CCY with subsequent MS changes and hypoxia\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elective cholecystectomy with subsequent mental status changes\n and hypoxia.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: .\n\n FINDINGS: A right-sided PIC catheter appears stable in position. Lung\n aeration is improved compared to the previous examination. However, residual\n bibasilar atelectasis remains. Bilateral pleural effusions are also present,\n small on the right, moderate on the left. No pneumothorax is present.\n\n IMPRESSION:\n Bibasilar atelectasis with moderate left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2139-03-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1177896, "text": " 12:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid status post lasix\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with increase O2 requirement\n REASON FOR THIS EXAMINATION:\n eval for fluid status post lasix\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing oxygen requirement, to assess for fluid status.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes.\n Enlargement of the cardiac silhouette with pulmonary vascular congestion and\n probable bilateral pleural effusions are again seen. It is difficult to\n definitely exclude pneumonia in the absence of a lateral view.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178189, "text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 yo M s/p elective CCY with subsequent MS changes and hypoxia\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:19 A.M. ON \n\n HISTORY: Mental status changes and hypoxia.\n\n IMPRESSION: AP chest compared to through 22:\n\n Mild-to-moderate pulmonary edema and moderate right pleural effusion have\n increased since . Left lower lobe remains collapsed, and the\n larger left pleural effusion may have increased as well. Cardiac silhouette\n is partially obscured, but may have increased in size. There is no\n pneumothorax. Right subclavian line ends centrally. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1178276, "text": " 2:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval dobhoff position\n Admitting Diagnosis: CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new dobhoff\n REASON FOR THIS EXAMINATION:\n eval dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a Dobbhoff tube that extends to the upper portion of the stomach.\n\n\n" }, { "category": "Echo", "chartdate": "2139-03-31 00:00:00.000", "description": "Report", "row_id": 92258, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 285\nBSA (m2): 2.48 m2\nBP (mm Hg): 96/49\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 14:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient is on phenylephrin 0.6 mcg/kg/min.\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nLV WALL MOTION: remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - body habitus. The patient appears to be in sinus rhythm.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion appear to be\nnormal . The number of aortic valve leaflets cannot be determined. There is no\naortic valve stenosis. No aortic regurgitation is seen. No mitral\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Sub-optimal study but -ventricular systolic function appear to\nbe normal with no evidence of valvular pathology.\n\n\n" }, { "category": "ECG", "chartdate": "2139-04-04 00:00:00.000", "description": "Report", "row_id": 256210, "text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the\nprevious tracing of the underlying artifact has improved.\n\n" }, { "category": "ECG", "chartdate": "2139-03-31 00:00:00.000", "description": "Report", "row_id": 256211, "text": "Normal sinus rhythm with diffuse baseline artifact. Low precordial lead\nvoltage. Non-specific ST-T wave flattening. Compared to the previous tracing\nof the rate is slower.\n\n" }, { "category": "ECG", "chartdate": "2139-03-29 00:00:00.000", "description": "Report", "row_id": 256212, "text": "Sinus tachycardia. Low precordial lead voltage. Diffuse non-specific\nST-T wave flattening. Compared to the previous tracing of the rate is\nincreased. There is diffuse ST-T wave flattening. Otherwise, no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2139-03-28 00:00:00.000", "description": "Report", "row_id": 256213, "text": "Sinus rhythm. Low precordial lead voltage. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2139-03-27 00:00:00.000", "description": "Report", "row_id": 256214, "text": "Sinus rhythm and frequent atrial ectopy. Low precordial lead voltage. Compared\nto the previous tracing of no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "Radiology", "chartdate": "2153-02-14 00:00:00.000", "description": "DISTINCT PROCEDURAL SERVICE", "row_id": 1056702, "text": " 11:24 AM\n US INTR-OP 60 MINS PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: OR ULTRASOUND GUIDANCE TO CHECK RENAL TRANSPLANT FOR ABNORMAL FLOW\n Admitting Diagnosis: CHRONIC RENAL FAILURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n new renal transplant with decreasing flow\n REASON FOR THIS EXAMINATION:\n check renal transplant for abnormal flow\n ______________________________________________________________________________\n FINAL REPORT\n INTRAOPERATIVE ULTRASOUND AND DOPPLER OF RENAL TRANSPLANT\n\n CLINICAL INDICATION: Postop day 1, recent renal transplant with decrease\n flow. To check for stenosis, thrombus or dissection.\n\n The renal pedicle including artery and vein was imaged directly through a\n water bath of sterile saline placed into the pelvis. The vein showed evidence\n of slow sludgy flow. Within the artery, there is a complex thrombus. Near\n the anastomotic site with the iliac vessel, the thrombus is subtotally\n occlusive and appears to arise along the anterior wall. Immediately distal to\n this, there is a few millimeter gap with no thrombus and then, there is an\n extensive posterior thrombus extending all the way to the renal hilus. This\n causes 50-70% narrowing of the lumen, but flow can be seen extending\n intermittently through the main renal artery of the transplant.\n\n Decision was made based on these findings to perform an arteriotomy and\n thrombectomy.\n\n Following thrombectomy, repeat scans were performed demonstrating clearing of\n most of the thrombus in the transplant renal artery, but a small amount of\n persistent thrombus was seen near the renal hilum extending from the main\n renal artery into its initial bifurcation. Again, some flow is seen around\n this residual thrombus. Intrarenal waveforms show very low systolic peak\n velocity of approximately 10 cm/sec and absolutely no diastolic flow through\n about 80% of the cardiac cycle. This pattern was repeated in the upper,\n middle and lower portions of the transplant.\n\n CONCLUSION: Initial scans show extensive thrombus in the transplant main\n renal artery as described. Following thrombectomy, a small amount of residual\n thrombus was seen at the renal hilum extending into its initial bifurcation.\n Further arteriotomy and thrombectomy was to be performed after the scan.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-13 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1056618, "text": " 11:26 PM\n RENAL TRANSPLANT U.S.; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval arterial/venous flow for evidence of thrombosis\n Admitting Diagnosis: CHRONIC RENAL FAILURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with kidney transplant, difficult dissection, required\n interposition graft of the renal artery due to intimal dissection. Patient now\n with decreasing urine ouput again and hypertensive\n REASON FOR THIS EXAMINATION:\n please eval arterial/venous flow for evidence of thrombosis or intimal flap\n causing obstruction\n ______________________________________________________________________________\n WET READ: DXAe WED 12:43 AM\n Patent renal artery and interlobar branches but decreasing RI and worsening\n parvus and tardus waveforms is concerning for increasing stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67 year old with kidney transplant.\n\n COMPARISON: 3 hours prior.\n\n FINDINGS: A right lower quadrant transplant kidney measures 10.4 cm. Simple\n cyst is unchanged since three hours prior. There is no change in normal\n kidney echogenicity and no hydronephrosis. Color Doppler evaluation of the\n transplant demonstrates a patent main renal artery and vein with decreased\n renal atery resistive index. All imaged arteries demonstrate worsening\n severity of a tardus and parvus waveform since three hours prior. The main\n renal artery demonstrates decreased flow to 10 cm/sec with a resistive index\n of 0.7. The right upper pole interlobar artery demonstrates 5.4 cm/s flow and\n a resistive index of 0.37. The middle interlobar artery demonstrates 6.8 cm/s\n flow with a RI of 0.4 and the lower pole demonstrates a flow of 6.8 with RI of\n 0.38. Doppler flow is markedly reduced with minimal flow noted throughout the\n transplanted kidney.\n\n IMPRESSION: Findings are concerning for increasing renal artery stenosis. The\n differential includes dissection and thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2153-02-14 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1056764, "text": " 3:34 PM\n RENAL TRANSPLANT U.S.; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess flow in the transplant kidney\n Admitting Diagnosis: CHRONIC RENAL FAILURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with poorly functioning transplant kidney\n REASON FOR THIS EXAMINATION:\n Please assess flow in the transplant kidney\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Poorly functioning transplant kidney, please assess for flow.\n\n COMPARISON: Same day intraoperative ultrasound and renal transplant\n ultrasound.\n\n TECHNIQUE: Renal transplant ultrasound.\n\n FINDINGS: Grayscale, color, and pulsed Doppler son of the transplanted\n kidney in the right lower quadrant was performed. The kidney measures 11.3 cm\n compared to 10.5 cm on the examination earlier today. A 1.2 cm cyst in the\n interpolar region of the transplant kidney is again seen. There is no\n perinephric fluid collection or hydronephrosis.\n\n The abnormal waveform in the main renal artery of the transplanted kidney,\n with prompt systolic upstroke, but reversed flow in diastole, is little\n changed from the examination of several hours earlier. The main renal vein is\n patent. Minimal intrarenal waveforms can be obtained, with waveforms in the\n lower pole and interpolar region of the transplanted kidney showing a parvus-\n tardus configuration.\n\n IMPRESSION: Reversal of diastolic flow in the grossly patent main renal\n artery with nearly undetectable intrarenal vascularity, suggestive of\n intrarenal resistance to flow, possibly due to ATN, parenchymal edema or acute\n rejection. Findings discussed with Dr. at the bedside.\n\n\n\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654932, "text": "Hypertension, benign\n Assessment:\n Patient and orientated X3 tolerated hemodialysis, blood pressure\n labile on activity increases to 180-190\nsover 90\ns, pain with\n activity increases to 5 out of 10 jp to bulb suction, continues with no\n urine output, abd soft positive bowel sounds. Incision dressing clean\n dry intact.\n Action:\n Titrating labetalol gtt for pressure between 130-160, henodialysis\n reomoved 1.7kg Morphine Pca for pain\n Response:\n Patient pressure between 140\ns-150\ns over 50\ns to 60\n Plan:\n Continue to titrate labatalol gtt , report any changes to Sicu and\n Transplant teams provide comfort and support as needed. Patinet Npo for\n surgery in am for ? removal of transplant kidney.\n" }, { "category": "Nursing", "chartdate": "2153-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655114, "text": "TITLE:\n Renal Transplant\n Assessment:\n Pt alert and oriented x 3\n NC 3L in place\n Rsr\n Hypertensive 190\ns systolic\n Afebrile\n Tol sips clears with meds\n Foley with low urine output\n Jp with serosang output\n Dsd to rlq\n Morphine pca for pain\n Action:\n Labetolol drip restarted\n Dr. and dr. notified of urine output\n Response:\n Sbp 130-150\ns on drip\n Plan:\n Continue to monitor urine output\n Possible OR today\n Possible central line placement today due to poor/limited access\n Continue morphine pca for pain\n" }, { "category": "Nursing", "chartdate": "2153-02-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654865, "text": "Hypertension, benign\n Assessment:\n Pt adm from PACU at 1505. Hypertensive to the 200\ns and was started on\n a Nitro drip in the PACU. On arrival to SICU pt SBP 160-180\ns, denied\n pain. 20mg IV labetolol adm with effect and SBP decreased to 150\n briefly then increased to 180\ns. pt is A+OX3, MAE, follows commands.\n Morphine PCA .\n Action:\n Nitro drip dc\nd and Labetalol gtt started at 2mg/min.\n Response:\n SBP decreased to 170\n Plan:\n Pt needs dialysis to remove 3-4liters of fluid. Pt is schedule for the\n OR tomorrow morning to remove donor kidney. Continue to monitor pain\n and encourage use of PCA pump. Continue to offer emotional support to\n the pt and pt family. Living related donor ( , youngest\n son) is on 10.\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654912, "text": "Hypertension, benign\n Assessment:\n Patient and orientated X3 tolerated hemodialysis, arterial line,\n pain jp to bulb suction, continues with no urine output, abd soft\n positive bowel sounds. Incision dressing clean dry intact.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654914, "text": "Hypertension, benign\n Assessment:\n Patient and orientated X3 tolerated hemodialysis, blood pressure\n labile on activity increases to 180-190\nsover 90\ns, pain with\n activity increases to 5 out of 10 jp to bulb suction, continues with no\n urine output, abd soft positive bowel sounds. Incision dressing clean\n dry intact.\n Action:\n Titrating labetalol gtt for pressure between 130-160, henodialysis\n reomoved 1.7kg Morphine Pca for pain\n Response:\n Patient pressure between 140\ns-150\ns over 50\ns to 60\n Plan:\n Continue to titrate labatalol gtt , report any changes to Sicu and\n Transplant teams provide comfort and support as needed. Patinet Npo for\n surgery in am for ? removal of transplant kidney.\n" }, { "category": "Physician ", "chartdate": "2153-02-16 00:00:00.000", "description": "Intensivist Note", "row_id": 655158, "text": "SICU\n HPI:\n 66F with end-stage renal disease who has been currently on dialysis for\n approximately one year. S/P living donor kidney transplant with post\n op anuria and possible transplant failure. Re operation to remove clot\n from renal vein with good blood flow.\n Chief complaint:\n end stage renal disease s/p LRRT complicated by white clot\n PMHx:\n ESRD, DM, HTN, and hypercholesterolemia\n Current medications:\n Acetaminophen. CloniDINE. DiphenhydrAMINE. Docusate Sodium. Insulin.\n Labetalol. Metoprolol Tartrate. MethylPREDNISolone Sodium Succ.\n Morphine Sulfate. Mycophenolate Mofetil. Nephrocaps. Nystatin Oral\n Suspension. Ondansetron. Pantoprazole. Piperacillin-Tazobactam Na.\n PredniSONE. Prochlorperazine. Sulfameth/Trimethoprim SS. Tacrolimus.\n ValGANCIclovir. Vancomycin. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n ULTRASOUND - At 08:12 AM\n Continues to be hypertensive requiring labetalol gtt\n HD yesterday, 1.5L removed\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Last dose of Antibiotics:\n Piperacillin - 09:13 AM\n Bactrim (SMX/TMP) - 10:07 AM\n Valgancyclovir - 10:07 AM\n Vancomycin - 04:13 PM\n Piperacillin/Tazobactam (Zosyn) - 09:16 PM\n Infusions:\n Labetalol - 2 mg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.8\nC (98.3\n HR: 74 (66 - 88) bpm\n BP: 138/56(83) {121/52(71) - 198/79(123)} mmHg\n RR: 14 (10 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,208 mL\n 293 mL\n PO:\n 200 mL\n Tube feeding:\n IV Fluid:\n 1,008 mL\n 293 mL\n Blood products:\n Total out:\n 1,861 mL\n 121 mL\n Urine:\n 41 mL\n 21 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 100 mL\n Balance:\n -653 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///19/\n Physical Examination\n GEN: NAD\n HEENT: PEERLA, EOMI\n RESP:CTAB\n CV:Sinus RRR\n ABD:Soft + BS\n EXT:+1 edema warm\n Labs / Radiology\n 65 K/uL\n 9.5 g/dL\n 93 mg/dL\n 4.7 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 27 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.7 %\n 12.5 K/uL\n [image002.jpg]\n 05:57 PM\n 02:17 AM\n 02:15 AM\n WBC\n 18.4\n 9.6\n 12.5\n Hct\n 26.6\n 27.7\n 27.7\n Plt\n 101\n 84\n 65\n Creatinine\n 6.4\n 5.8\n 4.7\n Glucose\n 135\n 79\n 93\n Other labs: PT / PTT / INR:15.6/41.2/1.4, Ca:9.3 mg/dL, Mg:1.8 mg/dL,\n PO4:5.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: Morphine PCA, Acetaminophen prn\n CV: hypertensive, on labetalol gtt\n Resp: stable on NC\n GI: sips with meds\n GU: minimal urine to anuric, HD per renal, ?OR for exploration,\n transplant U/S this am\n FEN: HLIV\n Heme: stable, f/u HIT panel\n Endo: steroid taper, RISS\n ID: Vanc/Zosyn (empiric) Bactrim/Valcyte (prophylaxis), f/u cultures\n TLD: A line, Foley\n Wound: C/D/I\n Prophylaxis: PPI, boots\n Imaging: transplant U/S\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:24 PM\n Dialysis Catheter - 03:24 PM\n 20 Gauge - 01:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654902, "text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654903, "text": "Hypertension, benign\n Assessment:\n Patient and orientated X3\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654906, "text": "Hypertension, benign\n Assessment:\n Patient and orientated X3 tolerated hemodialysis, labetalol drip\n weaned off, pain jp to bulb suction, continues with no urine\n output, abd soft positive bowel sounds\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2153-02-15 00:00:00.000", "description": "Intensivist Note", "row_id": 654982, "text": "SICU\n HPI:\n 66-year-old female with end-stage renal disease who has been\n currently on dialysis for approximately one year. S/P living donor\n kidney transplant with post op anurea and transplant possible failure.\n Re operation to remove clot from renal vein with good blood flow.\n Chief complaint:\n Possible failing renal transplant\n PMHx:\n ESRD, DM, HTN, and hyperchol\n Current medications:\n Acetaminophen 4. Anti-Thymocyte Globulin (Rabbit) 5. Anti-Thymocyte\n Globulin (Rabbit)\n 6. CloniDINE 7. DiphenhydrAMINE 8. Docusate Sodium 9. Haloperidol 10.\n Heparin Flush (5000 Units/mL)\n 11. Influenza Virus Vaccine 12. Labetalol 13. Labetalol 14. Metoprolol\n Tartrate 15. Meperidine 16. MethylPREDNISolone Sodium Succ\n 17. MethylPREDNISolone Sodium Succ 18. Morphine Sulfate 19. Morphine\n Sulfate 20. Mycophenolate Mofetil\n 21. Nephrocaps 22. Nitroglycerin 23. Nystatin Oral Suspension 24.\n Ondansetron 25. Ondansetron 26. Pantoprazole\n 27. Piperacillin-Tazobactam Na 28. Pneumococcal Vac Polyvalent 29.\n Promethazine HCl 30. Prochlorperazine\n 31. PredniSONE 32. PredniSONE 33. Prochlorperazine 34.\n Sulfameth/Trimethoprim SS 35. Tacrolimus\n 36. ValGANCIclovir 37. Vancomycin 38. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n DIALYSIS CATHETER - START 03:24 PM\n ULTRASOUND - At 03:30 PM\n US of donor kidney.\n FEVER - 101.5\nF - 06:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin - 08:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 02:00 AM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.9\nC (100.2\n HR: 76 (71 - 91) bpm\n BP: 166/62(92) {115/49(66) - 192/70(101)} mmHg\n RR: 14 (11 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 884 mL\n 258 mL\n PO:\n Tube feeding:\n IV Fluid:\n 884 mL\n 258 mL\n Blood products:\n Total out:\n 195 mL\n 130 mL\n Urine:\n 5 mL\n NG:\n Stool:\n Drains:\n 190 mL\n 130 mL\n Balance:\n 689 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 84 K/uL\n 9.6 g/dL\n 79 mg/dL\n 5.8 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 34 mg/dL\n 105 mEq/L\n 140 mEq/L\n 27.7 %\n 9.6 K/uL\n [image002.jpg]\n 05:57 PM\n 02:17 AM\n WBC\n 18.4\n 9.6\n Hct\n 26.6\n 27.7\n Plt\n 101\n 84\n Creatinine\n 6.4\n 5.8\n Glucose\n 135\n 79\n Other labs: PT / PTT / INR:15.6/41.2/1.4, Ca:7.6 mg/dL, Mg:1.6 mg/dL,\n PO4:4.4 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: Morphine Sulfate 1 mg IVPCA, Acetaminophen 650 mg PO\n Q6H:PRN\n Cardiovascular: stable A line, metoprolol. Nitroglycerin gtt, BP\n Labetalol 20 mg IV Q6H:PRN, CloniDINE 0.1 mg PO BID, labetelol gtt\n Pulmonary: stable on NC, monitor for signs of volume overload and\n possible intubation\n Gastrointestinal / Abdomen: Pantoprazole 40 mg PO Q24H\n Nutrition: NPO, sips with PO meds only\n Renal: Transplant failure, HD today in SICU, foley follow UOP\n Hematology: follow CBC\n Endocrine: Steroid for 4 days post op\n Infectious Disease: Check cultures, Sulfameth/Trimethoprim SS 1 TAB PO\n DAILY, ValGANCIclovir, vanco/zosyn added due to fevers 101.9 pan\n cultured\n Lines / Tubes / Drains: A line PIV\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:24 PM\n Dialysis Catheter - 03:24 PM\n 22 Gauge - 07:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2153-02-15 00:00:00.000", "description": "Intensivist Note", "row_id": 654994, "text": "SICU\n HPI:\n 66-year-old female with end-stage renal disease who has been\n currently on dialysis for approximately one year. S/P living donor\n kidney transplant with post op anurea and transplant possible failure.\n Re operation to remove clot from renal vein with good blood flow.\n Chief complaint:\n Possible failing renal transplant\n PMHx:\n ESRD, DM, HTN, and hyperchol\n Current medications:\n Acetaminophen 4. Anti-Thymocyte Globulin (Rabbit) 5. Anti-Thymocyte\n Globulin (Rabbit)\n 6. CloniDINE 7. DiphenhydrAMINE 8. Docusate Sodium 9. Haloperidol 10.\n Heparin Flush (5000 Units/mL)\n 11. Influenza Virus Vaccine 12. Labetalol 13. Labetalol 14. Metoprolol\n Tartrate 15. Meperidine 16. MethylPREDNISolone Sodium Succ\n 17. MethylPREDNISolone Sodium Succ 18. Morphine Sulfate 19. Morphine\n Sulfate 20. Mycophenolate Mofetil\n 21. Nephrocaps 22. Nitroglycerin 23. Nystatin Oral Suspension 24.\n Ondansetron 25. Ondansetron 26. Pantoprazole\n 27. Piperacillin-Tazobactam Na 28. Pneumococcal Vac Polyvalent 29.\n Promethazine HCl 30. Prochlorperazine\n 31. PredniSONE 32. PredniSONE 33. Prochlorperazine 34.\n Sulfameth/Trimethoprim SS 35. Tacrolimus\n 36. ValGANCIclovir 37. Vancomycin 38. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n DIALYSIS CATHETER - START 03:24 PM\n ULTRASOUND - At 03:30 PM\n US of donor kidney.\n FEVER - 101.5\nF - 06:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin - 08:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 02:00 AM\n Other medications:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 37.9\nC (100.2\n HR: 76 (71 - 91) bpm\n BP: 166/62(92) {115/49(66) - 192/70(101)} mmHg\n RR: 14 (11 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 884 mL\n 258 mL\n PO:\n Tube feeding:\n IV Fluid:\n 884 mL\n 258 mL\n Blood products:\n Total out:\n 195 mL\n 130 mL\n Urine:\n 5 mL\n NG:\n Stool:\n Drains:\n 190 mL\n 130 mL\n Balance:\n 689 mL\n 128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 84 K/uL\n 9.6 g/dL\n 79 mg/dL\n 5.8 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 34 mg/dL\n 105 mEq/L\n 140 mEq/L\n 27.7 %\n 9.6 K/uL\n [image002.jpg]\n 05:57 PM\n 02:17 AM\n WBC\n 18.4\n 9.6\n Hct\n 26.6\n 27.7\n Plt\n 101\n 84\n Creatinine\n 6.4\n 5.8\n Glucose\n 135\n 79\n Other labs: PT / PTT / INR:15.6/41.2/1.4, Ca:7.6 mg/dL, Mg:1.6 mg/dL,\n PO4:4.4 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: Morphine Sulfate 1 mg IVPCA, Acetaminophen 650 mg PO\n Q6H:PRN\n Cardiovascular: stable A line, metoprolol. Nitroglycerin gtt, BP\n Labetalol 20 mg IV Q6H:PRN, CloniDINE 0.1 mg PO BID, labetelol gtt\n Pulmonary: stable on NC, monitor for signs of volume overload and\n possible intubation\n Gastrointestinal / Abdomen: Pantoprazole 40 mg PO Q24H\n Nutrition: NPO, sips with PO meds only\n Renal: Transplant failure, HD today in SICU, not UOP, repeat US, likely\n to OR today\n Hematology: follow CBC\n Endocrine: Steroid for 4 days post op\n Infectious Disease: Check cultures, Sulfameth/Trimethoprim SS 1 TAB PO\n DAILY, ValGANCIclovir, vanco/zosyn added due to fevers 101.9 pan\n cultured\n Lines / Tubes / Drains: A line PIV\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Transplant\n Billing Diagnosis: Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 03:24 PM\n Dialysis Catheter - 03:24 PM\n 22 Gauge - 07:17 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2153-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655079, "text": "s/p renal transplant\n Assessment:\n Urine output during shift 32cc/hr of blood tinged urine.\n Action:\n Ultrasound of transplanted kidney done, pt received antirejection meds,\n HD done in afternoon, OR cancelled\n Response:\n 1 lter taken off by HD, minimal amt of urine noted in foley, received\n vanco dose by HD nursse\n Plan:\n Tacrollimus due at 1800, cont to monitor uo, ? OR tomorrow or\n additional US to be done\n Hypertension, benign\n Assessment:\n Abp labile , range 147-198, abp elevated when family in room,\n Action:\n Labetalol gtt off and on during shift , bloused x2 with 20 mg for\n continued elevated abp in the 190\ns, pt started on home meds nifidepine\n 90 mg CR\n Response:\n Labetalol back on after dialysis at 2mg, nifidepine given. currently\n systolic 170\n Plan:\n Continue to monitor abp and titrate labetalol to maintain systolic\n 130-170\n" }, { "category": "Physician ", "chartdate": "2153-02-16 00:00:00.000", "description": "Intensivist Note", "row_id": 655141, "text": "SICU\n HPI:\n 66F with end-stage renal disease who has been currently on dialysis for\n approximately one year. S/P living donor kidney transplant with post\n op anuria and possible transplant failure. Re operation to remove clot\n from renal vein with good blood flow.\n Chief complaint:\n end stage renal disease s/p LRRT complicated by white clot\n PMHx:\n ESRD, DM, HTN, and hypercholesterolemia\n Current medications:\n Acetaminophen. CloniDINE. DiphenhydrAMINE. Docusate Sodium. Insulin.\n Labetalol. Metoprolol Tartrate. MethylPREDNISolone Sodium Succ.\n Morphine Sulfate. Mycophenolate Mofetil. Nephrocaps. Nystatin Oral\n Suspension. Ondansetron. Pantoprazole. Piperacillin-Tazobactam Na.\n PredniSONE. Prochlorperazine. Sulfameth/Trimethoprim SS. Tacrolimus.\n ValGANCIclovir. Vancomycin. sevelamer HYDROCHLORIDE\n 24 Hour Events:\n ULTRASOUND - At 08:12 AM\n Continues to be hypertensive requiring labetalol gtt\n HD yesterday, 1.5L removed\n Allergies:\n Heparin Agents\n Thrombocytopeni\n Last dose of Antibiotics:\n Piperacillin - 09:13 AM\n Bactrim (SMX/TMP) - 10:07 AM\n Valgancyclovir - 10:07 AM\n Vancomycin - 04:13 PM\n Piperacillin/Tazobactam (Zosyn) - 09:16 PM\n Infusions:\n Labetalol - 2 mg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.8\nC (98.3\n HR: 74 (66 - 88) bpm\n BP: 138/56(83) {121/52(71) - 198/79(123)} mmHg\n RR: 14 (10 - 21) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,208 mL\n 293 mL\n PO:\n 200 mL\n Tube feeding:\n IV Fluid:\n 1,008 mL\n 293 mL\n Blood products:\n Total out:\n 1,861 mL\n 121 mL\n Urine:\n 41 mL\n 21 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 100 mL\n Balance:\n -653 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///19/\n Physical Examination\n Labs / Radiology\n 65 K/uL\n 9.5 g/dL\n 93 mg/dL\n 4.7 mg/dL\n 19 mEq/L\n 5.1 mEq/L\n 27 mg/dL\n 110 mEq/L\n 138 mEq/L\n 27.7 %\n 12.5 K/uL\n [image002.jpg]\n 05:57 PM\n 02:17 AM\n 02:15 AM\n WBC\n 18.4\n 9.6\n 12.5\n Hct\n 26.6\n 27.7\n 27.7\n Plt\n 101\n 84\n 65\n Creatinine\n 6.4\n 5.8\n 4.7\n Glucose\n 135\n 79\n 93\n Other labs: PT / PTT / INR:15.6/41.2/1.4, Ca:9.3 mg/dL, Mg:1.8 mg/dL,\n PO4:5.4 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: Morphine PCA, Acetaminophen prn\n CV: hypertensive, on labetalol gtt\n Resp: stable on NC\n GI: sips with meds\n GU: anuric, HD per renal, ?OR for exploration, transplant U/S this am\n FEN: HLIV\n Heme: stable, f/u HIT panel\n Endo: steroid taper, RISS\n ID: Vanc/Zosyn (empiric) Bactrim/Valcyte (prophylaxis), f/u cultures\n TLD: A line, Foley\n Wound: C/D/I\n Prophylaxis: PPI, boots\n Imaging: transplant U/S\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:24 PM\n Dialysis Catheter - 03:24 PM\n 20 Gauge - 01:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" } ]

[ { "category": "Radiology", "chartdate": "2176-07-31 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1247679, "text": " 1:58 PM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre op craniotomy\n Admitting Diagnosis: SEIZURE\n Contrast: GADAVIST Amt: 8\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with cavernoma going for resection\n REASON FOR THIS EXAMINATION:\n pre op craniotomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with right frontal cavernous angioma; obtained for\n pre-operative planning.\n\n COMPARISONS: .\n\n TECHNIQUE: MRI of the brain was obtained following uneventful administration\n of 8 mL of gadobutrol. Only post-contrast axial T1-weighted SE and MP-RAGE\n images, the latter with coronal and sagittal reformations, are provided.\n\n FINDINGS:\n\n Limited study is obtained for pre-operative planning. There is a 7 x 7 mm\n enhancing lesion in the right frontal region, unchanged since the recent\n exam. The degree of surrounding edema is grossly unchanged, but the\n extent of internal hemorrhage cannot be assessed due to lack of pre-contrast\n T1-weighted, FLAIR and susceptibility sequences. No additional focus of\n abnormal enhancement is seen within the brain. There is no mass effect.\n Sulci and ventricles are normal and unchanged in size and configuration.\n There is no shift of normally midline structures. Basal cisterns are patent.\n Paranasal sinuses are clear. A 4 x 1 cm lipoma in the left frontal\n subcutaneous tissues is again noted (3:50).\n\n IMPRESSION:\n\n 1. Limited pre-operative study redemonstrating the 7 x 7 mm enhancing lesion\n in the right frontal region consistent with the previously-characterized\n cavernous angioma, unchanged in appearance since .\n\n 2. Large left frontal subcutaneous lipoma.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-26 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1247021, "text": " 5:46 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess right frontal brain mass\n Admitting Diagnosis: SEIZURE\n Contrast: GADAVIST Amt: 9\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with new seizures, found to have right frontal brain mass\n REASON FOR THIS EXAMINATION:\n assess right frontal brain mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New seizures, with focal hemorrhage in the right frontal lobe.\n\n COMPARISON: Comparison is made to a head CT from dated\n .\n\n TECHNIQUE: Sagittal T1-weighted, FLAIR, axial T1-weighted, gradient echo,\n FLAIR, T2-weighted and diffusion-weighted images are acquired through the\n brain. Thereafter, following the uneventful intravenous administration of 9cc\n of Gadavist contrast, axial T1-weighted and sagittal MP-RAGE images were\n acquired through the brain. From the latter, coronal and axial reformats were\n created. Finally, MR angiographic images were acquired through the brain,\n notably after contrast administration. Per MR report, this was\n done as the order for the MR angiogram was not present with the original\n paperwork.\n\n FINDINGS: Corresponding to the focal hyperdensity in the right frontal lobe\n on the comparison CT is a 5 x 5 mm focus of intrinsic T1-hyperintensity\n (5:14). Post-contrast images show a moderate degree of surrounding\n enhancement, with the total region of enhancement measuring 10 x 6 mm (12:13).\n Of note, the FLAIR images reveal a paucity of surrounding parenchymal edema.\n There is a large degree of \"blooming\" susceptibility artifact seen on gradient\n echo images, though without a lamellated appearance. The T2-weighted images\n demonstrate punctate round hypointensities at the margins of the area of\n enhancement, suggesting vascular flow-voids. Post-contrast images show some\n enhancement within those flow voids, as well as in two filamentous vessels\n emanating from this lesion, extending anteriorly to reach the overlying dura\n (11:99), possibly communicating with a nearby cortical vein.\n\n Aside from the finding in the right frontal lobe, confirming the abnormal\n vessels extending to the dural, the (post-contrast) MR angiographic images are\n normal; specifically, no flow limiting stenosis, significant mural\n irregularity, thrombo-embolic filling defect or aneurysm larger than 3 mm is\n seen.\n\n There is no other abnormal focus of enhancement or intracranial hemorrhage.\n The ventricles and sulci are normal in size and configuration. Note is made\n of expansion of the bony sella turcica, with flattening of the pituitary\n glandular tissue and an orthotopic pituitary \"bright spot.\" Incidental note\n is also made of a 4.0 x 1,2 cm midline frontal subcutaneous lipoma (9:13).\n\n (Over)\n\n 5:46 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess right frontal brain mass\n Admitting Diagnosis: SEIZURE\n Contrast: GADAVIST Amt: 9\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. 10 x 6 mm enhancing lesion in the right frontal lobe, with central\n intrinsic T1-hyperintensity, \"blooming\" susceptibility and adjacent\n filamentous vascular structures extending to the nearby dura. Taken together,\n these findings suggest hemorrhage related to underlying cavernous angioma with\n possible associated developmental venous anomaly. A more remote possibility is\n dural AV fistula, with cortical venous drainage.\n\n Further evaluation via consultation with Interventional Neuroradiology service\n has been recommended.\n\n 2. Expanded sella turcica, with an appearance suggestive of an \"empty sella,\"\n a common variant, or possibly, arachnoid cyst of the suprasellar cistern.\n\n 3. Large frontal subcutaneous lipoma.\n\n COMMENT: These results were discussed with Dr. Nam (Neurology\n service), by Dr. via telephone at 1335h (as well as with Dr. ,\n Neurology Chief Resident, by Dr. on .\n\n Dr. also emailed these findings and concerns Dr. \n (Interventional Neuroradiology) at 1338h, and Dr. responded by email at\n 2010h on .\n\n" }, { "category": "Radiology", "chartdate": "2176-07-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1247024, "text": " 7:56 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with seizure, R frontal brain mass\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old lady with seizures, right frontal brain mass,\n evaluate for cardiopulmonary process.\n\n COMPARISON: No prior studies available.\n\n TECHNIQUE: AP upright and lateral chest radiographs.\n\n FINDINGS: Lungs are well expanded. Cardiac silhouette appears to be mildly\n enlarged; however, this could be due to the AP technique. Cardiomediastinal\n contours are unremarkable. Lungs are clear. No pleural effusions and no\n pneumothorax. Bony structures are intact.\n\n IMPRESSION: Normal radiographic study of the chest.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1247723, "text": " 9:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for post operative hemorrhage.\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with a right frontal cavernoma s/p resection\n REASON FOR THIS EXAMINATION:\n evaluate for post operative hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for postoperative hemorrhage in a patient status post\n resection of a right frontal cavernoma.\n\n COMPARISONS: MRI of the brain from .\n\n TECHNIQUE: MDCT-acquired contiguous axial images were obtained through the\n head without intravenous contrast.\n\n FINDINGS: The patient is status post right frontal craniotomy with expected\n soft tissue swelling in the overlying scalp, along with subcutaneous emphysema\n and pneumocephalus within the resection cavity. There is no evidence of\n postoperative hemorrhage. Otherwise, there is no shift of normally midline\n structures and the ventricles and sulci are normal in size and configuration.\n The -white matter differentiation is preserved. There is minimal mucosal\n thickening in the visualized portion of the maxillary sinuses. The mastoid\n air cells and middle ear cavities are clear.\n\n IMPRESSION: No evidence of postoperative hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2176-08-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1247871, "text": " 6:32 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for post surgical change\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman who p/w seizures, found to have R frontal cavernoma now s/p R\n craniectomy and cavernoma resection.\n REASON FOR THIS EXAMINATION:\n evaluate for post surgical change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient status post resection of right frontal cavernoma. Assess\n for postoperative changes.\n\n COMPARISONS: MR head of and postoperative CT head of .\n\n FINDINGS:\n\n Post-operative changes related to right frontal cavernoma resection are noted.\n Increased T1 signal within the resection bed, likely reflects hemorrhage.\n Subtle area of enhancement is seen anteriorly (14:15), which may be\n post-surgical. Linear focus of decreased diffusion is also seen within\n resection bed, with corresponding area of decreased signal on ADC maps (9:17).\n Punctate focus of increased diffusion is also seen in the left parietal white\n matter (9:14), new since prior study. Susceptibility artifact seen within the\n resection, also likely reflects hemorrhage. Otherwise, no new intracranial\n abnormality is detected. The sulci and ventricles are normal in size and\n configuration. There is no mass effect or shift of normally midline\n structures. Basal cisterns are patent. Soft tissue edema overlying right\n frontal and malar region is post-surgical. There is interval resection of the\n frontal lipoma. Principal intracranial flow voids are preserved.\n\n IMPRESSION:\n\n 1. Post-surgical changes related to right frontal cavernoma resection, as\n described above. Small amount of hemorrhage within the resection bed. A\n small focus of restricted diffusion in the resection bed is also seen, which\n may represent a focus of infarction, cytotoxic edema, or may relate to\n underlying blood products. Additional punctate focus of restricted diffusion\n in the left parietal region may represent a small infarction, not seen on\n exam. Subtle area of enhancement in post-surgical bed is likely\n post-surgical, attention on followup exams is recommended.\n\n 2. Interval resection of the frontal lipoma.\n\n" }, { "category": "Radiology", "chartdate": "2176-08-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1248674, "text": " 5:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p cavernoma resection, with increasing headache today.\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:18 PM\n Expected evolution of postoperative bed in the right frontal lobe. No\n evidence of new hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent cavernoma resection with increasing headache.\n Evaluation for interval change.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast.\n\n COMPARISON: Multiple prior examinations, most recent CT dated .\n\n FINDINGS: There is continued evolution of the postoperative bed in the right\n frontal lobe status post cavernoma resection with a developing area of\n encephalomalacia. No new interval hemorrhage or shift of midline structures\n is seen. The ventricles are normal in size and configuration. There remains\n a small amount of procedure-related pneumocephalus.\n\n No concerning osseous abnormality is identified. Soft tissue thickening and\n surgical staples from procedure appear grossly unchanged. There is a small\n amount of opacification in the right frontoethmoidal recess. Scattered\n opacification of the mastoid air cells greatest at the apices appears similar\n to the prior MRI of .\n\n IMPRESSION: Expected evolution of postoperative bed in the right frontal\n lobe. No evidence of new hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2176-08-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1248100, "text": " 10:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with recent right frontal cavernoma resection, now with\n increased lethargy and new clonus at left patella.\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent right frontal cavernoma resection. Lethargy and new\n clonus. Evaluation for interval change.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast.\n\n COMPARISON: NECT of the head . MR .\n\n FINDINGS: Again seen are expected post-surgical changes from right frontal\n craniotomy with pneumocephalus and overlying scalp soft tissue edema. There\n is no hemorrhage, edema, shift of midline structures, or territorial\n infarction. The ventricles and sulci are normal in size and configuration.\n The basal cisterns are patent and -white matter differentiation is\n preserved. The visualized paranasal sinuses, mastoid air cells, and middle\n ear cavities are clear.\n\n IMPRESSION: No evidence of interval hemorrhage from .\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1247379, "text": " 11:13 AM\n CAROT/CEREB Clip # \n Reason: Diagnostic angio\n Admitting Diagnosis: SEIZURE\n Contrast: OPTIRAY Amt: 162\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * EXT CAROTID UNILAT CAROTID/CEREBRAL UNILAT *\n * CAROTID/CERVICAL UNILAT MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with possible dural AV fistula\n REASON FOR THIS EXAMINATION:\n Diagnostic angio\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Hemorrhagic right frontal intra-axial lesion in a\n patient presenting with seizures. Question of cavernoma or dural\n arteriovenous fistula.\n\n PROCEDURE PERFORMED: Diagnostic cerebral angiogram.\n\n PHYSICIANS: , M.D., , M.D.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n Fentanyl (100mcg) and Versed (2mg) throughout the total intraservice time of\n 40minutes during which the patients hemodynamic parameters were continuously\n monitored.\n\n PROCEDURES PERFORMED: Right internal carotid arteriogram, Right external\n carotid arteriogram, Right vertebral arteriogram, Left common carotid\n arteriogram, Right femoral arteriogram.\n\n DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.\n Moderate sedation was induced (as described above) in the supine position.\n Following this, both groins were prepped and draped in a sterile fashion.\n After anesthetizing with local 1% Lidocaine, a 5F micropuncture set was used\n to access the right common femoral artery. Access was secured using Seldinger\n technique and a 5F sheath was sutured in place in the right groin. We now\n catheterized the above-mentioned vessels using 5F SIM2 and 4F Berenstein II\n catheters, and AP, lateral filming was done. A right common femoral artery\n arteriogram was done and a 6 French Angio-Seal was used for closure of the\n right common femoral artery puncture site.\n\n FINDINGS:\n Right internal carotid arteriogram - The right internal carotid artery is\n normal. Specifically, there were no intraluminal filling defects, aneurysms,\n dissections or evidence of an arteriovenous fistula. There is a large draining\n (Over)\n\n 11:13 AM\n CAROT/CEREB Clip # \n Reason: Diagnostic angio\n Admitting Diagnosis: SEIZURE\n Contrast: OPTIRAY Amt: 162\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vein in the right frontal regon.\n\n Right external carotid arteriogram - The right external carotid artery is\n normal. Specifically, there were no intraluminal filling defects, aneurysms,\n dissections or evidence of an arteriovenous fistula.\n\n Right vertebral arteriogram - The right vertebral artery is normal.\n Specifically, there were no intraluminal filling defects, aneurysms,\n dissections or evidence of an arteriovenous fistula.\n\n Left common carotid arteriogram - The left common carotid artery is normal.\n Specifically, there were no intraluminal filling defects, aneurysms,\n dissections or evidence of an arteriovenous fistula.\n\n Right femoral arteriogram - The right femoral artery is normal in caliber,\n without evidence of atherosclerotic or other luminal narrowing.\n\n IMPRESSION: underwent a diagnostic cerebral angiogram which\n was grossly normal, specifically with no evidence of a dural arteriovenous\n fistula. Given the pre-procedural imaging, this favours an occult vascular\n malformation (ie. cavernoma) as the underlying cause for the findings on those\n studies.\n\n" }, { "category": "Radiology", "chartdate": "2176-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1247899, "text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with right cavernoma s/p resection, new fevers\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Postop fever.\n\n Comparison is made with prior study, preop evaluation, .\n\n Mild cardiomegaly is improved. There are bibasilar atelectases, larger on the\n right side. There is no pneumothorax or pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2176-07-31 00:00:00.000", "description": "Report", "row_id": 305017, "text": "Normal sinus rhythm. Delayed R wave transition. Low voltage in the precordial\nleads. No previous tracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2176-08-06 00:00:00.000", "description": "Report", "row_id": 304839, "text": "Sinus rhythm. Delayed R wave transition. Cannot exclude prior anterior wall\nmyocardial infarction. Non-specific ST-T wave changes in the inferior and\nanterior leads. Low voltage in the anterior leads. Consider left ventricular\nhypertrophy. Consider left anterior fascicular block. Compared to the\nprevious tracing of findings are similar.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348226, "text": "Respiratory failure, chronic\n Assessment:\n Pt sedated on Fentanyl and Propofol gtts this am. Bs clear but\n diminished in bases. Sx for scant amt thin white secretions. On CMV\n with sats 99-100%\n Action:\n Propofol weaned to off, pt placed on cpap with 5 ips, sats monitored,\n RSBI 38. pt extubated and placed on open face tent , nasal cannula\n added to maintain sat>95%. Started on IS\n Response:\n Tol extubation well, currently on nc at 4 liters with sat96%, able to\n move on incentive spirometry\n Plan:\n Encourage pulm toilet, monitor resp parameters\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Fentanyl gtt d/c\nd this afternoon and pt placed on Dilaudid pca. Pt\n stating he has pain in left lower quadrant and pca is not helping.\n Action:\n Medicated with Dilaudid 0.25 x1 for breakthrough pain, explanation\n given as to how pca works, discussed pain management with DR .\n Response:\n Although pt appears to be comfortable, he continues to state that pca\n is not working as well\n Plan:\n Encourage pt to use pca , administer Dilaudid q3hrs as needed for\n breakthrough pain. ? increase dose if pain persists,\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 348386, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal pain level is a on a scale on\n \n Action:\n Pt using Dilaudid pca pump\n Response:\n Pt with acceptable level of pain per patient\n Plan:\n Continue to monitor\n .H/O hyperglycemia\n Assessment:\n Blood sugar 187\n Action:\n Pt received 4units of regular insulin per sliding scale\n Response:\n Await results from regular insulin\n Plan:\n Continue to monitor, check blood sugar every six hours as\n ordered\n .H/O wound infection\n Assessment:\n Dsg changed by dr. . Abd incision with staples,\n lower portion of incision open, draining serosanganoius drainage. Dsg\n packed with 1 4x8 by dr. \n Action:\n Dsg changed by dr. \n Response:\n No change, dsg changed, abd. Binder on\n Plan:\n Continue to monitor\n Change dsg as ordered\n Assess for signs of infection\n Pt oob to chair which he tolerated fine. Pt with ngtube, pt able to\n have small amt of ice chips per dr. \n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 154.1 kg\n Daily weight:\n Allergies/Reactions:\n Crestor (Oral) (Rosuvastatin Calcium)\n Patient states\n Precautions:\n PMH: GI Bleed\n CV-PMH: Angina, CAD, Hypertension\n Additional history: diverticulitis s/p sigmoidectomy, intaabdominal\n abscess, lv dysfunction, morbid obesity, ventral hernia\n psh- sigmoid colectomy and cecectomy at osh with development of\n enteocutaneous fistula and abscess, abd. wound exploration\n and ec fistula drainage.7/06ex lap, loa, abscess drainage sb ec fistula\n takedown partial ccy, ventral hernia repair, appendectomy\n Surgery / Procedure and date: ex lap, loa, repair of incisional\n hernia repair.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:77\n Temperature:\n 99.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 1,288 mL\n 24h total out:\n 1,595 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:11 AM\n Potassium:\n 3.7 mEq/L\n 03:11 AM\n Chloride:\n 105 mEq/L\n 03:11 AM\n CO2:\n 28 mEq/L\n 03:11 AM\n BUN:\n 11 mg/dL\n 03:11 AM\n Creatinine:\n 0.7 mg/dL\n 03:11 AM\n Glucose:\n 187\n 10:00 AM\n Hematocrit:\n 36.0 %\n 03:11 AM\n Finger Stick Glucose:\n 142\n 10:00 PM\n Valuables / Signature\n Patient valuables: pt has a jacket, clothes and brief case, pt has\n cellphone\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Respiratory ", "chartdate": "2151-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 348163, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Patient received post-operatively (S/P exploratory lap for\n lysis of adhesions) and placed on ventilatory support. No morning abg\n results at this time. RSBI = 36 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348290, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Adequate pain control\n Action:\n Pt encouraged to use PCA prior to any turning/repositioning\n Sleeping well throughout the shift\n Response:\n Rating pain @7 consistently\n Plan:\n Continue dilaudid pca\n" }, { "category": "Physician ", "chartdate": "2151-10-29 00:00:00.000", "description": "Intensivist Note", "row_id": 348189, "text": "SICU\n HPI:\n 43M p/w SBO, ? strangulated incisional hernia s/p ex lap, LOA .\n Chief complaint:\n SBO\n PMHx:\n PMH: IDDM, CAD with LV dysfunction, HTN, obesity, ventral hernia, h/o\n diverticulitis, s/p sigmoid colectomy and cecectomy (at OSH) c/b EC\n fistula and abcess, s/p abdominal abcess drainage, ventral hernia\n repair with SIS (), s/p wound exploration and EC fistula drainage\n (), s/p ex-lap, LOA, ECF takedown, partial CCY, ventral hernia\n repair with mesh and component separation ()\n Current medications:\n 1. 2. 3. 1000 mL LR 4. Calcium Gluconate 5. Famotidine 6. Fentanyl\n Citrate 7. Heparin 8. Insulin\n 9. Magnesium Sulfate 10. Metoprolol Tartrate 11. Ondansetron 12.\n Potassium Chloride 13. Propofol\n 14. Sodium Chloride 0.9% Flush 15. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INTUBATION - At 11:00 PM\n OR RECEIVED - At 11:26 PM\n INVASIVE VENTILATION - START 11:27 PM\n Post operative day:\n POD#1 - exp lap, lysis of adhesions, repair of incisional hernia\n Allergies:\n Crestor (Oral) (Rosuvastatin Calcium)\n Patient states\n Last dose of Antibiotics:\n Infusions:\n Fentanyl - 100 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 10:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 38\nC (100.4\n HR: 106 (82 - 107) bpm\n BP: 175/102(120) {122/57(67) - 179/102(120)} mmHg\n RR: 22 (16 - 22) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,020 mL\n 1,657 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,020 mL\n 1,657 mL\n Blood products:\n Total out:\n 400 mL\n 1,115 mL\n Urine:\n 1,115 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,620 mL\n 542 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 825 (725 - 825) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 36\n PIP: 15 cmH2O\n SPO2: 97%\n ABG: 7.31/50/187/19/-1\n Ve: 13.3 L/min\n PaO2 / FiO2: 416\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, No(t) Bowel sounds present, Obese\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 263 K/uL\n 13.2 g/dL\n 153 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 105 mEq/L\n 135 mEq/L\n 37.3 %\n 8.8 K/uL\n [image002.jpg]\n 10:38 PM\n 11:41 PM\n 03:03 AM\n 05:45 AM\n WBC\n 6.3\n 8.8\n Hct\n 41\n 29.4\n 37.3\n Plt\n 217\n 263\n Creatinine\n 0.6\n 0.9\n TCO2\n 26\n Glucose\n 211\n 153\n Other labs: Lactic Acid:2.4 mmol/L, Ca:8.3 mg/dL, Mg:1.4 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS), .H/O CORONARY\n ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE), .H/O DIABETES MELLITUS\n (DM), TYPE I, .H/O HYPERGLYCEMIA, .H/O OBSTRUCTIVE SLEEP APNEA (OSA),\n .H/O PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O WOUND INFECTION,\n RESPIRATORY FAILURE, CHRONIC\n Assessment and Plan: 43M p/w SBO, ? strangulated incisional hernia s/p\n ex lap, LOA .\n Neurologic: On fentanyl for pain. Off propofol.\n Cardiovascular: Beta-blocker, Hypertensive, tachy, ?agitation. EKG.\n Pulmonary: Extubate today, (Ventilator mode: CPAP + PS), Extubate.\n Gastrointestinal / Abdomen: Continue NPO/NGT/IVF. Abd binder.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Cr stable at 0.9.\n Hematology: Hct stable at 37.3.\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: No issues.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids: LR, LR @ 100.\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 11:23 PM\n 20 Gauge - 11:23 PM\n 16 Gauge - 11:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348156, "text": "43 year old male patient with h/o cad, htn, niddm, lv dysfunction,\n diverticulitis s/p sigmoidectomy, intaabdominal abscess, lv\n dysfunction, morbid obesity, ventral hernia\n psh- sigmoid colectomy and cecectomy at osh with development of\n enteocutaneous fistula and abscess, abd. wound exploration\n and ec fistula drainage.7/06ex lap, loa, abscess drainage sb ec fistula\n takedown partial ccy, ventral hernia repair, appendectomy.\n Admit to with 2 day h/o abdominal pain and nausea.taken to OR for\n exploratory lap, lysis of adhesions and repair of incisional\n hernia.arrived in sicu at 2315.\n Respiratory failure acute\n Assessment:\n Returned from OR intubated. Remains on cmv with 5 peep, rate 22, 50%\n fio2. only one abg drawn so far due to a-line was not able to be\n placed intraoperatively.\n Action:\n Vent changes made with results of abg.\n Response:\n O2 sats have remained at 98-100%\n Plan:\n Respiratory therapy to repeat abg this am.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Sedated on 60 mcg\ns of Propofol and 100 mcg of fentanyl for pain\n control.\n Action:\n Fenanyl gtt titrated up to a leveling out of vital signs.\n Response:\n Sbp remains in the 140\ns to 150\ns. appears comfortable.\n Plan:\n Continue to monitor for comfort and medicate for pain.\n .H/O wound infection\n Assessment:\n Incisional hernia fixed in the OR. Remains with small enterocutaneous\n fistula at base of incision.dressing was soaked and leaking\n serosanguines drainage.\n Action:\n Dressing changed to abdomen. Ns w/d to lower aspect of incision.\n Response:\n Dressing dry and intact\n Plan:\n Change dressing and prn.\n" }, { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348143, "text": "Respiratory failure, chronic\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O wound infection\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 348355, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal pain level is a on a scale on\n \n Action:\n Pt using Dilaudid pca pump\n Response:\n Pt with acceptable level of pain per patient\n Plan:\n Continue to monitor\n .H/O hyperglycemia\n Assessment:\n Blood sugar 187\n Action:\n Pt received 4units of regular insulin per sliding scale\n Response:\n Await results from regular insulin\n Plan:\n Continue to monitor, check blood sugar every six hours as\n ordered\n .H/O wound infection\n Assessment:\n Dsg changed by dr. . Abd incision with staples,\n lower portion of incision open, draining serosanganoius drainage. Dsg\n packed with 1 4x8 by dr. \n Action:\n Dsg changed by dr. \n Response:\n No change, dsg changed, abd. Binder on\n Plan:\n Continue to monitor\n Change dsg as ordered\n Assess for signs of infection\n Pt oob to chair which he tolerated fine. Pt with ngtube, pt able to\n have small amt of ice chips per dr. \n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 154.1 kg\n Daily weight:\n Allergies/Reactions:\n Crestor (Oral) (Rosuvastatin Calcium)\n Patient states\n Precautions:\n PMH: GI Bleed\n CV-PMH: Angina, CAD, Hypertension\n Additional history: diverticulitis s/p sigmoidectomy, intaabdominal\n abscess, lv dysfunction, morbid obesity, ventral hernia\n psh- sigmoid colectomy and cecectomy at osh with development of\n enteocutaneous fistula and abscess, abd. wound exploration\n and ec fistula drainage.7/06ex lap, loa, abscess drainage sb ec fistula\n takedown partial ccy, ventral hernia repair, appendectomy\n Surgery / Procedure and date: ex lap, loa, repair of incisional\n hernia repair.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:138\n D:77\n Temperature:\n 99.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 1,288 mL\n 24h total out:\n 1,595 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:11 AM\n Potassium:\n 3.7 mEq/L\n 03:11 AM\n Chloride:\n 105 mEq/L\n 03:11 AM\n CO2:\n 28 mEq/L\n 03:11 AM\n BUN:\n 11 mg/dL\n 03:11 AM\n Creatinine:\n 0.7 mg/dL\n 03:11 AM\n Glucose:\n 187\n 10:00 AM\n Hematocrit:\n 36.0 %\n 03:11 AM\n Finger Stick Glucose:\n 142\n 10:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2151-10-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348414, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Adequate pain control\n Action:\n Pt encouraged to use PCA prior to any turning/repositioning\n Sleeping well throughout the shift\n Response:\n Rating pain @7 consistently\n Plan:\n Continue dilaudid pca\n" }, { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 348237, "text": "Respiratory failure, chronic\n Assessment:\n Pt sedated on Fentanyl and Propofol gtts this am. Bs clear but\n diminished in bases. Sx for scant amt thin white secretions. On CMV\n with sats 99-100%\n Action:\n Propofol weaned to off, pt placed on cpap with 5 ips, sats monitored,\n RSBI 38. pt extubated and placed on open face tent , nasal cannula\n added to maintain sat>95%. Started on IS\n Response:\n Tol extubation well, currently on nc at 4 liters with sat96%, able to\n move on incentive spirometry\n Plan:\n Encourage pulm toilet, monitor resp parameters\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abd softly distended with hypoactive bs. Ngt patent and draining thick\n bilious fluid. Midline abd wound clean- lower aspect repacked by\n primary team.\n Action:\n Abd wound monitored, ngt irrigated as needed to maintain patency\n Response:\n Wound clean, hypoactive bs\n Plan:\n Change dressing and prn, irrigate ngt as needed\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Fentanyl gtt d/c\nd this afternoon and pt placed on Dilaudid pca. Pt\n stating he has pain in left lower quadrant and pca is not helping.\n Action:\n Medicated with Dilaudid 0.25 x1 for breakthrough pain, explanation\n given as to how pca works, discussed pain management with DR .\n Response:\n Although pt appears to be comfortable, he continues to state that pca\n is not working as well\n Plan:\n Encourage pt to use pca , administer Dilaudid q3hrs as needed for\n breakthrough pain. ? increase dose if pain persists,\n" }, { "category": "Physician ", "chartdate": "2151-10-30 00:00:00.000", "description": "Intensivist Note", "row_id": 348329, "text": "SICU\n HPI:\n 43M p/w SBO, ? strangulated incisional hernia s/p ex lap, LOA \n Chief complaint:\n SBO\n PMHx:\n IDDM, CAD with LV dysfunction, HTN, obesity, ventral hernia, h/o\n diverticulitis, s/p sigmoid colectomy and cecectomy (at OSH) c/b EC\n fistula and abcess, s/p abdominal abcess drainage, ventral hernia\n repair with SIS (, ), s/p wound exploration and EC fistula\n drainage (, ), s/p ex-lap, LOA, ECF takedown, partial CCY,\n ventral hernia repair with mesh and component separation (,\n /), h/o appy\n Current medications:\n . 2. 3. 20 mEq Potassium Chloride / 1000 mL D5 1/2 NS 4. Calcium\n Gluconate 5. Famotidine 6. HYDROmorphone (Dilaudid)\n 7. HYDROmorphone (Dilaudid) 8. Heparin 9. Insulin 10. Magnesium Sulfate\n 11. Metoprolol Tartrate\n 12. Ondansetron 13. Sodium Chloride 0.9% Flush 14. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n EXTUBATION - At 10:16 AM\n Positive cuff leak. Pt on cool mist 0.50 face tent. Tolerating well.\n INVASIVE VENTILATION - STOP 10:16 AM\n EKG - At 11:22 AM\n Extubated. Increased metoprolol.\n Post operative day:\n POD#2 - exp lap, lysis of adhesions, repair of incisional hernia\n Allergies:\n Crestor (Oral) (Rosuvastatin Calcium)\n Patient states\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Metoprolol - 04:47 AM\n Other medications:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.5\nC (99.5\n HR: 95 (83 - 112) bpm\n BP: 167/77(101) {140/63(85) - 189/102(120)} mmHg\n RR: 15 (10 - 23) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 3,193 mL\n 687 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,193 mL\n 687 mL\n Blood products:\n Total out:\n 2,975 mL\n 1,130 mL\n Urine:\n 2,475 mL\n 730 mL\n NG:\n 500 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n 218 mL\n -443 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 522 (522 - 825) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 11 cmH2O\n SPO2: 94%\n ABG: ///28/\n Ve: 15 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n occasional)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 232 K/uL\n 12.6 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 105 mEq/L\n 140 mEq/L\n 36.0 %\n 8.2 K/uL\n [image002.jpg]\n 10:38 PM\n 11:41 PM\n 03:03 AM\n 05:45 AM\n 03:11 AM\n WBC\n 6.3\n 8.8\n 8.2\n Hct\n 41\n 29.4\n 37.3\n 36.0\n Plt\n \n Creatinine\n 0.6\n 0.9\n 0.7\n TCO2\n 26\n Glucose\n \n Other labs: Lactic Acid:2.4 mmol/L, Ca:8.4 mg/dL, Mg:1.7 mg/dL, PO4:2.5\n mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), .H/O ABDOMINAL PAIN (INCLUDING\n ABDOMINAL TENDERNESS), .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC\n HEART DISEASE), .H/O DIABETES MELLITUS (DM), TYPE I, .H/O\n HYPERGLYCEMIA, .H/O OBSTRUCTIVE SLEEP APNEA (OSA), .H/O PAIN CONTROL\n (ACUTE PAIN, CHRONIC PAIN), .H/O WOUND INFECTION, RESPIRATORY FAILURE,\n CHRONIC\n Assessment and Plan: 43M p/w SBO, ? strangulated incisional hernia s/p\n ex lap, LOA \n Neurologic: Pain controlled, Dilaudid PCA.\n Cardiovascular: Beta-blocker, Continues to be hypertensive despite\n increasing IV metoprolol. Consider restarting home Toprol XL, statin.\n Pulmonary: Stable on NC. Wean FiO2 as tolerated. OOB, IS.\n Gastrointestinal / Abdomen: Place NGT, NGT/diet as per primary team.\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Hct stable at 36.\n Endocrine: RISS, FS<150.\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D5 1/2 NS, MIVF @ 75.\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:23 PM\n 20 Gauge - 11:23 PM\n 16 Gauge - 11:23 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2151-10-29 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 348239, "text": "43M p/w SBO, ? strangulated incisional hernia s/p ex lap, LOA .\n Chief complaint:\n SBO\n PMHx:\n PMH: IDDM, CAD with LV dysfunction, HTN, obesity, ventral hernia, h/o\n diverticulitis, s/p sigmoid colectomy and cecectomy (at OSH) c/b EC\n fistula and abcess, s/p abdominal abcess drainage, ventral hernia\n repair with SIS (), s/p wound exploration and EC fistula drainage\n (), s/p ex-lap, LOA, ECF takedown, partial CCY, ventral hernia\n repair with mesh and component separation ()\n HPI:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Pt weaned and extubated, hemodynamically stable,\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2151-10-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 348227, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient Extubated at 1018 to cool mist via face tent. Positive cuff\n leak and tolerated well with sats in the mid to high 90\n" }, { "category": "Nutrition", "chartdate": "2151-10-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 348203, "text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 43 y.o. M with extensive PMHx and PSHx, adm with likely SBO \n strangulated incisional hernia. Now s/p ex lap, LOA and repair of\n incisional hernia. Pt was just Extubated, remains NPO. Will follow\n pt\ns progress, diet advancement and po tolerance.\n Please page for nutrition recs if needed. \n" }, { "category": "Radiology", "chartdate": "2151-10-28 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1041499, "text": " 3:24 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: eval for free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with abdominal pain and distension\n REASON FOR THIS EXAMINATION:\n eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male with abdominal pain and distention. Evaluate for\n free air.\n\n COMPARISON: CT chest , and chest x-ray .\n\n CHEST, SINGLE VIEW: No subdiaphragmatic free air is identified. Lung volumes\n are low. There is no airspace consolidation. Cardiac and mediastinal\n silhouettes are stable. Pulmonary opacities identified on CT are\n not appreciated on this study.\n\n IMPRESSION: No acute process.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-02 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 1042450, "text": " 12:06 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: confirm placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p NGT placement\n REASON FOR THIS EXAMINATION:\n confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , the nasogastric tube remains\n in place, though the tip cannot be seen due to underpenetration of the\n abdomen. The endotracheal tube has been removed. Low lung volumes persist,\n though there is no evidence of acute pneumonia or vascular congestion or\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-10-28 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1041498, "text": " 3:24 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with abdominal pain and distension, numerous prior abdominal\n surgeries\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old male with abdominal pain and distention, numerous prior\n abdominal surgeries. Evaluate for obstruction.\n\n COMPARISON: KUB and upright , and CT abdomen and pelvis .\n\n TWO VIEWS OF THE ABDOMEN: This study is limited by technique due to patient\n body habitus.\n\n On supine view, air-filled loops of small bowel project over the midline\n abdomen, and measure approximately 6 cm in diameter. On upright view, there\n are multiple air-fluid levels.\n\n Air is seen throughout the imaged portion of the colon, which extends to the\n descending portion.\n\n IMPRESSION: Dilated small bowel loop with multiple air-fluid levels\n concerning for early or evolving small-bowel obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2151-11-02 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1042531, "text": " 10:26 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for ileus vs obstruction\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man s/p LOA\n REASON FOR THIS EXAMINATION:\n eval for ileus vs obstruction\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND ERECT ABDOMEN\n\n INDICATION: 43-year-old man status post lysis of adhesions with abdominal\n pain. Evaluate for ileus or obstruction.\n\n COMPARISON: Radiograph and CT from .\n\n FINDINGS: There are multiple dilated loops of small bowel in the mid abdomen.\n These may represent early small bowel obstruction or ileus. The NG tube tip\n is in the stomach. Surgical staples overlie the abdomen.\n\n IMPRESSION: Multiple dilated loops of small bowel which may represent\n post-operative ileus or early small bowel obstruction. No free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1041694, "text": ", J. SICU-A 2:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Volume overload. Severe bibasilar atelectasis is new. ET tube ends at\n the upper margin of the clavicles and should not be withdrawn.\n\n\n" }, { "category": "Radiology", "chartdate": "2151-10-28 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1041509, "text": " 5:29 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? diverticulitis/abscess/microperf/SBO\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with long hx complicated diverticulitis w/ surgeries, here w/\n LLQ pain c/w prior and N/V\n REASON FOR THIS EXAMINATION:\n ? diverticulitis/abscess/microperf/SBO\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:41 AM\n - findings concerning for strangulated hernia w/ incarceration w/ an element\n of ischemia\n - extensive post-surgical changes of anterior abdominal wall as on prior\n - new fat stranding and mesenteric fluid (2:50, 301b:41) associated w/ midline\n epigastric loops of small bowel, proximal SB dilation\n WET READ VERSION #1 7:27 AM\n - extensive post-surgical changes of anterior abdominal wall as on prior\n - new fat stranding and mesenteric fluid (2:50, 301b:41), perisplenic\n fluid associated w/ midline epigastric loops of small bowel\n - proximal loops of small bowel dilated, distally decompressed, but no\n discrete transition point identified\n WET READ VERSION #2 8:37 AM\n - findings concerning for strangulated hernia w/ incarceration\n - extensive post-surgical changes of anterior abdominal wall as on prior\n - new fat stranding and mesenteric fluid (2:50, 301b:41) associated w/ midline\n epigastric loops of small bowel, proximal SB dilation\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH CONTRAST:\n\n HISTORY: 43-year-old male long history of complicated diverticulitis of\n surgery coming here with left lower quadrant pain, consistent with prior\n nausea, vomiting. Question of diverticulitis, abscess, microperforation or\n small-bowel obstruction.\n\n COMPARISON: CT abdomen and pelvis .\n\n TECHNIQUE: MDCT-axial images were acquired from the lung bases to the pubic\n symphysis following administration of 130 mL of Optiray intravenous contrast.\n Oral contrast was also administered. Multiplanar coronal and sagittal\n reformatted images were generated.\n\n FINDINGS: Loops of small bowel are dilated up to 4 cm. Within the midline\n abdomen, postsurgical changes are again noted at the anterior abdominal wall.\n There is associated small bowel thickening, and an loop of small bowel that is\n adherent to the anterior abdominal wall with partial component within an\n anterior abdominal wall hernia. While some postoperative changes of the\n anterior abdominal wall are similar in comparison to , there is new\n inflammatory stranding within the mesentery and free fluid (2:58). There is a\n small amount of perisplenic free fluid. There is no pneumatosis.\n (Over)\n\n 5:29 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ? diverticulitis/abscess/microperf/SBO\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Superior to this, a midline anterior abdominal wall defect contains a loop of\n normal appearing large bowel. Surgical anastomoses in the left lower quadrant\n and right upper quadrant (2:43) are patent.\n\n The liver is diffusely low in attenuation, consistent with fatty infiltration.\n Surgical clips are seen within the gallbladder fossa. A fluid collection\n adjacent to the gallbladder fossa is again identified, now measuring 3.5 cm in\n diameter (previously 3.9 cm) and may represent a gallbladder remnant or\n biloma. The pancreas is diffusely fatty replaced. The spleen and adrenals\n are normal. A left kidney cyst is unchanged. The right kidney is normal.\n\n A periportal lymph node measures 1.5 cm in diameter and is slightly larger\n than the prior study (1.2 cm). The abdominal aorta is normal in caliber. The\n origins of major vessels are patent.\n\n Numerous mesenteric and retroperitoneal lymph nodes are not enlarged by size\n criteria.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum is normal. There are\n diverticula of the sigmoid colon without evidence of diverticulitis. The\n bladder, prostate and seminal vesicles are unremarkable. There is no free\n pelvic fluid. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: Multilevel degenerative changes of the lumbar spine are\n unchanged.\n\n IMPRESSION:\n 1. Findings concerning for incarcerated hernia with an element of ischemia\n and small-bowel obstruction. A discrete transition point is not identified.\n 2. Fatty infiltration of the liver.\n\n" }, { "category": "Radiology", "chartdate": "2151-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1041693, "text": " 2:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS FRI 2:04 PM\n PFI: Volume overload. Severe bibasilar atelectasis is new. ET tube ends at\n the upper margin of the clavicles and should not be withdrawn.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:50 A.M., ON \n\n HISTORY: New ET tube placement.\n\n IMPRESSION: AP chest compared to , 3:26 a.m., disposition and lower\n lung volumes may account in part for widening of the upper mediastinum, but\n since pulmonary vasculature, particularly in the left upper lobe is engorged,\n this probably reflects volume overload. Overall cardiac dimensions, not\n appreciably changed. Bibasilar consolidation is probably atelectasis.\n\n Feeding tube passes in the stomach and out of view. Tip of the ET tube is at\n the upper margin of the clavicles. I cannot identify central venous vascular\n line.\n\n\n" }, { "category": "ECG", "chartdate": "2151-11-02 00:00:00.000", "description": "Report", "row_id": 185061, "text": "Sinus rhythm. Borderline low voltage. Non-specific intraventricular\nconduction delay. Since the previous tracing of the rate has\ndecreased. The QRS complex is wider.\n\n" }, { "category": "ECG", "chartdate": "2151-10-29 00:00:00.000", "description": "Report", "row_id": 185062, "text": "Sinus tachycardia. Compared to tracing #1 the rate is faster. Otherwise,\nno major change is evident.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2151-10-29 00:00:00.000", "description": "Report", "row_id": 185063, "text": "Sinus rhythm. Mild intraventricular conduction delay. Compared to the\nprevious tracing of the findings are similar.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2191-12-03 00:00:00.000", "description": "Report", "row_id": 78326, "text": "PATIENT/TEST INFORMATION:\nIndication: acute hypoxia, on transplant list, assess RV\nHeight: (in) 63\nWeight (lb): 130\nBSA (m2): 1.61 m2\nBP (mm Hg): 132/73\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 15:38\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\nseptum.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis. Abnormal systolic septal motion/position consistent with RV\npressure overload.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR. Moderate PA systolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\nEchocardiographic results were reviewed with the houseofficer caring for the\npatient.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). The right ventricular\ncavity is moderately dilated with moderate global free wall hypokinesis. There\nis abnormal systolic septal motion/position consistent with right ventricular\npressure overload. The aortic valve is normal. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is moderate pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , right ventricular\ncavity enlargement and free wall hypokinesis with RV pressure overload\npattern. The estimated pulmonary artery systlolic pressure is similar.\nThese findings are c/w amd acute pulmonary process (e.g., pulmonary embolism,\netc.).\n\n\n" }, { "category": "Echo", "chartdate": "2191-12-01 00:00:00.000", "description": "Report", "row_id": 78327, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Liver failure, ? Transplant.\nBP (mm Hg): 191/98\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 12:00\nTest: Portable TTE (Congenital, complete)\nDoppler: Full doppler and color doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum. Left-to-right\nshunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe interatrial septum is aneurysmal. A left-to-right shunt across the\ninteratrial septum is seen at rest (and agitated saline contrast study is\nmarkedly positive at rest) consistent with atrial septal defect or stretched\npatent foramen ovale. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. There is moderate pulmonary artery systolic hypertension.\nThere is a trivial/physiologic pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 848767, "text": " 4:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for edema, hemorrhage, etc.\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with acute hepatic failure, encephelopathic- please perform\n after pt has been intubated.\n REASON FOR THIS EXAMINATION:\n Please assess for edema, hemorrhage, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with acute hepatic failure, encephalopathic.\n Assess for edema or hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage. There is no shift of\n normally midline structures or mass effect. The -white differentiation is\n preserved.\n\n Bone windows demonstrate no destructive lesions. There is fluid within the\n ethmoid air cells. There is also some partial opacification of the right\n mastoid air cells.\n\n IMPRESSION: No evidence of mass effect or edema. Depending upon clinical\n concern, an MR of the brain is more sensitive for subtle abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848827, "text": " 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET TUBE REPLACEMENT/ CHECK PLACEMENT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p L IJ placement for swan\n\n REASON FOR THIS EXAMINATION:\n tube replacement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease, status post left-sided IJ central venous\n line placement. Check position and evaluate for complication.\n\n FINDINGS: AP single view of the chest is analyzed in direct comparison with a\n similar study obtained one hour earlier the same day. The patient remains\n intubated, the ETT in unchanged position. The same holds for the NG tube and\n the left internal-jugular-approach sheath that carries the SG catheter\n terminating in the right pulmonary artery. There is no pneumothorax or any\n other placement-related complication. As before, marked perivascular haze\n exists, indicative of congestion. The left diaphragmatic contour remains\n obliterated and the patchy parenchymal densities in the right lower lung\n field also remain unchanged.\n\n IMPRESSION: No significant interval change since next previous examination.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848812, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p L IJ placement for swan\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56 y/o female with end stage liver disease, s/p left IJ catheter\n placement.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS: ETT terminates 2 cm above the level of the carina. As before, Swan-\n Ganz catheter terminates within the right interlobar pulmonary artery. NG tube\n tip terminates within the stomach. There has been no interval change in the\n appearance of mild interstitial edema. There is now an increasing parenchymal\n opacity at the right lung base concerning for pneumonia. As before, there is\n dense opacification of the retrocardiac portion of the left lower lobe, in\n keeping with atelectasis. Small left pleural effusion is again noted,\n unchanged.\n\n IMPRESSION:\n 1) Findings concerning for evolving right lower lobe pneumonia.\n 2) Unchanged appearance of mild interstitial edema, small left pleural\n effusion, and left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 848714, "text": " 9:46 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: portal vein patency, hepatic artery, hepatic veins, ascites,\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ACUTE LIVER FAILURE\n REASON FOR THIS EXAMINATION:\n portal vein patency, hepatic artery, hepatic veins, ascites,PLEASE MARK SPOT\n FOR PARACENTESIS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute liver failure, assess hepatic vasculature. Mark a spot for\n paracentesis.\n\n PORTABLE ABDOMEN ULTRASOUND: The liver is shrunken and nodular in appearance.\n The parenchyma is diffusely coarsened, without evidence of focal masses. There\n is no intra or extrahepatic ductal dilatation. There is a moderate amount of\n perihepatic ascites. The common duct measures 3 mm in diameter. The\n gallbladder shows an edematous wall, likely secondary to the patient's liver\n disease. The spleen is not enlarged, measuring 10 cm. The pancreas is\n unremarkable. The right kidney measures 11.5 cm. The left kidney measures\n 9.9 cm. There are no renal masses, stones or hydronephrosis. The intra-\n abdominal aorta is of normal caliber. There is a moderate amount of abdominal\n ascites.\n\n Color Doppler images of the liver were also obtained. Low flow is\n demonstrated within all of the interrogated vessels. The main, left and right\n portal veins are patent, with flow in the appropriate direction. The hepatic\n arteries and veins are also patent, with normal-appearing waveforms. Please\n note that the left hepatic vein was not well visualized secondary to the\n patient's inability to lie stationary/hold her breath for the exam.\n\n An appropriate spot was marked on the patient's skin for paracentesis to be\n performed by the clinical staff.\n\n IMPRESSION:\n 1) Coarsened liver echotexture, consistent with the patient's history of\n liver failure. No evidence of focal liver masses.\n\n 2) Moderate amount of abdominal ascites. A spot was marked on the patient's\n skin for a paracentesis to be performed by the clinical staff.\n\n 3) Patent hepatic vasculature, as discussed above.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2191-12-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 848791, "text": " 12:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please r/o intracranial bleeding s/p bolt placement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with hepatic encephalopathy, s/ bolt placement for\n ICP monitoring.\n REASON FOR THIS EXAMINATION:\n please r/o intracranial bleeding s/p bolt placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatic encephalopathy, status post bullet placement for\n ICP monitoring.\n\n Comparison is made to the prior CT scan obtained one day prior.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intraparenchymal or extra-axial hemorrhage. There is\n no shift of normally midline structures. The appearance of the brain\n parenchyma is unchanged compared to the recent prior study, however, the\n sulci of the cerebrum and cerebellum apper narrower, which may reflect mild\n edema.\n The ventricles are not dilated and basal cisterns are well visulaized. There\n has been interval placement of a metallic ICP monitoring device through the\n right frontal calvarium. The visualized paranasal sinuses and osseous\n structures are unchanged with note of a small amount of fluid layering in the\n ethmoid sinuses and sphenoid sinuses. A NG tube and endotracheal tube are also\n noted.\n\n IMPRESSION: No intracranial hemorrhage following placement of ICP monitoring\n device. Possible mild edema. Correlate with ICP monitoring.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848693, "text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please check ett placement\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p intubation\n REASON FOR THIS EXAMINATION:\n please check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ESLD, status post intubation.\n\n AP UPRIGHT CHEST: No priors for comparison. Endotracheal tube is identified,\n at the level of the carina, and angled toward the right main stem bronchus. It\n should be retracted several centimeters. There are low lung volumes. There is\n bilateral blunting of the CP angles, more prominent on the left, likely\n representing bilateral pleural effusions. Underlying atelectasis/infiltrate\n cannot be excluded at the left base. The heart size is within normal limits.\n The remaining portions of the lungs are clear. Residual contrast is seen in\n the bowel.\n\n IMPRESSION:\n 1) ETT malpositioned with its tip at the carina angling toward the right main\n stem bronchus. It should be retracted several centimeters for more optimal\n placement.. These findings were relayed to Dr. .\n 2) Bilateral pleural effusions (left greater than right); underlying\n consolidation/atelectasis not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 848769, "text": " 4:17 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: liver failure unkown cause\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with\n REASON FOR THIS EXAMINATION:\n liver failure unkown cause\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hematocrit drop, liver failure.\n\n TECHNIQUE: CT scan of the abdomen and pelvis was obtained with 5 mm\n columnation without intravenous contrast. No prior exams for comparison.\n\n CT ABDOMEN W/O IV CONTRAST: Moderate-to-large bilateral pleural effusions are\n identified, with bibasilar collapse and/or consolidation.\n\n There is a large amount of ascites. The liver is markedly atrophied and\n nodular in contour, consistent with cirrhosis. The unenhanced spleen,\n adrenals, kidneys, and pancreas are grossly unremarkable. The gallbladder\n contains dense material, possibly representing reflux of oral contrast.\n\n No evidence of intraperitoneal hematoma. The stomach is grossly normal. A\n nasogastric tube is in place.\n\n The small bowel demonstrates wall thickening, probably the result of the\n patient's portal hypertension.\n\n CT PELVIS W/O IV CONTRAST: The uterus and colon are unremarkable. The\n urinary bladder contains gas, presumably from Foley catheterization. There is\n a large amount of fluid within the pelvis, however, no definite hematoma is\n identified.\n\n A right common femoral vein catheter is noted.\n\n Note is made of anasarca.\n\n IMPRESSION\n 1. Changes of cirrhosis, portal hypertension, and anasarca, without evidence\n of intraperitoneal or retroperitoneal hematoma.\n\n Discussed with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848779, "text": " 7:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p L IJ placement for swan\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ESLD, S/P line placement, r/o pneumothorax.\n\n PA & LATERAL CHEST: Interval placement of Swan catheter, with its tip in a\n peripheral branch of the right pulmonary artery. This should probably be\n retracted slightly. NG tube and ETT unchanged in position. There is no obvious\n pneumothorax on this supine film. Small lung volumes. Allowing for technique,\n there has likely been mild improvement in underlying congestive heart failure.\n Unchanged appearance of small pleural effusions (left greater than right)\n slightly more prominent patchy opacities at the right base, consistent with\n atelectasis/consolidation.\n\n IMPRESSION:\n 1) Swan-Ganz catheter tip in a peripheral branch of the right pulmonary\n artery. It should be retracted slightly.\n 2) Slight improvement in congestive heart failure.\n 3) Patchy opacity at the right base, likely secondary to atelectasis,\n pneumonia not excluded.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848996, "text": " 1:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please r/o pneumothorax\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fulminant liver failure, acute desat\n\n REASON FOR THIS EXAMINATION:\n please r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up of lung changes.\n\n PORTABLE CHEST: Comparison is made to film from 9:33 A.M. the same day. The\n ET tube, nasograstic tube, and Swan-Ganz catheter are in stable position. The\n cardiac and mediastinal contours are grossly unchanged. Multifocal bilateral\n infiltrates are again identified, and could reflect pulmonary edema and or\n multifocal infiltrates. These are essentially without change. There is a\n right pleural effusion.\n\n Increased density in the left retrocardiac area persists without change.\n There is a somewhat atypical contour to the lateral aspect of the right\n hemidiaphragm which is relatively angled laterally. Note that this film is\n reportedly an upright film, while all the other prior films are either semi-\n erect or supine; no baseline for the appearance of the upright chest is\n therefore available. As an upright film, this appearance would not be\n expected for pneumothorax. Findings were, however, reviewed with the covering\n house staff.\n\n IMPRESSION: No significant interval change from earlier today.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2191-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848959, "text": " 8:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CXR done earlier this am but clinically changed since - plea\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fulminant liver failure, acute desat\n REASON FOR THIS EXAMINATION:\n CXR done earlier this am but clinically changed since - please take cxr STAT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Desaturation.\n\n pCXR: Comparison is made to film from earlier this morning as well as multiple\n films from the 17th and 16th.\n\n The ET tube, nasogastric tube, and Swan-Ganz catheter are all without\n significant change in position. The patient is somewhat lordotic on the\n current film. The cardiac and mediastinal contours are stable.\n\n As noted on the film from earlier today, aeration is worse compared to films\n of and 17. There is persistent increased density at the left base\n with small pleural effusions and worsened aeration in the central lung zones\n and right upper lobe. The above may represent worsening of congestive change\n and/or multifocal infiltrate. Allowing for differences in patient position\n the findings may not be significantly changed from earlier today.\n\n IMPRESSION: No change from earlier today.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848904, "text": " 4:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval s/p bronchoscopy\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p L IJ placement for swan\n\n REASON FOR THIS EXAMINATION:\n please eval s/p bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post bronchoscopy.\n\n PORTABLE SUPINE CHEST: Comparisons made earlier from 9:10 A.M. the same day.\n\n The ET tube, Swan Ganz catheter, nasogastric tube are in stable position.\n Cardiac and mediastinal contours are stable. There is some interval\n improvement in aeration in the right lung base (portions of the right\n hemidiaphragm are now better seen). The lungs are otherwise unchanged. There\n is no evidence of pneumothorax.\n\n IMPRESSION: 1) No change tubes and catheters.\n 2) Slight improved aeration right lung base.\n 3) No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 849036, "text": " 12:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fulminant liver failure, acute desat\n\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up of pulmonary status.\n\n PORTABLE CHEST: Comparison is made to film from one day earlier. Previously\n described tubes and catheters are in stable position. Extensive bilateral air\n space infiltrates persist. There is some interval improvement in aeration of\n the left retrocardiac area. There is otherwise no change.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848948, "text": " 6:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pulmonary edema\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fulminant liver failure\n\n REASON FOR THIS EXAMINATION:\n please eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fulminant liver failure; to evaluate for pulmonary edema.\n\n COMPARISON: .\n\n CHEST X-RAY, PORTABLE AP VIEW: There is interval worsening of aeration\n bilaterally, particularly in the right upper lobe, perihilar regions and right\n base. Findings are nonspecific, and could represnet pulmonary edema and/or\n pneumonia. There is no pneumothorax. As seen previously, again, the ET tube\n is 2 cm above the carina. The swan ganz catheter tip is in the right\n pulmonary artery. The NG tube tip is in the stomach.\n\n IMPRESSION: Worsening aeration bilaterally.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-03 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 848963, "text": " 9:12 AM\n RENAL U.S. PORT Clip # \n Reason: please eval with doppler for anatomic abnormality that could\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with ESLD and renal failure\n REASON FOR THIS EXAMINATION:\n please eval with doppler for anatomic abnormality that could be causing\n obstructive renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endstage liver disease and acute renal failure.\n\n FINDINGS: Comparison is made to a prior ultrasound from .\n\n The right kidney measures 10.8 cm. The left kidney measures 12.3 cm. No\n evidence of renal mass, stone, or hydronephrosis on this study limited by\n patient body habitus. A Foley catheter was in place, limiting evaluation of\n the urinary bladder. Color flow was seen within both kidneys. Ascites was\n seen.\n\n IMPRESSION\n No evidence of renal mass, stone, or hydronephrosis on this limited portable\n ultrasound. Ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-12-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 849031, "text": " 10:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm edema\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with fulminant liver failure, acute desat\n\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up of lung status.\n\n PORTABLE CHEST: Comparison is made to the film from 3 P.M. the same day.\n\n The ET tube, nasogastric tube, and Swan-Ganz catheter are in stable position.\n There is no change in the appearance of the lungs, allowing for some\n differences in patient positioning. Multifocal bilateral air space\n infiltrates are again noted, again with some relative sparing of the left lung\n apex. There is increased density in the left retrocardiac area without\n change. Blunting of the right lateral costophrenic angle is also unchanged.\n\n IMPRESSION: No change from earlier today.\n\n" }, { "category": "Radiology", "chartdate": "2191-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 848746, "text": " 2:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess NGT and ETT\n Admitting Diagnosis: LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with esld s/p intubation please assess NGT placement and ETT\n position after pulling back 3 cm.\n REASON FOR THIS EXAMINATION:\n please assess NGT and ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage lung disease status post intubation and retraction of\n ET tube by 3 cm.\n\n Comparison is made to previous dated , at 10:11.\n\n CHEST RADIOGRAPH PORTABLE, 14:06:\n\n When compared to previous, there has been retraction of the ET tube, which now\n lies about 4 cm above the carina. Poor inspiratory effort. Again is noted\n bilateral blunting of the costophrenic angle, likely representing unchanged\n bilateral pleural effusions. Cardiac size is within normal limits.\n\n CONCLUSION: Repositioned ET tube is now at about 4 cm above the carina. The\n remainder is unchanged when compared to previous.\n\n" }, { "category": "ECG", "chartdate": "2191-12-01 00:00:00.000", "description": "Report", "row_id": 191741, "text": "Sinus tachycardia. Non-diagnostic inferior Q wave pattern. Incomplete right\nbundle-branch block. Low QRS voltage. No previous tracing available for\ncomparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-12-01 00:00:00.000", "description": "Report", "row_id": 1494395, "text": "Condition Update\nPlease see Carevue for specifics.\n\nNeuro: Pt opening eyes to voice. Not following commands. Withdrawl with nailbed pressure. Pt able to move all extremities on the bed. PPF gtt started for am intubation. PERRL. Head CT this eve.\n\nCV: Sinus Tachy. No ectopy. SICU Team and transplant team informed. Right IJ placement attempted without success resulting in large right neck hematoma. No growth. Left femoral line placed. SBP decreased to 80's with propofol bolus for preocedures this am.. Neo gtt @ .5mcg/kg/min started X 10min till SBP 120's. Sinus Tachy continues, SBP increasing. SBP 160-180's. Transplant team aware.\n\nLabs checked q4/hours. Calcium repleted. INR 1.6 after 2 unit plasma given and plasma gtt started @ 100cc/hour. Plateletts 76. 2units plateletts given. Hct 25 down to 19. 4units PRBC given. Post transfusion HCT 32.\n\nResp: Intubated @ 0800am for airway protection. On IMV. Fio2 weaned to 50% and PEEP increase. See flowsheet for ABGs. Pt suctioned several times for moderate amts of thick yellow sputum. Sputum CX and gram stain sent.\n\nGI/GU: Pt is NPO. NG tube placed and placement confirmed by cxr. ABD with Ascites, u/s done and tapped and sent for cx. Foley intact. Pt with minimal u/o. 0-10cc/hour. MD and sicu team informed. IVF started. ABD CT this eve.\n\nEndo: fsbg WNL. no RISS.\n\nPlan: Cont q4 hour labs. Cont ffp gtt. Monitor for s/s bleeding, transfuse as ordered. Maintain pt comfort. Emotional support to family. Cont per current mgmt.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-12-01 00:00:00.000", "description": "Report", "row_id": 1494396, "text": "Resp Care\n56 y/o F with liver failure intubated this AM for airway protection. Currently vented on SIMV 50% 500 X 12 and is breathing over the vent with total rate in the low 20s at times. PEEP increased from 5 to 10 due to drop in PaO2. ABG pending. BS slightly course bilaterally sxing for yellow bile like secretions. ETT withdrawn to 19cm at the lip per chest x-ray. Will cont with vent support.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-03 00:00:00.000", "description": "Report", "row_id": 1494403, "text": "2 recruitment manuevers done at 1130pm at 35, one for one minute and another for 30 seconds.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-01 00:00:00.000", "description": "Report", "row_id": 1494394, "text": "Pt admitted from with Acute Liver Failure possibly related to drug pt took for rheumatoid arthritis. Neuro:Pt opens eyes to voice but does not follow commands, pupils size 5mm each briskly reactive. Pt does not follow command. Pt's O2 sat 100% on 100% NRB. LFTs elevated. Coags elevated. Pt recieved FFP 4 units for INR 7.\nFamily at bedside after admission than went home after conversing with Dr .\nPlan today to intubate pt for airway protection, Head CT to r/o bleed.\nAbd ultrasound today already ordered. Continue transplant workup.\n \n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-12-03 00:00:00.000", "description": "Report", "row_id": 1494401, "text": "condition upodate\nplease see carevue for specifics:\n\nPt condition has decompensated overnoc. HR95-120's nsr-st, sbp 120-160's, pap's 50's-80's (treated with propofol gtt and lasix), cvp 20-26, icp 9-24. Pt not responding well to lasix- total 140mg admin overnoc- pt +3L and +1L today; uop 10-100 dark amber urine. Pt was stable on eveigs, then was admin 2 uffp for inr 1.7 and ffp gtt was increased to 150cc/hr to maintian inr <1.5, 1 u plts for plt count 61 (returned at 110) and 1 u prbc for hct 24, tehn pap's increased, cvp increased and pt became increasingly fluid overloaded- lasix with no real effect. LS went coarse to wheezes (inspir/expir) and combivent was admin; suctioning copious amounts of thick bilious secretions q hour- only vent change was to increase fi02 t .60 to keep 02 sas greater than 90 (on .50 sats were 90-91 and increased to 92-93 with fi02 at .60). Pt started on lasix gtt this am at 10cc/hr to help with fluid status. NS unchanged- pt was off propofol until 2330 when pressures went up, then resedated and dr. did not want propofol off d/t icp's into 18-22 and hemodynamoc issues. off prop gtt, mae to nailbed pressure- doesn't follow commands, no eye opening on own- perrla 5mm/5mm and brisk. Mannitol admin this am. +pp/dp. abd +ascites, very hard (ho aware) +bs x 4, no bm. Pt has bleeding hemmroid- abd pad in place. Cont to monitor labs, vs, ns, i/o's.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-03 00:00:00.000", "description": "Report", "row_id": 1494402, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT SEDATED ON PROPOFOL GTT. PARALYZED WITH CISATRICURIUM THIS AFTERNOON FOR PCV VENITILATION. GTT TITRATED UP FOR TOF, NEURO EXAM (WITHDRAWING BLE), AND VENT COMPLIANCE/PA02. ICP'S THIS AM UP TO 20S. DECREASING WITH CRRT/SEDATION/PCV.\nRESP: ABGS WITH DECREASING PAO2 (50S) DESPITE INCREASING PEEP AND FIO2. VENT MODE CHANGED TO PCV, 100% FIO2 WITH INITIAL INCREASE IN 02 SATS TO 98, DECREASING TO 91-95. ABG WITH PAO2 80, AND ALKALOSIS. RR DECREASED. SEE FLOWSHEET. CXR'S TO ASSESS EFFSIONS V. INFILTRATE.\nCV: AFEBRILE. BAIR HUGGER FOR DECREASED CORE TEMPS WITH CVVHD. NSR. EKG THIS AM FOR ? BBB, SHOWN TO MD . PA PRESSURES UP THIS AM. CRRT INITIATED FOR FLUID REMOVAL. PA NUMERS DECREASING WITH 100-300CC NEGATIVE Q1 HOUR. UF TITRATED DOWN THIS EVE D/T SBP 90S-100S. CCO, SVO2, PAO2 AND SAO2 DECREASING THROUGH DAY, ECHO DONE TO ASSESS CARDIAC FUNCTION. 1U PRBC'S GIVEN WITH NO EFFECT ON HCT. FFP GTT INCREASED TO 150CC/HOUR. TO RECEIVE BLOOD PRODUCTS THIS EVE AS ORDERED.\nGI: NGT TO LCWS, DIFFICULT TO SUMP. UNABLE TO WITHDRAW FLUID ON LAVAGE. SM AMT CLOTS. DRAINING SM AMT BILIOUS, SL BLOOD TINGED DRG.\nGU: MIN U/O. LASIX STOPPED AND CRRT UP. RENAL U/S DONE TO ASSESS FOR PRERENAL/HYDRONEPHROSIS.\nENDO: FSBG WNL.\nPLAN: MONITOR CLOSELY. Q4HOUR LABS, MORE OFTEN AS NEEDED. TITRATE PARALYTIC TO VENT COMPLIANCE, RESP STATUS AND PNS RESPONSE. CONT CRRT WITH FLUID REMOVAL AS PT TOLERATES. AWAIT POSSIBLE LIVER WHEN PT MORE STABLE.\n\n" }, { "category": "Nursing/other", "chartdate": "2191-12-02 00:00:00.000", "description": "Report", "row_id": 1494399, "text": "Condition Update\nPlease see carevue for Specifics.\n\nNeuro: Pt sedated on PPF gtt. With gtt off pt is not opening her eyes or following commands. PERRL. Pt withdraws all extremities to nailbed pressure off the gtt only. bolt in place with icps 10s to 20s. Increased with stimulation. Propofol gtt titrated for ICPs and Blood pressure.\n\nCV: PAP's 60's-70's this am. 40 mg IV lasix given X1. Pt continues to with ST. FFP gtt continues, rate increased d/t INR 1.0-1.4. Briefly on neo during bronch d/t increased propofol. K and Ca repleted. + 2edema noted in extremities.\n\nResp: D/T cuff malfunction, pt reintubated over cook catheter this am. RR up to 40s. SIMV+PS vent settings changed to AC to make pt more comfortable. Abgs show hypoxmeia. MD notified of low pao2's and paco2s. PEEP increased from 5 to 7. Bronchoscopy performed. Sputum sent for culture and gram stain. Post bronchoscopy CXR done. Sats remained 98% throughout the day. LS clear to coarse. Pt sxn'd for sml amts thick yellow sputum.\n\nGI/GU: Foley intact. U/O 0-100cc/hour. Transplant team notified. 20mg Lasix started . Pt is NPO. TPN started this evening. NGT is to LCS and is draining bilious fluid. Bladder pressure transduced and is 9.\n\nEndo: Blood sugars checked q hour. Pt requiring AMP Dextrose x2 for BS of 53,60. IVF of D10 started then d/c'd this evening after TPN started.\n\nPlan: Continue with pre-transplant care. Offer emotional support to family. Labs Q 4/hours, q1hour fingersticks. Pt awaiting transplant.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-03 00:00:00.000", "description": "Report", "row_id": 1494400, "text": "Respiratory Care:\nPt. remains on full vent support. Oxygenation was improved at start of shift, then after transfusing multiple blood products, and decreased U/O, PIP's/Plateau increased, and oxygenation decreased, but still at acceptable level. Pt. continues with a combined resp./met. alkalosis. B/S with LUL wheezes, and course crackles throughout>>ETS moderate to copious amounts of bilious appearing secretions>>cuff hyperinflated, and started on combivent inhalers with little effect. Per report, will continue minimal acceptable vent support.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-02 00:00:00.000", "description": "Report", "row_id": 1494397, "text": " condition update\nPlease see carevue for specifics:\n\nPt had swan placed at which showed pawcp 16, pap 42/24, ra 15, rv 28/13; during noc CVP 12-25, PAP 40'S-70'S/20'S-40'S (HO AWARE OF HIGH PAP'S AND TREATED WITH LASIX), wedge to 20, hr 110-120's ST. Pt was placed on prop gtt for increased pap's as well as iv lasix with good results- uop increased to 100-200cc clear amber urine q hour, and cvp's decreased. Pressures increased post admin of 2 u ffp pre bolt placement and 2 u prbc post bolt placement. ICP's (ho aware- ok with icp less than 20); post head ct showed no bleeding. Per Dr. , pt admin 25gm mannitol. pt with no eye opening and not follwing commands. Moves lower extrems to nailbed pressure, but no movement noted on upper extrem- dr. aware +pulses. Perrla with 5m/5mm briskly reactive. Abd +ascites and +bs x4 - hypoactive; no bm overnoc. NGT to LCS with baricat out, then pink tinged/bilious output. Pt extremely swollen all over body- hands, feet and weight up from 60 to 68.2. LS coarse throughout and pt on simv with 7.2/5 .50- peep was dereased from 10 b/c pao2 was 64, post abg returned pao2 to 94. labs being followed closely; admin 2 u prbc for hct 24, 2u ffp admin for inr 1.6 pre bolt placement- inr came down to 1.5 and factor VII was admin with a return inr .05. family in to see pt and aware of POC. Cont to monitor labs q 4 hours, vs, i/o's, ns, icp's\n" }, { "category": "Nursing/other", "chartdate": "2191-12-02 00:00:00.000", "description": "Report", "row_id": 1494398, "text": "RESP. CARE NOTE\nPt received intubated with 7.0ETT secured at 21cm lip. Persistant cuff leak on ETT so tube changed over cook catheter to 7.5ETT by anesthesia. Pt also very tachypneic and air hungry with RR to 40's at times. Changed to AC with settings as per resp flowsheet. Pt appears more comfortable on AC, ABG's with resp alkalosis and marginal oxygenation. Peep increased from and ABG pending. Sats have been 97-98% but do not correlate with PaO2. Sxn for thick bilious secretions, CXR with possible pna RLL. Pt bronched today and specimen obtained. Cont present settings, follow ABG's.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-04 00:00:00.000", "description": "Report", "row_id": 1494404, "text": "condition updated\nSEE CAREVUE FOR SPECIFICS\n PT HAS PROGRESSIVELY DECOMPENSATED. PARALYZED W/CISAST AND SEDATED W/PROPOFOL CVVH WORKING WELL IN FLUID REMOVAL BUT FILTER CLOTTED CHANGED W/O INCIDENT.BLOOD PRODUCTS OXYGEN LEVEL LOW (SEE ABG'S)\nCXR SHOWS FLUID OVERLOAD- NTG/MSO4 GIVEN FOR PULMONARY STATUS\nNTG EFFECTIVE IN REDUCING PA NUMBERS BUT DROPPPED CO.\nCONSTANT COMMUNICATION W/ICU TEAM AND TRANSPLANT. DISCUSSED GRAVE SITUATION W/SON AND WHO HAVE BEEN @ BEDSIDE. HUSBAND CALLED AND IS PESENT NOW @ BEDSIDE. DISCUSSED CONDITION IN DEPTH AND IT HAS BEEN DECIDED PT WILL BE DNR W/COMFORT OF MSO4 GTT BUT NOT WITHDRAW VENT @PRESENT\n" }, { "category": "Nursing/other", "chartdate": "2191-12-04 00:00:00.000", "description": "Report", "row_id": 1494405, "text": "pt's SpO2 progressively became worse through PM and BP dropped as well despite all efforts with ventilator such as high PEEP and pressure control\n. Therefore Pt's family made her CMO.pt was still being slowly withdrawn close to shift change.\n" }, { "category": "Nursing/other", "chartdate": "2191-12-04 00:00:00.000", "description": "Report", "row_id": 1494406, "text": "Focus-Update\nData-Pt asystolic. no spon respirations. Dr. pronounced pt at 07:02. Family at bedside.\nOrgan bank notified.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 535266, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 85 (75 - 107) bpm\n BP: 99/51(63) {74/35(44) - 108/72(79)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 71 mL\n PO:\n 750 mL\n TF:\n IVF:\n 424 mL\n 71 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 262 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 535268, "text": "Chief Complaint:\n 24 Hour Events:\n Paracentesis done and 2L fluid removed, cytology with 133 total WBCs\n which r/o SBP. Serial HCTs from yesturday 27-29.9 range.\n After c/o neck pain had a CT neck which did not show any evidence of\n bone mets on prelim read, will f/up final report.\n Cardiology saw yesturday and felt no need for pericardiocentesis for\n now.\n Overnight the patient had fevers to 102 F range and became tachycardic\n to 120s so urine and cultures sent and pending today\n EKG done last yesturday was unchanged from prior admission EKG\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 85 (75 - 107) bpm\n BP: 99/51(63) {74/35(44) - 108/72(79)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 71 mL\n PO:\n 750 mL\n TF:\n IVF:\n 424 mL\n 71 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination:\n General: pallid complexion, NAD\n HEENT: PERRL, anicteric sclerae, pale conjunctivae, nonerythematous\n oropharynx\n Neck exam: No JVD, no cervical lymphadenopathy, supple\n CVS: S1/S2 appreciated, has rub noted on auscultation, no murmurs or\n clicks\n Lungs: breath sounds blunted on left, -basilar crackles noted. No\n wheeze\n Abd: Soft, NT, distention mild but improved from yesturday\ns exam ,\n normoactive BS\n Ext: negative \ns sign, no edema, 2+ pedal pulses\n Neuro: A& O x3, CNs grossly intact, no focal deficits, Strength\n UE/LE. Did not assess gait today.\n Skin: no jaundice, bruises or rashes noted\n Labs / Radiology\n 262 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise, transferred to the with transient\n hypotension.\n .\n Plan:\n .\n # Hypotension: the differential includes infection, given that the\n patient is febrile on arrival, although her wbc is within normal limits\n without a left shift, it may be that the fever is secondary to tumor\n burden. Infectious sources could be any of the number of effusions the\n patient has, including pleural and ascitic. Other possibilities which\n are more concerning could be tamponade physiology from a new\n pericardial effusion. Stat echo by cardiology seemed to indicate no\n evidence of tamponade while patient was hypotensive, and she was fluid\n responsive to 1L. Other possible etiologies include hypovolemia from\n poor PO intake, but patient denies change in intake lately, or 3rd\n spacing with resultant poor forward flow (but patient is asymptomatic).\n Currently, very fluid responsive.\n - stat TTE this morning\n - q4 hour pulsus\n - pan culture - there are urine and cultures pending from ED\n - hold on abx for now, as there is no clear source right now, no\n leukocytosis -> re culture if spikes\n - diagnostic paracentesis, ?SBP\n - diagnostic thoracentesis\n .\n # Hypoxia: Patient has an increased pleural effusion on the left with a\n new RUL mass on wet read of the CT chest, likely met vs. infection.\n These could both account for increased hypoxia. Currently the patient\n is comfortable on minimal O2, but O2 requirement is new.\n - consider diagnostic/therapeutic \n - heme/onc input on RUL mass\n .\n # Stage III peritoneal serous CA: patient just completed her 3rd round\n of Alimta. She had a mild transaminitis which was being attributed to\n the chemotherapeutic. Initially seemed to be having good response with\n reduction in CA-125 levels, but now has mets in the spine which are new\n and a possible new met in the RUL of the lung.\n -\n - heme/onc notified of patient's admission\n CA-125 trend 75 () , then 48 () and last night 35.\n .\n # Recurrent DVT/PE: patient was to be on lifelong coumadin therapy,\n which was stopped by patient's PCP for unclear reasons. Heme/onc had\n discussed restarting this with the patient on the last admission given\n her high risk. That being said, with a pericardial effusion and concern\n for tamponade physiology, should not restart anticoagulation at this\n time. CTA wet read is negative for new PE.\n - check coags, reverse if necessary\n - DVT ppx with heparin subcut only\n .\n # Anemia: likely secondary to chronic disease, Sent type and screen ,\n will keep transfusion threshold <21 for now.\n .\n # FEN: regular diet, replete lytes prn. IVF with caution for BP\n support.\n .\n # Access: PIV\n .\n # PPx: heparin subcut\n .\n # Code: Full\n .\n # Dispo: pending clinical stabilization\n .\n # Comm: With patient and sisters\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535271, "text": "PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L. During Her ICU course\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at yesterday evening\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Continues with low grade temp this AM to 99.1\n Plan:\n Continue to follow temp curve, follow up on culture data\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done yesterday for approximately 2L of serous fluid.\n Tolerated procedure well.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given PRN\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Follow up with results on CT\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535273, "text": "PMH/HPI: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown? chamber collapse. Pulsus wnl. Cardiology\n was called, and their stat echo showed small to moderate effusion with\n no evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers (which have subsequently been D/C\nd). Upon\n arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50 BP\n responded to IVF. During Her ICU course she received the echo as\n previously noted. A Paracentesis done and 2L fluid removed, cytology\n with 133 total WBCs which r/o SBP. Serial HCTs from yesterday 27-29.9\n range. After c/o neck pain had a CT neck which did not show any\n evidence of bone mets on prelim read, will f/up final report.\n Cardiology saw yesterday and felt no need for pericardiocentesis for\n now. Overnight the patient had fevers to 102 F and became tachycardic\n to 120s so urine and cultures sent and pending today. She is\n currently running a low grade temp and tachycardia has resolved. Her\n BP has returned to its baseline of 90\ns/50\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at yesterday evening\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Continues with low grade temp this AM to 99.1\n Plan:\n Continue to follow temp curve, follow up on culture data\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done yesterday for approximately 2L of serous fluid.\n Tolerated procedure well.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given PRN\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Follow up with results on CT\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535263, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n Hypotension (not Shock)\n Assessment:\n SBP 90-100s. HR 80-90s. denying dizziness, alert and oriented x3.\n speech clear. MAE well. ? pericardial fluid noted on CT. Slightly\n more tachycardiac in the afternoon. White count down to 7. Tmax 100.9.\n Action:\n 250 bolus given early this a.m for SBP in low 80s. Closely monitored\n SBP throughout the day. No pulsus paradox noted manually. Team\n notified of increasing tachycardia however BP remains stable at 100 and\n tachycardia most likely related to anxiety. IV antibiotics\n discontinued.\n Response:\n SBP remained >90 since approximately 10 this morning. Remains\n asymptomatic.\n Plan:\n Closely monitor hemodynamics. Provide comfort and support. Monitor for\n s/s of tamponade (i.e pulsus, any changes in hemodynamics). Monitor\n labs and temp.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given a/o.\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n CT of spine at 1700.\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done at 1500 for approximately 2L of serous fluid.\n Tolerated procedure well. 1 mg PO ativan given for moderate anxiety\n with good effect.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n" }, { "category": "General", "chartdate": "2125-06-19 00:00:00.000", "description": "ICU Event Note", "row_id": 535255, "text": "Clinician: Attending\n I supervised the resident (Dr and intern (Dr in\n performance of paracentesis under sterile conditions. Needle/catheter\n insertion performed smoothly in left, lower, lateral abdomen.\n Approximately 2L of fairly clear, yellow fluid removed. Samples sent\n for cell count, culture, cytology, chemistry.\n Patient tolerated procedure well.\n , MD\n Total time spent: 45 minutes\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 535256, "text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 535257, "text": "This is a 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise. A CT torso was performed which showed a\n worsening pleural effusion, new pericardial effusion, and no abdominal\n process seen. She initially had stable vitals, was at her baseline\n SBP's in the 90's with a small O2 requirement and was to be sent to the\n floor, but became hypotensive to the 70's this morning with hr's to\n 120's. She was asymptomatic and was responsive to 1L fluid, with BP's\n coming back up to 90/60. The concern was for tamponade from the\n enlarging pericardial effusion and they did a bedside echo which they\n thought might have shown ? chamber collapse. Pulsus wnl. Cardiology was\n called, and their stat echo showed small to moderate effusion with no\n evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers. She remains 97% 2L NC upon transfer to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n Hypotension (not Shock)\n Assessment:\n SBP 90-100s. HR 80-90s. denying dizziness, alert and oriented x3.\n speech clear. MAE well. ? pericardial fluid noted on CT. Slightly\n more tachycardiac in the afternoon. White count down to 7. Tmax 100.9.\n Action:\n 250 bolus given early this a.m for SBP in low 80s. Closely monitored\n SBP throughout the day. No pulsus paradox noted manually. Team\n notified of increasing tachycardia however BP remains stable at 100 and\n tachycardia most likely related to anxiety. IV antibiotics\n discontinued.\n Response:\n SBP remained >90 since approximately 10 this morning. Remains\n asymptomatic.\n Plan:\n Closely monitor hemodynamics. Provide comfort and support. Monitor for\n s/s of tamponade (i.e pulsus, any changes in hemodynamics). Monitor\n labs and temp.\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done at 1500 for approximately 2L of serous fluid.\n Tolerated procedure well. 1 mg PO ativan given for moderate anxiety\n with good effect.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given a/o.\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Awaiting CT of c spine this evening.\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535258, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n SBP 70-80s in ED.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535259, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 535250, "text": "Pt presented to ED with fever and neck pain. Had CT ,pelvis,chest\n and spine which showed increased lt sided pleural effusion,moderate\n pericardial effusion which is new, new RUL mass @9mm, large volume of\n pelvic and ascitis, hyperdense spinal and sternal lesions most\n likely metastatic. Pt was hypotensive to low 80's(base line in 90's)\n had\n 500cc FB x2,had one dose of cefepime and vanco. Pt transfered to \n for close monitoring.\n While in sbp dropped down to systolic 83,pt is getting 250 ccFB at\n time of report.\n" }, { "category": "Physician ", "chartdate": "2125-06-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 535251, "text": "Chief Complaint: Hypotension\n HPI:\n This is a 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise. A CT torso was performed which showed a\n worsening pleural effusion, new pericardial effusion, and no abdominal\n process seen. She initially had stable vitals, was at her baseline\n SBP's in the 90's with a small O2 requirement and was to be sent to the\n floor, but became hypotensive to the 70's this morning with hr's to\n 120's. She was asymptomatic and was responsive to 1L fluid, with BP's\n coming back up to 90/60. The concern was for tamponade from the\n enlarging pericardial effusion and they did a bedside echo which they\n thought might have shown ? chamber collapse. Pulsus wnl. Cardiology was\n called, and their stat echo showed small to moderate effusion with no\n evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers. She remains 97% 2L NC upon transfer to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1 dose of vanco/cefepime in the ED\n DEXAMETHASONE 2 mg Tablet - 1 Tablet(s) by mouth once a day take twice\n a day the day before, day of and day after chemo\n DOLASETRON [ANZEMET] - 50 mg Tablet - 1 Tablet(s) by mouth \n GABAPENTIN [NEURONTIN] - 300 mg Capsule - 1 Capsule(s) by mouth TID\n LATANOPROST 0.005 % Drops - 1 drop at bedtime to both eyes\n LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1\n Adhesive(s) DAILY (Daily) do not leave on longer than 12 hours\n LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth q4-6hrs prn\n OLANZAPINE [ZYPREXA] 2.5 mg Tablet - 1 Tablet(s) by mouth prn and hs\n OXYCODONE - 5 mg Tablet - Tablet(s) by mouth q4-6hrs as needed for\n breakthrough pain\n RANITIDINE HCL 150 mg Tablet - 1 Tablet(s) by mouth twice a day\n TRAMADOL [ULTRAM] 50 mg Tablet - 2 Tablet by mouth four times a day\n WARFARIN [COUMADIN] ***NOT TAKING***- 6 mg Tablet - 1 Tablet(s) by\n mouth every other day alternates with 7.5mg qd\n Past medical history:\n Family history:\n Social History:\n Stage IIIC primary peritoneal serous carcinoma diagnosed in \n with a history of right-sided pulmonary embolism diagnosed in \n . Postoperatively, she did have recurrent right-sided pulmonary\n embolism in . On , surgical exploration and\n partial excision with suboptimal debulking was performed by Dr.\n . Evacuation of ascites, bilateral salpingo-oophorectomy,\n supracervical hysterectomy, and omental biopsies were performed. Large\n tumor mass engulfed the entire greater omentum up to the stomach\n involving the transverse colon, hepatic flexure, and proximal portion\n of the descending colon. There is no retroperitoneal tumor, 6-cm\n portion of the tumor and omental biopsies were resected. The patient\n is status post six cycles of carboplatin and Taxol. She has\n carboplatin resistant disease. She was briefly on Arimidex from\n through . She then received gemcitabine, which\n was complicated by a drug rash and fatigue. She then completed six\n cycles of low-dose weekly Taxol, which was complicated by severe\n colitis including C. difficile. She subsequently status post six\n cycles of Doxil. She is now on 3rd cycle of Alimta. She recently\n underwent paracentesis, which was performed on due to pain\n from accumulating ascites (she requires these every several months).\n .\n Recurrent DVT and PE, was on coumadin until stopped recently at PCP's\n discretion.\n .\n History of recent c diff colitis\n mother with lung CA. CVD and DM2.\n Occupation:\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: 2 sisters, both very supportive\n Review of systems: The patient denies any weight change, nausea,\n vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, orthopnea, PND, lower extremity edema, cough, urinary\n frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal\n weakness, vision changes, headache, rash or skin changes.\n Flowsheet Data as of 07:31 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 76 (76 - 83) bpm\n BP: 88/53(62) {83/50(58) - 95/71(77)} mmHg\n RR: 21 (10 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Total In:\n 1,257 mL\n PO:\n TF:\n IVF:\n 257 mL\n products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,257 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n Vitals: T: 97.5 BP: 95/71 HR: 94 RR: 16 O2Sat: 98% 2L NC\n GEN: Chronically ill-appearing, no acute distress\n HEENT: EOMI, PERRL, sclerae anicteric, MMM, OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, no cervical\n lymphadenopathy, trachea midline\n COR: RRR, +rub no M/G, normal S1 S2, radial pulses +2\n PULM: Decreased breath sounds half way up on left, basilar crackles on\n the right.\n ABD: Soft, NT, mild distention, +BS, no HSM, +fluid wave and shifting\n dullness.\n EXT: No C/C/E, no palpable cords\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\n disturbance. No cerebellar dysfunction.\n SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.\n Labs / Radiology\n 287\n 120\n 0.7\n 9\n 28\n 97\n 4.1\n 135\n 31\n 9.4\n [image002.jpg]\n Other labs: Differential-Neuts:64, Band:0, Lymph:13\n Imaging: CTA, CT abd/pelvis: Preliminary Report !! WET READ !!\n Moderate pericardial effusion new. No PE. Probably new RUL mass 9 mm.\n Increased left pleural effusion. Large volume abdominal and pelvic\n ascites which limits assessment. Large volume of dense stool. Numerous\n hyperdense spinal and sternal lesions suspicious for metatasis, all new\n compared to study.\n Microbiology: cultures x 2 pending\n Urine culture x 1 pending\n ECG: NSR @ 95, normal axis/intervals. No STTW. Normal voltage, good R\n wave progression.\n Assessment and Plan\n Assessment: 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise, transferred to the with transient\n hypotension.\n .\n Plan:\n .\n # Hypotension: the differential includes infection, given that the\n patient is febrile on arrival, although her wbc is within normal limits\n without a left shift, it may be that the fever is secondary to tumor\n burden. Infectious sources could be any of the number of effusions the\n patient has, including pleural and ascitic. Other possibilities which\n are more concerning could be tamponade physiology from a new\n pericardial effusion. Stat echo by cardiology seemed to indicate no\n evidence of tamponade while patient was hypotensive, and she was fluid\n responsive to 1L. Other possible etiologies include hypovolemia from\n poor PO intake, but patient denies change in intake lately, or 3rd\n spacing with resultant poor forward flow (but patient is asymptomatic).\n Currently, very fluid responsive.\n - stat TTE this morning\n - q4 hour pulsus\n - pan culture - there are urine and cultures pending from ED\n - hold on abx for now, as there is no clear source right now, no\n leukocytosis -> re culture if spikes\n - diagnostic paracentesis, ?SBP\n - diagnostic thoracentesis\n .\n # Hypoxia: Patient has an increased pleural effusion on the left with a\n new RUL mass on wet read of the CT chest, likely met vs. infection.\n These could both account for increased hypoxia. Currently the patient\n is comfortable on minimal O2, but O2 requirement is new.\n - consider diagnostic/therapeutic \n - heme/onc input on RUL mass\n .\n # Stage III peritoneal serous CA: patient just completed her 3rd round\n of Alimta. She had a mild transaminitis which was being attributed to\n the chemotherapeutic. Initially seemed to be having good response with\n reduction in CA-125 levels, but now has mets in the spine which are new\n and a possible new met in the RUL of the lung.\n - symptomatic support\n - will alert heme/onc to patient's admission this morning for further\n assistance with management and discussion of prognosis given new\n diffuse metastasis\n .\n # Recurrent DVT/PE: patient was to be on lifelong coumadin therapy,\n which was stopped by patient's PCP for unclear reasons. Heme/onc had\n discussed restarting this with the patient on the last admission given\n her high risk. That being said, with a pericardial effusion and concern\n for tamponade physiology, should not restart anticoagulation at this\n time. CTA wet read is negative for new PE.\n - check coags, reverse if necessary\n - DVT ppx with heparin subcut only\n .\n # Anemia: likely secondary to chronic disease, albeit below her\n baseline. Send type and screen, transfusion threshold <21 for now.\n .\n # FEN: regular diet, replete lytes prn. IVF with caution for BP\n support.\n .\n # Access: PIV\n .\n # PPx: heparin subcut\n .\n # Code: Full\n .\n # Dispo: pending clinical stabilization\n .\n # Comm: With patient and sisters\n ICU \n Nutrition:\n Comments: Normal diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2125-06-19 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 535252, "text": "Chief Complaint: 53 year old woman, admitted MICU for hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Hx of ovarian ca. Came to ED with fever and malaise 3 days after chemo.\n CT scan showed increased left pleural effusion and new pericardial\n effusion. Developed hypotension to 70's. Asymptomatic. Responded to 1\n liter of fluid. ED echo raised question of RV collapse. Cardiology echo\n did not show evidence of tamponade physiology. Started on cefipime and\n vancomycin. Not neutropenic. O2 sats good on 2L of nasal O2.\n In MICU, BP dropped to 80's. Again responded well to fluid bolus.\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Neurontin, lido patch, heparin sc, ranitidine, ativan, lactulose, senna\n Past medical history:\n Family history:\n Social History:\n Stage 3 ovarian ca - s/p surgical debulking, s/p platinum and taxol,\n s/p gemcitobin, now on folate inhibitor with evidence of response by CA\n 125\n DVT\n PE\n Ascites\n Home meds: dexamethasone pre chemo, neurontin, lidocaine patch,\n ranitidine, tramadol, ativan\n Mother lung ca\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: Low BP at baseline\n Flowsheet Data as of 09:45 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 77 (76 - 83) bpm\n BP: 88/52(61) {83/50(58) - 96/71(77)} mmHg\n RR: 12 (10 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Total In:\n 1,394 mL\n PO:\n 120 mL\n TF:\n IVF:\n 274 mL\n products:\n Total out:\n 0 mL\n 550 mL\n Urine:\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 844 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n Fixed), No(t) S3, No(t) S4, Rub, (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : Dullness at both bases, No(t)\n Hyperresonant: , Dullness : ), (Breath Sounds: No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , Diminished: Egophony left midzone, No(t)\n Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place time, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 243 K/uL\n 27.8 %\n 9.1 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 7 mg/dL\n 25 mEq/L\n 108 mEq/L\n 3.7 mEq/L\n 140 mEq/L\n 7.0 K/uL\n [image002.jpg]\n 07:11 AM\n WBC\n 7.0\n Hct\n 27.8\n Plt\n 243\n Cr\n 0.6\n Glucose\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:7.6 mg/dL, Mg++:1.6\n mg/dL, PO4:3.9 mg/dL\n Imaging: CT scan: no PE. 9 mm nodule in RUL. Large left pleural\n effusion. Pericardial effusion, large ascites, + spinal and sternal\n mets\n ECG: Minimal PR depression. No acute ischemic changes.\n Assessment and Plan\n 1) Hypotension\n 2) Pericardial effusion\n 3) Pleural effusion\n 4) Ovarian ca\n 5) Fever\n 6) Hypoxemia\n 7) Anemia\n Hypotension likely due to vasodilation from fever/infection, and\n possible third spacing of fluid into ascites and effusions. Patient\n responds well to fluids. Urine output good at this point. Continue to\n support with intermittent fluid boluses as needed. No evidence for\n tamponade physiology now. No evidence for acute myocardial ischemia.\n Pericardial and pleural effusions likely metastatic. No symptoms to\n suggest inflammatory conditions, although pericardial friction rub is\n present. Absence of pain argues against infectious pericarditis.\n Consider tap of ascites and possibly pericardial fluid if fever\n persists. No obvious source of fever now. WBC not suggestive of\n bacterial infection. Hold antibiotics now and follow cultures. Monitor\n pulsus paradoxus for now, but I would favor a tap to define if\n malignant and, if so, consider pericardial window to prevent future\n tamponade.\n Mild hypoxemia, possibly related to pleural effusion. No PE on CTA.\n Good O2 sats on minimal supplemental oxygen.\n Anemia likely related in large part to her underlying cancer and\n chemotherapy. Present Hct down from baseline with volume resuscitation.\n No evidence of bleeding. Monitor stool guaiac. No need for transfusion\n now.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 06:43 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535253, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n SBP 70-80s in ED.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535254, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n SBP 70-80s in ED.\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535260, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n Hypotension (not Shock)\n Assessment:\n SBP 90-100s. HR 80-90s. denying dizziness, alert and oriented x3.\n speech clear. MAE well. ? pericardial fluid noted on CT. Slightly\n more tachycardiac in the afternoon. White count down to 7. Tmax 100.9.\n Action:\n 250 bolus given early this a.m for SBP in low 80s. Closely monitored\n SBP throughout the day. No pulsus paradox noted manually. Team\n notified of increasing tachycardia however BP remains stable at 100 and\n tachycardia most likely related to anxiety. IV antibiotics\n discontinued.\n Response:\n SBP remained >90 since approximately 10 this morning. Remains\n asymptomatic.\n Plan:\n Closely monitor hemodynamics. Provide comfort and support. Monitor for\n s/s of tamponade (i.e pulsus, any changes in hemodynamics). Monitor\n labs and temp.\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535261, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n Hypotension (not Shock)\n Assessment:\n SBP 90-100s. HR 80-90s. denying dizziness, alert and oriented x3.\n speech clear. MAE well. ? pericardial fluid noted on CT. Slightly\n more tachycardiac in the afternoon. White count down to 7. Tmax 100.9.\n Action:\n 250 bolus given early this a.m for SBP in low 80s. Closely monitored\n SBP throughout the day. No pulsus paradox noted manually. Team\n notified of increasing tachycardia however BP remains stable at 100 and\n tachycardia most likely related to anxiety. IV antibiotics\n discontinued.\n Response:\n SBP remained >90 since approximately 10 this morning. Remains\n asymptomatic.\n Plan:\n Closely monitor hemodynamics. Provide comfort and support. Monitor for\n s/s of tamponade (i.e pulsus, any changes in hemodynamics). Monitor\n labs and temp.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given a/o.\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Awaiting CT of c spine this evening.\n" }, { "category": "Nursing", "chartdate": "2125-06-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535262, "text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/Chills\n Precautions: Standard\n PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L.\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past.Has undergone chemo\n and radiation therapies.Las chemo 5 days ago.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:54\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,869 mL\n 24h total out:\n 1,300 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 07:11 AM\n Potassium:\n 3.7 mEq/L\n 07:11 AM\n Chloride:\n 108 mEq/L\n 07:11 AM\n CO2:\n 25 mEq/L\n 07:11 AM\n BUN:\n 7 mg/dL\n 07:11 AM\n Creatinine:\n 0.6 mg/dL\n 07:11 AM\n Glucose:\n 93 mg/dL\n 07:11 AM\n Hematocrit:\n 29.9 %\n 12:27 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n Pertinent Lab Results:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1173\n Date & time of Transfer: 1735\n Hypotension (not Shock)\n Assessment:\n SBP 90-100s. HR 80-90s. denying dizziness, alert and oriented x3.\n speech clear. MAE well. ? pericardial fluid noted on CT. Slightly\n more tachycardiac in the afternoon. White count down to 7. Tmax 100.9.\n Action:\n 250 bolus given early this a.m for SBP in low 80s. Closely monitored\n SBP throughout the day. No pulsus paradox noted manually. Team\n notified of increasing tachycardia however BP remains stable at 100 and\n tachycardia most likely related to anxiety. IV antibiotics\n discontinued.\n Response:\n SBP remained >90 since approximately 10 this morning. Remains\n asymptomatic.\n Plan:\n Closely monitor hemodynamics. Provide comfort and support. Monitor for\n s/s of tamponade (i.e pulsus, any changes in hemodynamics). Monitor\n labs and temp.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given a/o.\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Awaiting CT of c spine this evening.\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 535264, "text": "This is a 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise. A CT torso was performed which showed a\n worsening pleural effusion, new pericardial effusion, and no abdominal\n process seen. She initially had stable vitals, was at her baseline\n SBP's in the 90's with a small O2 requirement and was to be sent to the\n floor, but became hypotensive to the 70's this morning with hr's to\n 120's. She was asymptomatic and was responsive to 1L fluid, with BP's\n coming back up to 90/60. The concern was for tamponade from the\n enlarging pericardial effusion and they did a bedside echo which they\n thought might have shown ? chamber collapse. Pulsus wnl. Cardiology was\n called, and their stat echo showed small to moderate effusion with no\n evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers. She remains 97% 2L NC upon transfer to .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at . Skin hot to touch.\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Temp down to 98 by midnight. Skin warm. No c/o chills.\n Plan:\n Pt no longer called out per hospitalist. Pt to remain on 4 over\n noc for observation.\n Tachycardia, Other\n Assessment:\n HR 70\ns-100\ns in SR. No further ectopy noted. Tachycardic with fever\n and when OOB to commode.\n Action:\n Pt remaines under observsation on 4.\n Response:\n During night HR maintained 70\ns-80\ns when afebrile. Still tachy when\n OOB\n Plan:\n Con\nt to monitor HR and rhythym\n Skin: Warm and dry. No breakdown noted. Pt turns by herself in bed.\n Up to commode.\n GI: Abd firm, slightly tender. Pt tapped yesterday for ascites. Hx\n of cancer. Positive bowel sounds. Pt had medium sized BM, formed with\n no frank .\n Resp: Pt placed on 2LNC when sats down to 93% on RA. LS clear,\n diminished at bases. No resp distress or SOB noted. Sats up to 99% on\n 2LNC.\n Social: Sisters are both very involved. At pt\ns bedside during\n evening.\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 535265, "text": "This is a 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise. A CT torso was performed which showed a\n worsening pleural effusion, new pericardial effusion, and no abdominal\n process seen. She initially had stable vitals, was at her baseline\n SBP's in the 90's with a small O2 requirement and was to be sent to the\n floor, but became hypotensive to the 70's this morning with hr's to\n 120's. She was asymptomatic and was responsive to 1L fluid, with BP's\n coming back up to 90/60. The concern was for tamponade from the\n enlarging pericardial effusion and they did a bedside echo which they\n thought might have shown ? chamber collapse. Pulsus wnl. Cardiology was\n called, and their stat echo showed small to moderate effusion with no\n evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers. She remains 97% 2L NC upon transfer to .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at . Skin hot to touch.\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Temp down to 98 by midnight. Skin warm. No c/o chills.\n Plan:\n Pt no longer called out per hospitalist. Pt to remain on 4 over\n noc for observation.\n Tachycardia, Other\n Assessment:\n HR 70\ns-100\ns in SR. No further ectopy noted. Tachycardic with fever\n and when OOB to commode.\n Action:\n Pt remaines under observsation on 4.\n Response:\n During night HR maintained 70\ns-80\ns when afebrile. Still tachy when\n OOB\n Plan:\n Con\nt to monitor HR and rhythym\n Skin: Warm and dry. No breakdown noted. Pt turns by herself in bed.\n Up to commode.\n GI: Abd firm, slightly tender. Pt tapped yesterday for ascites. Hx\n of cancer. Positive bowel sounds. Pt had medium sized BM, formed with\n no frank .\n Resp: Pt placed on 2LNC when sats down to 93% on RA. LS clear,\n diminished at bases. No resp distress or SOB noted. Sats up to 99% on\n 2LNC.\n Social: Sisters are both very involved. At pt\ns bedside during\n evening.\n" }, { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 535267, "text": "Chief Complaint:\n 24 Hour Events:\n Paracentesis done and 2L fluid removed, cytology with 133 total WBCs\n which r/o SBP. Serial HCTs from yesturday 27-29.9 range.\n After c/o neck pain had a CT neck which did not show any evidence of\n bone mets on prelim read, will f/up final report.\n Cardiology saw yesturday and felt no need for pericardiocentesis for\n now.\n Overnight the patient had fevers to 102 F range and became tachycardic\n to 120s so urine and cultures sent and pending today\n EKG done last yesturday was unchanged from prior admission EKG\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 85 (75 - 107) bpm\n BP: 99/51(63) {74/35(44) - 108/72(79)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 71 mL\n PO:\n 750 mL\n TF:\n IVF:\n 424 mL\n 71 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n Labs / Radiology\n 262 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise, transferred to the with transient\n hypotension.\n .\n Plan:\n .\n # Hypotension: the differential includes infection, given that the\n patient is febrile on arrival, although her wbc is within normal limits\n without a left shift, it may be that the fever is secondary to tumor\n burden. Infectious sources could be any of the number of effusions the\n patient has, including pleural and ascitic. Other possibilities which\n are more concerning could be tamponade physiology from a new\n pericardial effusion. Stat echo by cardiology seemed to indicate no\n evidence of tamponade while patient was hypotensive, and she was fluid\n responsive to 1L. Other possible etiologies include hypovolemia from\n poor PO intake, but patient denies change in intake lately, or 3rd\n spacing with resultant poor forward flow (but patient is asymptomatic).\n Currently, very fluid responsive.\n - stat TTE this morning\n - q4 hour pulsus\n - pan culture - there are urine and cultures pending from ED\n - hold on abx for now, as there is no clear source right now, no\n leukocytosis -> re culture if spikes\n - diagnostic paracentesis, ?SBP\n - diagnostic thoracentesis\n .\n # Hypoxia: Patient has an increased pleural effusion on the left with a\n new RUL mass on wet read of the CT chest, likely met vs. infection.\n These could both account for increased hypoxia. Currently the patient\n is comfortable on minimal O2, but O2 requirement is new.\n - consider diagnostic/therapeutic \n - heme/onc input on RUL mass\n .\n # Stage III peritoneal serous CA: patient just completed her 3rd round\n of Alimta. She had a mild transaminitis which was being attributed to\n the chemotherapeutic. Initially seemed to be having good response with\n reduction in CA-125 levels, but now has mets in the spine which are new\n and a possible new met in the RUL of the lung.\n -\n - heme/onc notified of patient's admission\n CA-125 trend 75 () , then 48 () and last night 35.\n .\n # Recurrent DVT/PE: patient was to be on lifelong coumadin therapy,\n which was stopped by patient's PCP for unclear reasons. Heme/onc had\n discussed restarting this with the patient on the last admission given\n her high risk. That being said, with a pericardial effusion and concern\n for tamponade physiology, should not restart anticoagulation at this\n time. CTA wet read is negative for new PE.\n - check coags, reverse if necessary\n - DVT ppx with heparin subcut only\n .\n # Anemia: likely secondary to chronic disease, Sent type and screen ,\n will keep transfusion threshold <21 for now.\n .\n # FEN: regular diet, replete lytes prn. IVF with caution for BP\n support.\n .\n # Access: PIV\n .\n # PPx: heparin subcut\n .\n # Code: Full\n .\n # Dispo: pending clinical stabilization\n .\n # Comm: With patient and sisters\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 535269, "text": "Chief Complaint:\n 24 Hour Events:\n Paracentesis done and 2L fluid removed, cytology with 133 total WBCs\n which r/o SBP. Serial HCTs from yesturday 27-29.9 range.\n After c/o neck pain had a CT neck which did not show any evidence of\n bone mets on prelim read, will f/up final report.\n Cardiology saw yesturday and felt no need for pericardiocentesis for\n now.\n Overnight the patient had fevers to 102 F range and became tachycardic\n to 120s so urine and cultures sent and pending today\n EKG done last yesturday was unchanged from prior admission EKG\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 85 (75 - 107) bpm\n BP: 99/51(63) {74/35(44) - 108/72(79)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 71 mL\n PO:\n 750 mL\n TF:\n IVF:\n 424 mL\n 71 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination:\n General: pallid complexion, NAD\n HEENT: PERRL, anicteric sclerae, pale conjunctivae, nonerythematous\n oropharynx\n Neck exam: No JVD, no cervical lymphadenopathy, supple\n CVS: S1/S2 appreciated, has rub noted on auscultation, no murmurs or\n clicks\n Lungs: breath sounds blunted on left, -basilar crackles noted. No\n wheeze\n Abd: Soft, NT, distention mild but improved from yesturday\ns exam ,\n normoactive BS\n Ext: negative \ns sign, no edema, 2+ pedal pulses\n Neuro: A& O x3, CNs grossly intact, no focal deficits, Strength\n UE/LE. Did not assess gait today.\n Skin: no jaundice, bruises or rashes noted\n Labs / Radiology\n 262 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise, transferred to the with transient\n hypotension.\n .\n Plan:\n .\n # Hypotension: etiology includes infection, given recent fevers,\n malaise, multiple effusions. However, WBC within normal limits with\n no left shift. Other possibilities which are more concerning could be\n tamponade physiology from a new pericardial effusion but echo by\n cardiology indicated no evidence of tamponade. Other possible etiology\n includes hypovolemia from poor PO intake/dehydration or 3rd spacing\n with resultant poor forward flow. Currently, very fluid responsive\n with IVFs.\n Will f/up urine and cultures pending. Will discuss diagnostic\n thoracentesis plans today per Oncology recs.\n #Fevers ---Infectious sources could be patient\ns pleural effusion with\n possible empyema developing. Ascites fluid WBC 133 so SBP ruled out.\n Fevers may also be worsening underlying malignancy process. Tmax 102\n last night, will f/up on urine and cultures. Patient denies\n cough, SOB improving and denies dysuria or sore throats. Holding on\n antibiotics as no clear source now. Will consider thoracentesis today\n per Oncoogy\ns recs given continuing fever spikes to explore pleural\n fluid as source.\n .\n # Hypoxia: Patient has an increased pleural effusion on the left with a\n new RUL mass on CT chest, likely met vs. infection. These could both\n account for increased hypoxia. Currently the patient is comfortable on\n minimal O2 of 2L NC and oxygen sats consistently >96%. She has no home\n oxygen and O2 requirement is new.\n - consider diagnostic/therapeutic thoracentesis\n - heme/onc notified of RUL mass\n .\n # Stage III peritoneal serous CA: patient just completed her 3rd round\n of Alimta. She had a mild transaminitis which was being attributed to\n the chemo. Initially seemed to be having good response with reduction\n in CA-125 levels, but now has mets in the spine which are new and a\n possible new met in the RUL of the lung. Recent CT neck last night\n prelim read states no mets to c-spine despite neck pain which may be\n positional from sleeping in slightly different position.\n CA-125 trend 75 () , then 48 () and last night 35.\n .\n # Recurrent DVT/PE: patient was to be on lifelong coumadin therapy,\n which was stopped by patient's PCP for unclear reasons. Heme/onc\n consulted and suggests pt. restarts Coumadin after discharge given her\n high risk. Will plan to continue SC daily Heparin for now. CTA done\n was negative for new PE. Will con\nt follow coags, monitor, reverse if\n necessary\n - DVT ppx with heparin subcut only for now\n .\n # Anemia: likely secondary to chronic disease, Sent type and screen ,\n will keep transfusion threshold <21 for now. Hct 30.5 today, stable.\n .\n # FEN: continues to tolerate regular diet well , replete lytes prn. IVF\n with caution for BP support.\n .\n # Access: PIV\n .\n # PPx: heparin SC and daily Ranitidine Rx for GI protection\n .\n # Code: Full\n .\n # Dispo: pending clinical stabilization\n .\n # Comm: With patient and sisters\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535270, "text": "PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L. During Her ICU course\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Pericardial effusion (without tamponade)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535272, "text": "PMH: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown ? chamber collapse. Pulsus wnl.\n Cardiology was called, and their stat echo showed small to moderate\n effusion with no evidence of tamponade per cards fellow. She was given\n cefepime and vanco for her fevers. She remains 97% 2L NC upon transfer\n to .\n .\n Upon arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50. She is\n satting 99%2L. During Her ICU courseParacentesis done and 2L fluid\n removed, cytology with 133 total WBCs which r/o SBP. Serial HCTs from\n yesturday 27-29.9 range.\n After c/o neck pain had a CT neck which did not show any evidence of\n bone mets on prelim read, will f/up final report.\n Cardiology saw yesturday and felt no need for pericardiocentesis for\n now.\n Overnight the patient had fevers to 102 F range and became tachycardic\n to 120s so urine and cultures sent and pending today\n CV-PMH:\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. .Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at yesterday evening\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Continues with low grade temp this AM to 99.1\n Plan:\n Continue to follow temp curve, follow up on culture data\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done yesterday for approximately 2L of serous fluid.\n Tolerated procedure well.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given PRN\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Follow up with results on CT\n" }, { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 535274, "text": "Chief Complaint: Fever, hypotension, ovarian ca\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient had paracentesis yesterday. Cytology pending.\n CT of neck negative for bone mets.\n Review of echocardiogram - insufficient fluid to tap.\n Had fever and tachycardia last night. BP was stable during this\n episode.\n 24 Hour Events:\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n History obtained from Patient\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Neurontin, lido patch, colace, zyprexa, zantac, oxycodone, tramadol,\n zofran, tylenol, lactulose, senna\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:26 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 37.2\nC (99\n HR: 91 (75 - 107) bpm\n BP: 93/57(66) {74/35(44) - 105/72(79)} mmHg\n RR: 20 (14 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 175 mL\n PO:\n 750 mL\n 100 mL\n TF:\n IVF:\n 424 mL\n 75 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -876 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, Rub, (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Hyperresonant: , Dullness : Left base), (Breath\n Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :\n , No(t) Diminished: , No(t) Absent : , Rhonchorous: Rare expiratory\n rhonchus)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.0 g/dL\n 262 K/uL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Fluid analysis / Other labs: Ascites - WBC 130\n Assessment and Plan\n 1) Fever\n 2) Hypotension\n 3) Ovarian Ca\n 4) Anemia\n Patient still febrile, but hemodynamically stable. Source of the\n infection not clear. Ascitic fluid cell counts non consistent with\n peritonitis. Pericardial fliud too small to be tapped. Infected pleural\n fluid still a possibility, but seems unlikely given the chronicity of\n the effusion. Continue to monitor cultures.\n Hct stable. No need for transfusion at this time.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2125-06-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 535275, "text": "Chief Complaint:\n 24 Hour Events:\n Paracentesis done and 2L fluid removed, cytology with 133 total WBCs\n which r/o SBP. Serial HCTs from yesturday 27-29.9 range.\n After c/o neck pain had a CT neck which did not show any evidence of\n bone mets on prelim read, will f/up final report.\n Cardiology saw yesturday and felt no need for pericardiocentesis for\n now.\n Overnight the patient had fevers to 102 F range and became tachycardic\n to 120s so urine and cultures sent and pending today\n EKG done last yesturday was unchanged from prior admission EKG\n EKG - At 12:15 PM\n PARACENTESIS - At 03:05 PM\n FEVER - 102.0\nF - 08:00 PM\n Allergies:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 85 (75 - 107) bpm\n BP: 99/51(63) {74/35(44) - 108/72(79)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.8 kg (admission): 62.8 kg\n Height: 68 Inch\n Total In:\n 2,174 mL\n 71 mL\n PO:\n 750 mL\n TF:\n IVF:\n 424 mL\n 71 mL\n products:\n Total out:\n 2,090 mL\n 1,050 mL\n Urine:\n 2,090 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 84 mL\n -979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination:\n General: pallid complexion, NAD\n HEENT: PERRL, anicteric sclerae, pale conjunctivae, nonerythematous\n oropharynx\n Neck exam: No JVD, no cervical lymphadenopathy, supple\n CVS: S1/S2 appreciated, has rub noted on auscultation, no murmurs or\n clicks\n Lungs: breath sounds blunted on left, -basilar crackles noted. No\n wheeze\n Abd: Soft, NT, distention mild but improved from yesturday\ns exam ,\n normoactive BS\n Ext: negative \ns sign, no edema, 2+ pedal pulses\n Neuro: A& O x3, CNs grossly intact, no focal deficits, Strength\n UE/LE. Did not assess gait today.\n Skin: no jaundice, bruises or rashes noted\n Labs / Radiology\n Paracentesis fluid : wbc 133, rbc 203, Pro 3.9, Alb 2.5\n 262 K/uL\n 10.0 g/dL\n 93 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 105 mEq/L\n 142 mEq/L\n 30.5 %\n 7.2 K/uL\n [image002.jpg]\n 07:11 AM\n 12:27 PM\n 04:28 AM\n WBC\n 7.0\n 7.2\n Hct\n 27.8\n 29.9\n 30.5\n Plt\n 243\n 262\n Cr\n 0.6\n 0.6\n Glucose\n 93\n 93\n Other labs: PT / PTT / INR:14.3/26.2/1.2, ALT / AST:36/29, Alk Phos / T\n Bili:93/0.3, Albumin:2.8 g/dL, LDH:254 IU/L, Ca++:8.5 mg/dL, Mg++:1.7\n mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: 53 year-old female with a history of Stage III peritoneal\n serous CA who presents to the ED 5 days s/p third cycle of Alimta, with\n mild fever and malaise, transferred to the with transient\n hypotension.\n .\n Plan:\n .\n # Hypotension: etiology includes infection, given recent fevers,\n malaise, multiple effusions. However, WBC within normal limits with\n no left shift. Other possibilities which are more concerning could be\n tamponade physiology from a new pericardial effusion but echo by\n cardiology indicated no evidence of tamponade. Other possible etiology\n includes hypovolemia from poor PO intake/dehydration or 3rd spacing\n with resultant poor forward flow. Currently, very fluid responsive\n with IVFs.\n Will f/up urine and cultures pending. Will discuss diagnostic\n thoracentesis plans today per Oncology recs.\n #Fevers ---Infectious sources could be patient\ns pleural effusion with\n possible empyema developing. Ascites fluid WBC 133 so SBP ruled out.\n Fevers may also be worsening underlying malignancy process. Tmax 102\n last night, will f/up on urine and cultures. Patient denies\n cough, SOB improving and denies dysuria or sore throats. Holding on\n antibiotics as no clear source now. Will consider thoracentesis today\n per Oncoogy\ns recs given continuing fever spikes to explore pleural\n fluid as source.\n .\n # Hypoxia: Patient has an increased pleural effusion on the left with a\n new RUL mass on CT chest, likely met vs. infection. These could both\n account for increased hypoxia. Currently the patient is comfortable on\n minimal O2 of 2L NC and oxygen sats consistently >96%. She has no home\n oxygen and O2 requirement is new.\n - consider diagnostic/therapeutic thoracentesis\n - heme/onc notified of RUL mass\n .\n # Stage III peritoneal serous CA: patient just completed her 3rd round\n of Alimta. She had a mild transaminitis which was being attributed to\n the chemo. Initially seemed to be having good response with reduction\n in CA-125 levels, but now has mets in the spine which are new and a\n possible new met in the RUL of the lung. Recent CT neck last night\n prelim read states no mets to c-spine despite neck pain which may be\n positional from sleeping in slightly different position.\n CA-125 trend 75 () , then 48 () and last night 35.\n .\n # Recurrent DVT/PE: patient was to be on lifelong coumadin therapy,\n which was stopped by patient's PCP for unclear reasons. Heme/onc\n consulted and suggests pt. restarts Coumadin after discharge given her\n high risk. Will plan to continue SC daily Heparin for now. CTA done\n was negative for new PE. Will con\nt follow coags, monitor, reverse if\n necessary\n - DVT ppx with heparin subcut only for now\n .\n # Anemia: likely secondary to chronic disease, Sent type and screen ,\n will keep transfusion threshold <21 for now. Hct 30.5 today, stable.\n .\n # FEN: continues to tolerate regular diet well , replete lytes prn. IVF\n with caution for BP support.\n .\n # Access: PIV\n .\n # PPx: heparin SC and daily Ranitidine Rx for GI protection\n .\n # Code: Full\n .\n # Dispo: Will call-out today to OMED for continuing care\n .\n # Communication: With patient and sisters\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:43 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2125-06-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 535276, "text": "PMH/HPI: This is a 53 year-old female with a history of Stage III\n peritoneal serous CA who presents to the ED 5 days s/p third cycle of\n Alimta, with mild fever and malaise. A CT torso was performed which\n showed a worsening pleural effusion, new pericardial effusion, and no\n abdominal process seen. She initially had stable vitals, was at her\n baseline SBP's in the 90's with a small O2 requirement and was to be\n sent to the floor, but became hypotensive to the 70's this morning with\n hr's to 120's. She was asymptomatic and was responsive to 1L fluid,\n with BP's coming back up to 90/60. The concern was for tamponade from\n the enlarging pericardial effusion and they did a bedside echo which\n they thought might have shown? chamber collapse. Pulsus wnl. Cardiology\n was called, and their stat echo showed small to moderate effusion with\n no evidence of tamponade per cards fellow. She was given cefepime and\n vanco for her fevers (which have subsequently been D/C\nd). Upon\n arrival, the patient seems comfortable and says she feels tired.\n Initial BP was 90/58, but she dropped subsequently to 83/50 BP\n responded to IVF. During Her ICU course she received the echo as\n previously noted. A Paracentesis done and 2L fluid removed, cytology\n with 133 total WBCs which r/o SBP. Serial HCTs from yesterday 27-29.9\n range. After c/o neck pain had a CT neck which did not show any\n evidence of bone mets on prelim read, will f/up final report.\n Cardiology saw yesterday and felt no need for pericardiocentesis for\n now. Overnight the patient had fevers to 102 F and became tachycardic\n to 120s so urine and cultures sent and pending today. She is\n currently running a low grade temp (99) and tachycardia has resolved.\n Her BP has returned to its baseline of 90\ns/50\n Today she is A&Ox3, sleeping in naps, denies pain. Hemodynamically\n stable, BP 90-100/50\ns. Tele SR 90\ns. HR up to 110\ns with activity.\n No edema. LSCTA bilaterally, diminished at bases. Sats 95-97 on 2 LNC\n sats down to 91 on RA. Tolerating regular diet, abdomen soft distended\n last BM in the evening. + BS in 4 quadrents. Voiding\n concentrated yellow urine via commode. Temp ranging 98-5-99.5 today\n although still feels clammy and warm, off all antibiotics at this\n time. Mag & K repleted this AM. Sisters at bedside and are very\n supportive.\n Additional history: Schizophrenia, Stage 3 peritoneal serous cancer,\n metastatic ovarian ca, cdiff colitis in the past r/t chemo. Has under\n gone chemo and radiation therapies. Last chemo 5 days ago. new lesions\n noted on CT on spine and ? RUL lesion.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt had temp of 102 at yesterday evening\n Action:\n 650mg PO Tylenol given. cx\ns drawn x 2 and urine culture sent.\n Response:\n Continues with low grade temp this AM to 99.1\n Plan:\n Continue to follow temp curve, follow up on culture data\n Ascites\n Assessment:\n Abd firm, distended. Distant bowel sounds though present. At times abd\n painful to palpation in RLQ.\n Action:\n Paracentesis done yesterday for approximately 2L of serous fluid.\n Tolerated procedure well.\n Response:\n Denying abdominal pain. Abdomen appears less distended. Fluid sent for\n cytology & culture.\n Plan:\n Continue to closely monitor.\n .H/O cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine,\n Cervical, Endometrial)\n Assessment:\n CT o/n showed ? new lesions. c/o intermittent pain in neck. . At\n home, pt usually uses lidocaine patch and tramadol for pain mgmt with\n good effect.\n Action:\n Lidocaine patch applied to neck. Tramadol given PRN\n Response:\n Tramadol and lido with good effect. on pain scale.\n Plan:\n Follow up with results on CT\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n FEVER\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 62.8 kg\n Daily weight:\n 62.8 kg\n Allergies/Reactions:\n Gemzar (Intraven.) (Gemcitabine Hcl)\n Rash; Fever/\n Precautions:\n Universal\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:56\n Temperature:\n 98.7\n Arterial BP:\n S:\n D:59\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 725 mL\n 24h total out:\n 1,550 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:28 AM\n Potassium:\n 3.6 mEq/L\n 04:28 AM\n Chloride:\n 105 mEq/L\n 04:28 AM\n CO2:\n 28 mEq/L\n 04:28 AM\n BUN:\n 6 mg/dL\n 04:28 AM\n Creatinine:\n 0.6 mg/dL\n 04:28 AM\n Glucose:\n 93 mg/dL\n 04:28 AM\n Hematocrit:\n 30.5 %\n 04:28 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 405\n Transferred to: 1167\n Date & time of Transfer: 17:00 PM\n" }, { "category": "Echo", "chartdate": "2125-06-19 00:00:00.000", "description": "Report", "row_id": 64675, "text": "PATIENT/TEST INFORMATION:\nIndication: Tamponade. ?pericardial effusion\nHeight: (in) 63\nWeight (lb): 120\nBSA (m2): 1.56 m2\nBP (mm Hg): 83/55\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 05:32\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\nLeft pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. No aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is high\nnormal. There is a small circumferential pericardial effusion without evidence\nfor hemodynamic compromise.\n\nIMPRESSION: Small circumferential pericardial effusion without evidence for\nhemodynamic compromise. Preserved global biventricular systolic function.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1025015, "text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with serous ca stage III with new pleural effusion on left.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FH WED 11:02 AM\n Interval appearance right pleural and possible pericardial effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ovarian CA.\n\n AP BEDSIDE CHEST. The cardiac silhouette is enlarged. No vascular\n congestion. There are bilateral pleural effusions with associated bibasilar\n atelectasis and possible loculation. No vascular congestion or\n consolidations. No bone destruction. Since last exam the right\n effusion has developed and the cardiac silhouette has increased in size.\n\n IMPRESSION: Interval appearance right effusion and possible pericardial\n effusion. No CHF or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2125-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1025016, "text": ", M. MED 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with serous ca stage III with new pleural effusion on left.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n PFI REPORT\n Interval appearance right pleural and possible pericardial effusions.\n\n" }, { "category": "Radiology", "chartdate": "2125-06-19 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1024790, "text": " 12:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: CP, RLQ TENDERNESS, OVARIAN CA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with CP and RLQ tenderness.\n REASON FOR THIS EXAMINATION:\n Please r/o PE and r/o appendicitis or other intra-abd process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj TUE 3:13 AM\n Moderate pericardial effusion new. No PE.\n Probably new RUL mass 9 mm.\n Increased left pleural effusion.\n Large volume abdominal and pelvic ascites which limits assessment.\n Large volume of dense stool.\n Numerous hyperdense spinal and sternal lesions suspicious for metatasis, all\n new compared to study.\n See report for other details.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT torso.\n\n INDICATION: 53-year-old female presenting with chest pain and right lower\n quadrant tenderness. Patient with history of ovarian cancer.\n\n COMPARISONS: CT .\n\n TECHNIQUE: Following the administration of intravenous contrast, MDCT axial\n images were acquired of the chest, abdomen and pelvis. Coronal, sagittal, and\n oblique reformatted images were obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no filling defects\n present within the pulmonary arterial vasculature. There is a moderate\n pericardial effusion, which appears new compared to the previous examination.\n There has been interval increase in size of a left pleural effusion. A small\n right pleural effusion is also present. A small hyperdense metastasis is\n noted at the posterior left lung base measuring approximately 1 cm in length\n and is similar compared to the previous CT. In the right upper lobe, there is\n a spiculated density measuring 9 mm, which appears new compared to \n (3A:45). No other opacities are noted. There is left lower lobe atelectasis.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Hyperdense lesions within the segment II\n of the liver and segment IVb are not significantly changed compared to\n . No new hyperdense lesions are identified. There are scattered low-\n attenuation foci, which are too small to characterize, but likely represent\n simple cysts. Mild intra- and extra-hepatic biliary dilatation is again\n noted. The gallbladder is not distended. The spleen, adrenal glands,\n kidneys, pancreas, stomach, and abdominal portions of the large and small\n bowel appear unremarkable. A right lower quadrant metastasis measuring 2.0 x\n 1.3 cm is grossly stable compared to the most recent CT (3B:133).\n (Over)\n\n 12:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: CP, RLQ TENDERNESS, OVARIAN CA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Thickening and enhancement mesentery is consistent with metastatic\n disease. Assessment is somewhat limited secondary to a large volume of\n abdominal and pelvic ascites. The abdominal portions of the large and small\n bowel appear grossly unremarkable. Large volumes of colonic stool which are\n dense are noted.\n\n CT OF THE PELVIS WITH IV CONTRAST: Large volume of stool is noted within the\n rectum and sigmoid colon. There is a large amount of pelvic ascites as well.\n Hyperdense focus within the space of Retzius measuring 1.3 x 1.0 cm and is\n consistent with a peritoneal implant which is stable compared to the most\n recent CT examination.\n\n OSSEOUS STRUCTURES: The right iliac appears sclerotic, and this is\n increased compared to the most recent prior examination. There are new\n hyperdense foci within the sternum, T12, L1, L2, L4, and L5 vertebral bodies\n concerning for metastasis and new compared to .\n\n IMPRESSION:\n\n 1. New moderate pericardial effusions.\n\n 2. Worsening left pleural effusion.\n\n 3. No pulmonary embolism.\n\n 4. New right upper lobe 9-mm spiculated mass concerning for metastasis.\n\n 5. Stable liver and peritoneal lesions.\n\n 6. Multiple new bony hyperdense foci concerning for spinal and sternal\n metastasis.\n\n 7. Large volume abdominal and pelvic ascites, which somewhat limits\n assessment. No evidence of an acute bowel process.\n\n 8. Large volume of dense colonic and rectal stool.\n\n Findings were discussed in person with Dr. at 2:45 a.m. on by\n Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2125-06-19 00:00:00.000", "description": "CT C-SPINE W/CONTRAST", "row_id": 1024944, "text": " 5:02 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: Please assess for C-spine mets.\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with peritoneal carcinoma unknown primary, known L and\n T-spine mets, now with neck pain\n REASON FOR THIS EXAMINATION:\n Please assess for C-spine mets.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DSsd TUE 6:09 PM\n No evidence of C-spine metastatic disease. Tiny sclerotic focus in the medial\n left first rib.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with peritoneal carcinomatosis of unknown\n primary, with known L- and T-spine mets, now with neck pain. Please evaluate\n for cervical spine mets.\n\n COMPARISON: CT of the torso from .\n\n TECHNIQUE: Non-contrast CT of the cervical spine with multiplanar\n reformations.\n\n FINDINGS: There is no fracture or cervical spine malalignment. Prevertebral\n and paraspinal soft tissues are normal. Vertebral body and intervertebral\n disc space heights are normal.\n\n No abnormal lucent or sclerotic osseous lesion is seen within the cervical\n spine. There is a tiny sclerotic focus in the medial aspect of the left first\n rib (4, 13).\n\n Minimal multilevel degenerative changes are seen, with small facet\n osteophytes, but no significant neural foraminal narrowing. There are small\n posterior disc bulges at C3-C4 and C4-C5, but no significant central canal\n stenosis. Visualized outline of the thecal sac appears unremarkable, but\n please note that CT is unable to provide intrathecal detail comparable to MRI.\n\n IMPRESSION: A tiny sclerotic focus in the medial aspect of the left first\n rib, but otherwise no evidence of osseous metastatic disease within the\n cervical spine.\n\n\n" }, { "category": "Radiology", "chartdate": "2125-06-19 00:00:00.000", "description": "CT C-SPINE W/CONTRAST", "row_id": 1024945, "text": ", M. MED 5:02 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: Please assess for C-spine mets.\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with peritoneal carcinoma unknown primary, known L and\n T-spine mets, now with neck pain\n REASON FOR THIS EXAMINATION:\n Please assess for C-spine mets.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of C-spine metastatic disease. Tiny sclerotic focus in the medial\n left first rib.\n\n\n" }, { "category": "ECG", "chartdate": "2125-06-19 00:00:00.000", "description": "Report", "row_id": 134614, "text": "Sinus rhythm. No diagnostic abnormality.\n\n" }, { "category": "ECG", "chartdate": "2125-06-18 00:00:00.000", "description": "Report", "row_id": 134615, "text": "Sinus rhythm. Within normal limits.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2164-05-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 675219, "text": "TITLE:\n Chief Complaint: S/p RV lead replacement causing recurrent ICD firing\n HPI:\n 76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .\n On arrival to the CCU, VS were: T 97.1, HR 78, BP 141/63, RR 17, 100%\n Vent Mask. the patient is still very groggy under general anesthesia\n and has difficulty answering questions. She is, however, able to state\n that she has no chest pain, palpitations, shortness of breath, or\n lightheadedness. She does have some expected shoulder pain. At\n baseline, she gets short of breath with 1-2 flights of stairs. No PND.\n No LE edema at baseline. ROS is otherwise negative in detail.\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity ;\n Other ICU medications:\n Morphine Sulfate - 08:32 PM\n Home Meds:\n Omeprazole 10mg po bid\n ASA 81mg po daily\n Verapamil 240mg po daily\n 60mg po bid\n Rosuvastatin 10mg po daily\n Evista 50mg po daily\n Quinapril 10mg po bid\n Transfer Medications:\n Omeprazole 20 mg PO DAILY\n Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n Oxycodone-Acetaminophen 1 TAB PO Q6-8H:PRN pain\n Aspirin 81 mg PO DAILY\n Cephalexin 500 mg PO Q6H Duration: 7 Days Start \n Quinapril 10 mg PO BID\n Verapamil SR 240 mg PO Q24H\n Docusate Sodium 100 mg PO BID:PRN constipation\n Rosuvastatin Calcium 10 mg PO DAILY\n Evista *NF* 60 mg Oral daily\n Fexofenadine 60 mg PO BID:PRN allergies\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n Hypertension\n HOCM with ICD placed ( 2 V243 dual chamber ICD)\n Moderate MR\n H/o benign pulmonary nodules\n H/o appendectomy, hysterectomy and oopherectomy\n Father died of heart attack at age 80. Maternal uncle died in his teens\n of heart condition (unknown).\n Occupation: Lives alone in a seniors apartment.\n Drugs: -\n Tobacco: -\n Alcohol: -\n Review of systems:\n Flowsheet Data as of 08:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 78 (77 - 79) bpm\n BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,000 mL\n PO:\n TF:\n IVF:\n 2,000 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 100%\n Physical Examination\n Tmax: 36.2\nC (97.1\nF) Tcurrent: 36.2\nC (97.1\nF) HR: 78 (77 - 79)\n bpm BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19)\n GENERAL: elderly female in NAD. Oriented x1, sleepy, arouseable.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. Harsh early peaking systolic murmur loudest at\n LUSB.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Present by doppler BL in LE's; R and L UE's slight. All extremities\n WWP.\n Labs / Radiology\n CXR: IMPRESSION: No acute pulmonary process\n 212\n 10.8\n .6\n 22\n 23\n 110\n 4.3\n 142\n 32.7\n 8.7\n [image002.jpg]\n Assessment and Plan\n This is a 76 yo F with h/o HOCM, s/p ICD placement in , with RV\n fracture causing inappropriate firing, now s/p uncomplicated RV\n extraction and replacement, admitted to the CCU for post-procedure\n monitoring.\n .\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active.\n -- post-op pain control\n -- monitor for signs of bleeding\n -- f/u post-op CXR\n -- will get Keflex x 7 day course following procedure\n -- monitor on telemetry\n .\n # CORONARIES: No known CAD, but have HTN and HL as risk factors\n -- continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n .\n # HOCM, No history of fluid overload or need for diuretics.\n -- monitor volume status.\n -- consider outpt echo, none in our records.\n .\n # HTN\n -- continue Quinapril, Verapamil per outpatient regimen\n .\n # FEN:\n -- Cardiac HH regular diet.\n .\n # ACCESS: PIV's, will d/c aline\n .\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n .\n # CODE: FULL confirmed. Sisters are .\n .\n #DISPO: CCU for now. Anticipate fast turnover to floor.\n .\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675488, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .She underwent successful RV lead extraction and replacement via a R\n femoral vein approach on . A new RV lead and new ICD was placed.\n She was extubated without complication and was admitted to the CCU\n brief post-op monitoring.\n She was mildly nauseated overnight but this resolved in am. She\n ate well, and was up in the chair. Foley draining clear urine and urine\n output increased in the afternoon.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of mild pain at pacemaker incision site. When lying still she\n has only minimal discomfort. Area is eccymotic and the skin of breast\n is taute and tender.\n Action:\n Pt refused any medication at this point. She got up to the chair and\n tolerated it well. Arm kept in sling.\n Response:\n She is tolerating not having pain med. She sleeps when left alone.\n Plan:\n Use sling if pt finds it more comfortable. Offer pain med especially at\n bedtime. Assist pt with position changes.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt in NSR. She has rare PVCs and has had one 5 beat run of Vt and one\n short run of SVT. Over night she had short run of V-paced rhythm with a\n lower BP, but that resolved quickly.\n Action:\n Pt being monitored for rhythm changes. Pacemaker was interrogated and\n is working properly.\n Response:\n Pt stable in NSR with hr in 70s and rare ectopy.\n Plan:\n Continue to monitor for dysrhythmia.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Dsg soaked through with blood this am. Area lateral to incision site\n eccymotic. Area distal to wound on L breast taute and tender, though\n not discolored.Hematocrit this am 25.3 down from baseline 32. Urine\n output poor overnight with 250NS bolus given .\n Action:\n Repeat crit drawn and it was 23.8. She received 2u PRBCs this\n afternoon. Dsg was changed. I & O done Q1 hr.\n Response:\n Urine output increased in early afternoon and pt in now autodiuresing.\n Plan:\n Check crit and lytes this evening. Monitor dressing for further\n staining and re-inforce as necessary.\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675489, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .She underwent successful RV lead extraction and replacement via a R\n femoral vein approach on . A new RV lead and new ICD was placed.\n She was extubated without complication and was admitted to the CCU\n brief post-op monitoring.\n She was mildly nauseated overnight but this resolved in am. She\n ate well, and was up in the chair. Foley draining clear urine and urine\n output increased in the afternoon.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of mild pain at pacemaker incision site. When lying still she\n has only minimal discomfort. Area is eccymotic and the skin of breast\n is taute and tender.\n Action:\n Pt refused any medication at this point. She got up to the chair and\n tolerated it well. Arm kept in sling.\n Response:\n She is tolerating not having pain med. She sleeps when left alone.\n Plan:\n Use sling if pt finds it more comfortable. Offer pain med especially at\n bedtime. Assist pt with position changes.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt in NSR. She has rare PVCs and has had one 5 beat run of Vt and one\n short run of SVT. Over night she had short run of V-paced rhythm with a\n lower BP, but that resolved quickly.\n Action:\n Pt being monitored for rhythm changes. Pacemaker was interrogated and\n is working properly.\n Response:\n Pt stable in NSR with hr in 70s and rare ectopy.\n Plan:\n Continue to monitor for dysrhythmia.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Dsg soaked through with blood this am. Area lateral to incision site\n eccymotic. Area distal to wound on L breast taute and tender, though\n not discolored.Hematocrit this am 25.3 down from baseline 32. Urine\n output poor overnight with 250NS bolus given .\n Action:\n Repeat crit drawn and it was 23.8. She received 2u PRBCs this\n afternoon. Dsg was changed. I & O done Q1 hr.\n Response:\n Urine output increased in early afternoon and pt in now autodiuresing.\n Plan:\n Check crit and lytes this evening. Monitor dressing for further\n staining and re-inforce as necessary.\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675401, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o of mild pain at pacemaker incision site. When lying still she\n has only minimal discomfort. Area is eccymotic and the skin of breast\n is taute and tender.\n Action:\n Pt refused any medication at this point. She got up to the chair and\n tolerated it well. Arm kept in sling.\n Response:\n She is tolerating not having pain med. She sleeps when left alone.\n Plan:\n Use sling if pt finds it more comfortable. Offer pain med especially at\n bedtime. Assist pt with position changes.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt in NSR. She has rare PVCs and has had one 5 beat run of Vt and one\n short run of SVT. Over night she had short run of V-paced rhythm with a\n lower BP, but that resolved quickly.\n Action:\n Pt being monitored for rhythm changes. Pacemaker was interrogated and\n is working properly.\n Response:\n Pt stable in NSR with hr in 70s and rare ectopy.\n Plan:\n Continue to monitor for dysrhythmia.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Dsg soaked through with blood this am. Area lateral to incision site\n eccymotic. Area distal to wound on L breast taute and tender, though\n not discolored.Hematocrit this am 25.3 down from baseline 32. Urine\n output poor overnight with 250NS bolus given .\n Action:\n Repeat crit drawn and it was 23.8. She received 2u PRBCs this\n afternoon. Dsg was changed. I & O done Q1 hr.\n Response:\n Urine output increased in early afternoon and pt in now autodiuresing.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675395, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-05-05 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 675382, "text": "TITLE:\n Chief Complaint: S/p RV lead replacement causing recurrent ICD firing\n HPI:\n 76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .\n On arrival to the CCU, VS were: T 97.1, HR 78, BP 141/63, RR 17, 100%\n Vent Mask. the patient is still very groggy under general anesthesia\n and has difficulty answering questions. She is, however, able to state\n that she has no chest pain, palpitations, shortness of breath, or\n lightheadedness. She does have some expected shoulder pain. At\n baseline, she gets short of breath with 1-2 flights of stairs. No PND.\n No LE edema at baseline. ROS is otherwise negative in detail.\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity ;\n Other ICU medications:\n Morphine Sulfate - 08:32 PM\n Home Meds:\n Omeprazole 10mg po bid\n ASA 81mg po daily\n Verapamil 240mg po daily\n 60mg po bid\n Rosuvastatin 10mg po daily\n Evista 50mg po daily\n Quinapril 10mg po bid\n Transfer Medications:\n Omeprazole 20 mg PO DAILY\n Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n Oxycodone-Acetaminophen 1 TAB PO Q6-8H:PRN pain\n Aspirin 81 mg PO DAILY\n Cephalexin 500 mg PO Q6H Duration: 7 Days Start \n Quinapril 10 mg PO BID\n Verapamil SR 240 mg PO Q24H\n Docusate Sodium 100 mg PO BID:PRN constipation\n Rosuvastatin Calcium 10 mg PO DAILY\n Evista *NF* 60 mg Oral daily\n Fexofenadine 60 mg PO BID:PRN allergies\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n Hypertension\n HOCM with ICD placed ( 2 V243 dual chamber ICD)\n Moderate MR\n H/o benign pulmonary nodules\n H/o appendectomy, hysterectomy and oopherectomy\n Father died of heart attack at age 80. Maternal uncle died in his teens\n of heart condition (unknown).\n Occupation: Lives alone in a seniors apartment.\n Drugs: -\n Tobacco: -\n Alcohol: -\n Review of systems:\n Flowsheet Data as of 08:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 78 (77 - 79) bpm\n BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,000 mL\n PO:\n TF:\n IVF:\n 2,000 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 100%\n Physical Examination\n Tmax: 36.2\nC (97.1\nF) Tcurrent: 36.2\nC (97.1\nF) HR: 78 (77 - 79)\n bpm BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19)\n GENERAL: elderly female in NAD. Oriented x1, sleepy, arouseable.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. Harsh early peaking systolic murmur loudest at\n LUSB.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Present by doppler BL in LE's; R and L UE's slight. All extremities\n WWP.\n Labs / Radiology\n CXR: IMPRESSION: No acute pulmonary process\n 212\n 10.8\n .6\n 22\n 23\n 110\n 4.3\n 142\n 32.7\n 8.7\n [image002.jpg]\n Assessment and Plan\n This is a 76 yo F with h/o HOCM, s/p ICD placement in , with RV\n fracture causing inappropriate firing, now s/p uncomplicated RV\n extraction and replacement, admitted to the CCU for post-procedure\n monitoring.\n .\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active.\n -- post-op pain control\n -- monitor for signs of bleeding\n -- f/u post-op CXR\n -- will get Keflex x 7 day course following procedure\n -- monitor on telemetry\n .\n # CORONARIES: No known CAD, but have HTN and HL as risk factors\n -- continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n .\n # HOCM, No history of fluid overload or need for diuretics.\n -- monitor volume status.\n -- consider outpt echo, none in our records.\n .\n # HTN\n -- continue Quinapril, Verapamil per outpatient regimen\n .\n # FEN:\n -- Cardiac HH regular diet.\n .\n # ACCESS: PIV's, will d/c aline\n .\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n .\n # CODE: FULL confirmed. Sisters are .\n .\n #DISPO: CCU for now. Anticipate fast turnover to floor.\n .\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n I have reviewed the progress note by Dr. on . I\n agree with the events over the past 24 hours. I was present during the\n pertinent portions of the physical examination and agree with the\n findings noted above. The assessment and plans that is documented is\n consistent with our strategy over the next 24 hours. Mrs. \n has done well over the past 24 hours since the replacement of her RV\n lead. She has no chest pain or dyspnea. Her physical examination\n shows no evidence of heart failure and there are no apparent hemotomas\n due to access site complications. Her Hct has fallen to 23 likely\n secondary to a chest wall hematoma. We are providing blood products to\n support her Hct > 30. An echocardiogram this AM showed only a small\n pericardial effusion unchanged from the TEE in the OR. She has\n developed a potential pacemaker mediated tachycardia and we will\n interrogate the device this afternoon. All questions addressed with\n the patient. , MD .\n ------ Protected Section Addendum Entered By: , MD\n on: 14:03 ------\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675231, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt. s/p ICD placement in . underwent a successful lead extraction\n (due to fracture) and replacement of ICD on in OR. On arrival to\n CCU from OR pt. was lethargic but arousable. Left subclavian site\n intact with dressing, small amt of oozing on DSD. Left arm in sling to\n immobilze left arm. Extremity warm to touch, good CSM. C/O left\n shoulder discomfort. One episode of pacemaker mediated tachycardia\n with hr 105, abp 77/40, pt. asymptomatic (sleeping). Dr. \n aware. Pacer magnet outside of room if needed.\n Action:\n Left arm in sling as ordered, repositioned for comfort. Medicated for\n pain.\n Response:\n Pain relief from meds, more comfortable with left arm on pillow.\n Plan:\n Maintain left arm in sling, keep left arm activity to minimum. Monitor\n incision site for bleeding.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o pain in left shoulder due to pacer replacement. Good csm to left\n upper extremitiy.\n Action:\n Given morphine 2mg ivp x2 doses.\n Response:\n Gradual relief from pain.\n Plan:\n Cont to assess pacemaker insertion site, medicate for pain as needed.\n Reposition left arm on pillow for comfort.\n" }, { "category": "Nursing", "chartdate": "2164-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 675320, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .H/O cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-05-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675572, "text": "Chief Complaint:\n 24 Hour Events:\n \n - CXR 1V - No evidence of hemothorax or pneumothorax\n - TTE (to assess for pericardial effusion s/p pacer lead removal) -\n mild symmetric LVH; severe resting LVOT obstruction (>64mmHg); 2+ MR.\n - Hct trend since CCU admission: 33.3 > 25.3 > 23.8 (transfused 2\n units pRBCs) > 29.3\n - Taut left breast; no evidence of bleeding elsewhere, and patient is\n hemodynamically stable\n - Per EP recs, also ordered 2V; if stable, call out to 3 on\n ; antibiotics 7 days; follow-up in one week in device clinic\n - Per EP, on interrogation, atrial tachycardia overnight \n - K 3.8 at midnight, KCl 20mEq PO x1 given\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity\n Last dose of Antibiotics:\n Keflex - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.8\n HR: 88 (73 - 102) bpm\n BP: 150/63(85) {125/45(68) - 151/67(87)} mmHg\n RR: 27 (14 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,788 mL\n 240 mL\n PO:\n 960 mL\n 240 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 578 mL\n Total out:\n 1,830 mL\n 600 mL\n Urine:\n 1,830 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -42 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n GENERAL: elderly female in NAD. Oriented x1, sleepy, arouseable.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. Harsh early peaking systolic murmur loudest at\n LUSB.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Present by doppler BL in LE's; R and L UE's slight. All extremities\n WWP.\n Labs / Radiology\n 176 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.2 %\n 9.5 K/uL\n [image002.jpg]\n 05:03 AM\n 10:55 AM\n 10:31 PM\n 04:14 AM\n WBC\n 12.4\n 11.1\n 11.4\n 9.5\n Hct\n 25.3\n 23.8\n 29.3\n 30.2\n Plt\n 76\n Cr\n 0.6\n 0.6\n Glucose\n 113\n 110\n Other labs: PT / PTT / INR:13.3/39.8/1.1, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 76F with HOCM, s/p ICD placement in , with RV fracture causing\n inappropriate firing, now s/p uncomplicated RV extraction and\n replacement, admitted to the CCU for post-procedure monitoring.\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active.\n -- post-op pain control\n -- monitor for signs of bleeding\n -- f/u post-op CXR\n -- will get Keflex x 7 day course following procedure\n -- monitor on telemetry\n # CORONARIES: No known CAD, but have HTN and HL as risk factors\n -- continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n # HOCM, No history of fluid overload or need for diuretics.\n -- monitor volume status.\n -- consider outpt echo, none in our records.\n # HTN\n -- continue Quinapril, Verapamil per outpatient regimen\n # FEN:\n -- Cardiac HH regular diet.\n # ACCESS: PIV's, will d/c aline\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n # CODE: FULL confirmed. Sisters are .\n #DISPO: CCU for now. Anticipate fast turnover to floor.\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:45 PM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-05-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 675567, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Left shoulder ecchymotic, area around left breast tender to touch, skin\n taute. Pressure dressing D&I. received 2 units prbc yest afternoon,\n repeat hct last eve 29.3, am hct pending. Left radial pulse strong,\n good csm left arm.\n Action:\n Monitoring hct for s/s further bleeding\n Response:\n Left shoulder ecchymotic, no further s/s bleeding, dressing dry.\n Plan:\n Follow hct, monitor site for further bleeding.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n c/o left shoulder discomfort with activity, ie turning, getting in and\n out of bed,\n Action:\n Refused pain med at this time.\n Response:\n Pain subsides when pt. is at rest.\n Plan:\n Cont to offer emotional support, offer pain med frequently. Limit\n extensive use of left arm.\n .H/O cardiac dysrhythmia other\n Assessment:\n NSR hr 85, occ pac earlier in eve, now no ectopic beats noted. Bp\n 130-150/60\ns. K+ 3.8.\n Action:\n Repleted K with 20 meq kcl po. Foley d/c\n Response:\n No vent ectopy noted. Diuresing well.\n Plan:\n Cont to monitor rhythm, rate. Follow lytes and replete as needed.\n" }, { "category": "Physician ", "chartdate": "2164-05-04 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 675201, "text": "TITLE:\n Chief Complaint: S/p RV lead replacement causing recurrent ICD firing\n HPI:\n 76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via a\n sub-clavian approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU brief\n post-op monitoring.\n .\n On arrival to the CCU, VS were: T 97.1, HR 78, BP 141/63, RR 17, 100%\n Vent Mask. the patient is still very groggy under general anesthesia\n and has difficulty answering questions. She is, however, able to state\n that she has no chest pain, palpitations, shortness of breath, or\n lightheadedness. She does have some expected shoulder pain. At\n baseline, she gets short of breath with 1-2 flights of stairs. No PND.\n No LE edema at baseline. ROS is otherwise negative in detail.\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity ;\n Other ICU medications:\n Morphine Sulfate - 08:32 PM\n Home Meds:\n Omeprazole 10mg po bid\n ASA 81mg po daily\n Verapamil 240mg po daily\n 60mg po bid\n Rosuvastatin 10mg po daily\n Evista 50mg po daily\n Quinapril 10mg po bid\n Transfer Medications:\n Omeprazole 20 mg PO DAILY\n Acetaminophen 325-650 mg PO Q6H:PRN pain, fever\n Oxycodone-Acetaminophen 1 TAB PO Q6-8H:PRN pain\n Aspirin 81 mg PO DAILY\n Cephalexin 500 mg PO Q6H Duration: 7 Days Start \n Quinapril 10 mg PO BID\n Verapamil SR 240 mg PO Q24H\n Docusate Sodium 100 mg PO BID:PRN constipation\n Rosuvastatin Calcium 10 mg PO DAILY\n Evista *NF* 60 mg Oral daily\n Fexofenadine 60 mg PO BID:PRN allergies\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n Hypertension\n HOCM with ICD placed ( 2 V243 dual chamber ICD)\n Moderate MR\n H/o benign pulmonary nodules\n H/o appendectomy, hysterectomy and oopherectomy\n Father died of heart attack at age 80. Maternal uncle died in his teens\n of heart condition (unknown).\n Occupation: Lives alone in a seniors apartment.\n Drugs: -\n Tobacco: -\n Alcohol: -\n Review of systems:\n Flowsheet Data as of 08:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 78 (77 - 79) bpm\n BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,000 mL\n PO:\n TF:\n IVF:\n 2,000 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,500 mL\n Respiratory\n O2 Delivery Device: Venti mask\n SpO2: 100%\n Physical Examination\n Tmax: 36.2\nC (97.1\nF) Tcurrent: 36.2\nC (97.1\nF) HR: 78 (77 - 79)\n bpm BP: 141/63(94) {139/63(94) - 162/75(109)} mmHg\n RR: 13 (13 - 19)\n GENERAL: elderly female in NAD. Oriented x1, sleepy, arouseable.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of at clavicle.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. Harsh early peaking systolic murmur loudest at\n LUSB.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: Warm well perfused. No edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Present by doppler BL in LE's; R and L UE's slight. All extremities\n WWP.\n Labs / Radiology\n CXR: IMPRESSION: No acute pulmonary process\n 212\n 10.8\n .6\n 22\n 23\n 110\n 4.3\n 142\n 32.7\n 8.7\n [image002.jpg]\n Assessment and Plan\n This is a 76 yo F with h/o HOCM, s/p ICD placement in , with RV\n fracture causing inappropriate firing, now s/p uncomplicated RV\n extraction and replacement, admitted to the CCU for post-procedure\n monitoring.\n .\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active.\n -- post-op pain control\n -- monitor for signs of bleeding\n -- f/u post-op CXR\n -- will get Keflex x 7 day course following procedure\n -- monitor on telemetry\n .\n # CORONARIES: No known CAD, but have HTN and HL as risk factors\n -- continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n .\n # HOCM, No history of fluid overload or need for diuretics.\n -- monitor volume status.\n -- consider outpt echo, none in our records.\n .\n # HTN\n -- continue Quinapril, Verapamil per outpatient regimen\n .\n # FEN:\n -- Cardiac HH regular diet.\n .\n # ACCESS: PIV's, will d/c aline\n .\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n .\n # CODE: FULL confirmed. Sisters are .\n .\n #DISPO: CCU for now. Anticipate fast turnover to floor.\n .\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 675597, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .\n She underwent successful RV lead extraction and replacement via R\n femoral vein approach on . A new RV ICD was placed. She was\n extubated without complication and was admitted to the CCU post-op\n monitoring. Groin site stable and all pulses dopplerable. On she\n had crit drop top 23.8, oozing on the pacemaker insertion site. She has\n eccymosis lateral to the incision and her breast and skin distal to the\n wound is taute and tender. RESP: Lung sounds are decreased. She is\n sating 95-97% on RA. GI: Pt eating and drinking without problem. BM.\n RENAL: Foley out . MS: Pt A & O X 3. Teaching re-pacemaker on\n going.\n .H/O cardiac dysrhythmia other\n Assessment:\n Action:\n Response:\n Plan:\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2164-05-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675679, "text": "Chief Complaint:\n 24 Hour Events:\n \n - CXR 1V - No evidence of hemothorax or pneumothorax\n - TTE (to assess for pericardial effusion s/p pacer lead removal) -\n mild symmetric LVH; severe resting LVOT obstruction (>64mmHg); 2+ MR.\n - Hct trend since CCU admission: 33.3 > 25.3 > 23.8 (transfused 2\n units pRBCs) > 29.3\n - Taut left breast; no evidence of bleeding elsewhere, and patient is\n hemodynamically stable\n - Per EP recs, also ordered 2 units pRBCs; if stable, call out to \n 3 on ; antibiotics 7 days; follow-up in one week in device\n clinic\n - Per EP, on interrogation, atrial tachycardia overnight \n - K 3.8 at midnight, KCl 20mEq PO x1 given\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity\n Last dose of Antibiotics:\n Keflex - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:02 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n C/o left shoulder stiffness; bruising at left breast; no active\n bleeding; overall feels more energetic\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.8\n HR: 88 (73 - 102) bpm\n BP: 150/63(85) {125/45(68) - 151/67(87)} mmHg\n RR: 27 (14 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,788 mL\n 240 mL\n PO:\n 960 mL\n 240 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 578 mL\n Total out:\n 1,830 mL\n 600 mL\n Urine:\n 1,830 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -42 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n GENERAL: Sitting in chair, NAD, awake, alert\n HEENT: NC/AT; sclera anicteric; moist mucous membranes\n NECK: No JVD\n CARDIAC: RRR, normal S1/S2, II/VI early systolic murmur LUSB\n CHEST: Eccymoses at left breast, left arm\n LUNGS: Crackles left base, otherwise clear to auscultation bilaterally\n ABDOMEN: Soft, NTND\n EXTREMITIES: Warm, well-perfused; no lower extremity edema\n PULSES: Radial pulses 2+ and symmetric\n Labs / Radiology\n 176 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.2 %\n 9.5 K/uL\n [image002.jpg]\n 05:03 AM\n 10:55 AM\n 10:31 PM\n 04:14 AM\n WBC\n 12.4\n 11.1\n 11.4\n 9.5\n Hct\n 25.3\n 23.8\n 29.3\n 30.2\n Plt\n 76\n Cr\n 0.6\n 0.6\n Glucose\n 113\n 110\n Other labs: PT / PTT / INR:13.3/39.8/1.1, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 76F with HOCM, s/p ICD placement in , with RV fracture causing\n inappropriate firing, now s/p uncomplicated RV extraction and\n replacement, admitted to the CCU for post-procedure monitoring.\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active. Hemorrhaging in chest wall secondary to procedure; hematocrit\n now stable.\n - Monitor for signs of bleeding\n - CXR 2V per EP recs\n - Keflex x7 day course following procedure, currently day 2\n # CORONARIES: No known CAD, but has HTN and HL as risk factors\n - Continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n # HOCM: Currently slightly fluid overloaded. Expect patient to\n autodiurese. She is preload dependent so do not want to overdiurese.\n - Consider outpt echo, none in our records.\n # HTN: Blood pressure currently well-controlled.\n - Continue Quinapril, Verapamil per outpatient regimen\n # FEN:\n - Cardiac HH regular diet\n - Replete lytes as needed\n # ACCESS: PIV; arterial line discontinued\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n # CODE: FULL confirmed. Sisters are .\n #DISPO: To 3 today\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:45 PM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n I have reviewed the progress note by Dr. on . I agree\n with the events over the past 24 hours. I was present during the\n pertinent portions of the physical examination and agree with the\n findings noted above. The assessment and plans that is documented is\n consistent with our strategy over the next 24 hours. Mrs. \n has done well over the past 48hours since the replacement of her RV\n lead. She has no chest pain or dyspnea. Her physical examination\n shows no evidence of heart failure. She has a left chest wall hematoma\n due to chest wall hematoma. She received 2 U PRBCs but has had a\n stable HCT since. All questions addressed with the patient. \n , MD .\n ------ Protected Section Addendum Entered By: , MD\n on: 14:31 ------\n" }, { "category": "Physician ", "chartdate": "2164-05-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675648, "text": "Chief Complaint:\n 24 Hour Events:\n \n - CXR 1V - No evidence of hemothorax or pneumothorax\n - TTE (to assess for pericardial effusion s/p pacer lead removal) -\n mild symmetric LVH; severe resting LVOT obstruction (>64mmHg); 2+ MR.\n - Hct trend since CCU admission: 33.3 > 25.3 > 23.8 (transfused 2\n units pRBCs) > 29.3\n - Taut left breast; no evidence of bleeding elsewhere, and patient is\n hemodynamically stable\n - Per EP recs, also ordered 2 units pRBCs; if stable, call out to \n 3 on ; antibiotics 7 days; follow-up in one week in device\n clinic\n - Per EP, on interrogation, atrial tachycardia overnight \n - K 3.8 at midnight, KCl 20mEq PO x1 given\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity\n Last dose of Antibiotics:\n Keflex - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:02 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n C/o left shoulder stiffness; bruising at left breast; no active\n bleeding; overall feels more energetic\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.8\n HR: 88 (73 - 102) bpm\n BP: 150/63(85) {125/45(68) - 151/67(87)} mmHg\n RR: 27 (14 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,788 mL\n 240 mL\n PO:\n 960 mL\n 240 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 578 mL\n Total out:\n 1,830 mL\n 600 mL\n Urine:\n 1,830 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -42 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n GENERAL: Sitting in chair, NAD, awake, alert\n HEENT: NC/AT; sclera anicteric; moist mucous membranes\n NECK: No JVD\n CARDIAC: RRR, normal S1/S2, II/VI early systolic murmur LUSB\n CHEST: Eccymoses at left breast, left arm\n LUNGS: Crackles left base, otherwise clear to auscultation bilaterally\n ABDOMEN: Soft, NTND\n EXTREMITIES: Warm, well-perfused; no lower extremity edema\n PULSES: Radial pulses 2+ and symmetric\n Labs / Radiology\n 176 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.2 %\n 9.5 K/uL\n [image002.jpg]\n 05:03 AM\n 10:55 AM\n 10:31 PM\n 04:14 AM\n WBC\n 12.4\n 11.1\n 11.4\n 9.5\n Hct\n 25.3\n 23.8\n 29.3\n 30.2\n Plt\n 76\n Cr\n 0.6\n 0.6\n Glucose\n 113\n 110\n Other labs: PT / PTT / INR:13.3/39.8/1.1, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 76F with HOCM, s/p ICD placement in , with RV fracture causing\n inappropriate firing, now s/p uncomplicated RV extraction and\n replacement, admitted to the CCU for post-procedure monitoring.\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active. Hemorrhaging in chest wall secondary to procedure; hematocrit\n now stable.\n - Monitor for signs of bleeding\n - CXR 2V per EP recs\n - Keflex x7 day course following procedure, currently day 2\n # CORONARIES: No known CAD, but has HTN and HL as risk factors\n - Continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n # HOCM: Currently slightly fluid overloaded. Expect patient to\n autodiurese. She is preload dependent so do not want to overdiurese.\n - Consider outpt echo, none in our records.\n # HTN: Blood pressure currently well-controlled.\n - Continue Quinapril, Verapamil per outpatient regimen\n # FEN:\n - Cardiac HH regular diet\n - Replete lytes as needed\n # ACCESS: PIV; arterial line discontinued\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n # CODE: FULL confirmed. Sisters are .\n #DISPO: To 3 today\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:45 PM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2164-05-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 675649, "text": "Chief Complaint:\n 24 Hour Events:\n \n - CXR 1V - No evidence of hemothorax or pneumothorax\n - TTE (to assess for pericardial effusion s/p pacer lead removal) -\n mild symmetric LVH; severe resting LVOT obstruction (>64mmHg); 2+ MR.\n - Hct trend since CCU admission: 33.3 > 25.3 > 23.8 (transfused 2\n units pRBCs) > 29.3\n - Taut left breast; no evidence of bleeding elsewhere, and patient is\n hemodynamically stable\n - Per EP recs, also ordered 2 units pRBCs; if stable, call out to \n 3 on ; antibiotics 7 days; follow-up in one week in device\n clinic\n - Per EP, on interrogation, atrial tachycardia overnight \n - K 3.8 at midnight, KCl 20mEq PO x1 given\n Allergies:\n Valium (Oral) (Diazepam)\n hyperactivity\n Last dose of Antibiotics:\n Keflex - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:02 PM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n C/o left shoulder stiffness; bruising at left breast; no active\n bleeding; overall feels more energetic\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.8\n HR: 88 (73 - 102) bpm\n BP: 150/63(85) {125/45(68) - 151/67(87)} mmHg\n RR: 27 (14 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,788 mL\n 240 mL\n PO:\n 960 mL\n 240 mL\n TF:\n IVF:\n 250 mL\n Blood products:\n 578 mL\n Total out:\n 1,830 mL\n 600 mL\n Urine:\n 1,830 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -42 mL\n -360 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n GENERAL: Sitting in chair, NAD, awake, alert\n HEENT: NC/AT; sclera anicteric; moist mucous membranes\n NECK: No JVD\n CARDIAC: RRR, normal S1/S2, II/VI early systolic murmur LUSB\n CHEST: Eccymoses at left breast, left arm\n LUNGS: Crackles left base, otherwise clear to auscultation bilaterally\n ABDOMEN: Soft, NTND\n EXTREMITIES: Warm, well-perfused; no lower extremity edema\n PULSES: Radial pulses 2+ and symmetric\n Labs / Radiology\n 176 K/uL\n 10.2 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 12 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.2 %\n 9.5 K/uL\n [image002.jpg]\n 05:03 AM\n 10:55 AM\n 10:31 PM\n 04:14 AM\n WBC\n 12.4\n 11.1\n 11.4\n 9.5\n Hct\n 25.3\n 23.8\n 29.3\n 30.2\n Plt\n 76\n Cr\n 0.6\n 0.6\n Glucose\n 113\n 110\n Other labs: PT / PTT / INR:13.3/39.8/1.1, Ca++:8.1 mg/dL, Mg++:2.1\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 76F with HOCM, s/p ICD placement in , with RV fracture causing\n inappropriate firing, now s/p uncomplicated RV extraction and\n replacement, admitted to the CCU for post-procedure monitoring.\n # ICD s/p lead replacement: ICD was deactivated at OSH, new device is\n active. Hemorrhaging in chest wall secondary to procedure; hematocrit\n now stable.\n - Monitor for signs of bleeding\n - CXR 2V per EP recs\n - Keflex x7 day course following procedure, currently day 2\n # CORONARIES: No known CAD, but has HTN and HL as risk factors\n - Continue ASA, Crestor, Quinapril, Verapamil per outpatient regimen.\n # HOCM: Currently slightly fluid overloaded. Expect patient to\n autodiurese. She is preload dependent so do not want to overdiurese.\n - Consider outpt echo, none in our records.\n # HTN: Blood pressure currently well-controlled.\n - Continue Quinapril, Verapamil per outpatient regimen\n # FEN:\n - Cardiac HH regular diet\n - Replete lytes as needed\n # ACCESS: PIV; arterial line discontinued\n # PROPHYLAXIS:\n -- DVT ppx with heparin SQ\n -- Bowel regimen with Colace PRN consipation\n # CODE: FULL confirmed. Sisters are .\n #DISPO: To 3 today\n COMM: With patient\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 07:45 PM\n 22 Gauge - 08:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2164-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 675655, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .She underwent successful RV lead extraction and replacement via a R\n femoral vein approach on . A new RV lead and new ICD was placed.\n She was extubated without complication and was admitted to the CCU\n post-op monitoring.\n She was mildly nauseated overnight but this resolved in am. She\n had a crit drop to 23 (31) with eccyhmosis and swelling of peri-wound\n area. She was transfused with 2U PRBCs and had echo which showed no\n effusion. R groin site is dry with no ooze or hematoma and all pulses\n are dopplerable. She is back on all her cardiac meds and is tolerating\n them. . She is OOB to chair with no assist. She is in NSR with rare\n PVCs. She was KCL replaced today. She is eating and drinking without\n problem and had large BM. She has minimal pain and has not required\n analgesics. She is voiding on commode and is ~500cc neg for LOS. She\n will likely go home tomorrow. She needs PA/LAT in radiology today.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Dressing is dry and in tact. There is no staining on dsg. Area lateral\n and distal to pacer incision site is becoming more eccyhmotic. This am\n crit is 30.2. She is Hemodynamically stable, and moving around without\n problem\n Action:\n Supervised moving around room. Monitor dsg for staining and assess for\n increase in pain.\n Response:\n Pt remains comfortable with DSD.\n Plan:\n Monitor for renewed bleeding. ? crit in afternoon. PA/LAT this\n afternoon.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt with new pac\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2164-05-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 675657, "text": "76 year old woman with HOCM, s/p ICD implant in , moderate MR,\n hypertension, who was transferred to the Service on with ICD\n lead fracture requiring extraction. Her device had not caused her any\n problems up until , when her ICD spontaneously fired 20 times while\n having mother's day lunch. She felt well before and after these shocks.\n She presented to OSH.\n .\n While in the OSH ED, she had repeated ICD shocks while in NSR. The\n device was deactivated. Her device was interrogated at the OSH. She was\n transferred to on for lead extraction.\n .She underwent successful RV lead extraction and replacement via a R\n femoral vein approach on . A new RV lead and new ICD was placed.\n She was extubated without complication and was admitted to the CCU\n post-op monitoring.\n She was mildly nauseated overnight but this resolved in am. She\n had a crit drop to 23 (31) with eccyhmosis and swelling of peri-wound\n area. She was transfused with 2U PRBCs and had echo which showed no\n effusion. R groin site is dry with no ooze or hematoma and all pulses\n are dopplerable. She is back on all her cardiac meds and is tolerating\n them. . She is OOB to chair with no assist. She is in NSR with rare\n PVCs. She was KCL replaced today. She is eating and drinking without\n problem and had large BM. She has minimal pain and has not required\n analgesics. She is voiding on commode and is ~500cc neg for LOS. She\n will likely go home tomorrow. She needs PA/LAT in radiology today.\n Hemorrhage/hematoma, procedure-related (e.g., cath, pacemaker, ICD\n bleed)\n Assessment:\n Dressing is dry and in tact. There is no staining on dsg. Area lateral\n and distal to pacer incision site is becoming more eccyhmotic. This am\n crit is 30.2. She is Hemodynamically stable, and moving around without\n problem\n Action:\n Supervised moving around room. Monitor dsg for staining and assess for\n increase in pain.\n Response:\n Pt remains comfortable with DSD.\n Plan:\n Monitor for renewed bleeding. ? crit in afternoon. PA/LAT this\n afternoon.\n .H/O cardiac dysrhythmia other\n Assessment:\n Pt with new pacemaker and one new lead. She has rare PVCs and\n occasional short runs of SVT. No high grade ectopy.\n Action:\n She was KCL replaced. Pacer was interrogated yesterday and is working\n properly. She has documentation for new pacer with belongings.\n Response:\n She is hemodynamically stable with no high grade ectopy and no pacing\n at this point.\n Plan:\n Likely home tomorrow. PA/Lat this afternoon.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n FRACTURED ICD LEAD ICD LEAD EXTRACTION; LEAD IMPLANTATION\n Code status:\n Height:\n Admission weight:\n 70 kg\n Daily weight:\n Allergies/Reactions:\n Valium (Oral) (Diazepam)\n hyperactivity ;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CHF, Hypertension, Pacemaker\n Additional history: HOCM\n GERD\n Mod MR\n H/O appendectomy/hysterectomy/oopherectomy\n benign pulmonary nodules\n Surgery / Procedure and date: Successful RV lead extraction and\n ICD replacement via right femoral approach in OR.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:58\n Temperature:\n 97.8\n Arterial BP:\n S:122\n D:51\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 640 mL\n 24h total out:\n 1,220 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:14 AM\n Potassium:\n 3.5 mEq/L\n 04:14 AM\n Chloride:\n 111 mEq/L\n 04:14 AM\n CO2:\n 23 mEq/L\n 04:14 AM\n BUN:\n 12 mg/dL\n 04:14 AM\n Creatinine:\n 0.6 mg/dL\n 04:14 AM\n Glucose:\n 110 mg/dL\n 04:14 AM\n Hematocrit:\n 30.2 %\n 04:14 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Echo", "chartdate": "2164-05-05 00:00:00.000", "description": "Report", "row_id": 74259, "text": "PATIENT/TEST INFORMATION:\nIndication: Hypertrophic cardiomyopathy.\nHeight: (in) 64\nWeight (lb): 150\nBSA (m2): 1.73 m2\nBP (mm Hg): 103/58\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 11:45\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Hyperdynamic LVEF\n>75%. Severe resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. of mitral valve leaflets. Moderate (2+) MR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). There is valvular with a severe resting\nleft ventricular outflow tract obstruction (>64mmHg). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (?#)\nappear structurally normal with good leaflet excursion. No aortic\nregurgitation is seen.The mitral valve leaflets are mildly thickened. There is\nsystolic anterior motion of the mitral valve leaflets. At least moderate (2+)\nmitral regurgitation is seen. There is an anterior space which most likely\nrepresents a fat pad.\n\nIMPRESSION: Suboptimal image quality. Hypertrophic obstructive cardiomyopathy.\nAt least moderate mitral regurgitation.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-05-03 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1078522, "text": " 6:33 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: FRACTURED ICD LEAD\\ICD LEAD EXTRACTION; LEAD IMPLANTATION\n Admitting Diagnosis: FRACTURED ICD LEAD\\ICD LEAD EXTRACTION; LEAD IMPLANTATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with HOCM, planned for ICD extraction\n REASON FOR THIS EXAMINATION:\n please eval for effusions or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE PA AND LATERAL CHEST, AT 18:35 HOURS.\n\n HISTORY: Hypertrophic cardiomyopathy. Planned ICD extraction.\n\n COMPARISON: None.\n\n FINDINGS: Consistent with the given history, a dual-chamber pacemaker/AICD is\n noted in standard position from a left subclavian approach. Please note there\n is suggestion of more proximal migration of the defibrillator leads. Lungs\n are clear without consolidation or edema. There is a small hiatal hernia. No\n effusion or pneumothorax is noted. Mild degeneration is noted throughout the\n thoracic spine. There is atheromatous disease of the aorta. The cardiac\n silhouette is borderline enlarged.\n\n IMPRESSION: No acute pulmonary process. Incidental findings as above.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078724, "text": " 8:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX? leads location?\n Admitting Diagnosis: FRACTURED ICD LEAD\\ICD LEAD EXTRACTION; LEAD IMPLANTATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with HCM. s/p ICD lead extraction and new RV lead implant.\n REASON FOR THIS EXAMINATION:\n PTX? leads location?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED .\n\n COMPARISON: Study of .\n\n INDICATION: New right ventricular lead implant.\n\n FINDINGS: Permanent pacemaker is present with leads terminating overlying the\n expected locations of the right atrium and right ventricle with no evidence of\n pneumothorax. Heart is mildly enlarged, and lungs are remarkable for linear\n areas of atelectasis at the left base. Questionable very small left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-05-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1078783, "text": " 10:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval leads, r/o hemo/PTX\n Admitting Diagnosis: FRACTURED ICD LEAD\\ICD LEAD EXTRACTION; LEAD IMPLANTATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with new RV ICD lead\n REASON FOR THIS EXAMINATION:\n eval leads, r/o hemo/PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: New right ventricular ICD lead.\n\n ICD leads overlie the expected locations of the right atrium and right\n ventricle with no evidence of pneumothorax. Minor atelectasis persists at\n left base and there is a questionable small left effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2164-05-05 00:00:00.000", "description": "Report", "row_id": 178354, "text": "Sinus rhythm. Possible left atrial abnormality. Modest lateral ST-T wave\nchanges which are non-specific. Compared to the previous tracing of \nthere is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2164-05-04 00:00:00.000", "description": "Report", "row_id": 178355, "text": "Sinus rhythm. Left atrial abnormality. Non-specific lateral ST-T wavea\nchanges. Atrial premature beat. No previous tracing available for comparison.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-05-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1078917, "text": " 1:40 PM\n CHEST (PA & LAT) Clip # \n Reason: Interval change\n Admitting Diagnosis: FRACTURED ICD LEAD\\ICD LEAD EXTRACTION; LEAD IMPLANTATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old female with recent lead fracture, s/p repair\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of recent rib fracture and repair.\n\n The heart size is top normal. Mediastinal position, contour and width are\n unremarkable. The pacemaker leads terminate in right atrium and right\n ventricle, unchanged in appearance since the prior study. Within the\n limitations of this study technique, no break within the leads was\n demonstrated. Lungs are essentially clear except for right basilar opacities\n that might represent an area of atelectasis, although attention to this area\n should be paid to exclude developing infection. Left basal linear atelectasis\n is new.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2153-12-05 00:00:00.000", "description": "Report", "row_id": 208952, "text": "Sinus rhythm upper normal rate\nShort P-R interval\nEarly R wave progression\nConsider left ventricular hypertrophy\nST-T wave abnormalities\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2153-12-06 00:00:00.000", "description": "Report", "row_id": 1432627, "text": "NPN 7P-7a\nSee carevue for specifics:\nA&Ox2-3 with periods of confusion, follow commands inconsistantly, appears to be more alert when family members present. , denies pain, SBP 80s-low 100s, HR 70-80s NSR, LCTA, spo2 95-100% on 2L. Uneventful noc, slept most of the shift, easily arousable. No obivous sz activity noted. Am Labs drawn K+2.9 currently repletely.\nA/P-Stable, monitor lytes, assess pain level offer prns, monitor neuro status, ? to for radiatin/chemo today. Provide emotional support.\n" }, { "category": "Radiology", "chartdate": "2153-12-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934951, "text": " 9:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 61 year old man with MS changes, melanoma, on steroids with\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MS changes, melanoma, on steroids with elev wbc ct and\n low grade temp - please perform repeat CXR on 12 hrs after last CXR to\n look for interval change, development of ?infiltrate\n REASON FOR THIS EXAMINATION:\n 61 year old man with MS changes, melanoma, on steroids with elev wbc ct and low\n grade temp - please perform repeat CXR on 12 hrs after last CXR to look\n for interval change, development of ?infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:12 A.M., \n\n HISTORY: Mental status changes, melanoma, elevated white count, and low-grade\n fever.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are low in volume, but clear. The heart is normal size. Mild\n dilatation of the mediastinal veins could be due to elevated central venous\n pressure, but there is no other evidence of cardiac decompensation. Tip of\n the right supraclavicular infusion port projects over the junction of the\n brachiocephalic veins. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-12-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 935069, "text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, possible aspiration risk\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MS changes, melanoma, on steroids with elev wbc ct and\n low grade temp - please perform repeat CXR on 12 hrs after last CXR to\n look for interval change, development of ?infiltrate\n REASON FOR THIS EXAMINATION:\n interval change, possible aspiration risk\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fevers and aspiration.\n\n Portable AP chest radiograph compared to done at 10:12 a.m.\n\n The heart size is slightly enlarged but normal. The mediastinal contours are\n unremarkable. The tip of the right Port-A-Cath catheter is in mid SVC. The\n lungs are clear except for small areas of discoid atelectasis in both bases.\n There is no crackle or pleural effusion.\n\n IMPRESSION: Bibasilar atelectasis. No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-12-07 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 935302, "text": " 12:14 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evaluate for aspiration\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with metastatic melanoma to brain\n REASON FOR THIS EXAMINATION:\n evaluate for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of metastatic melanoma. Evaluate for aspiration.\n\n VIDEO OROPHARYNGEAL SWALLOW: The study was performed in conjunction with the\n speech pathology staff. Fluoroscopic guidance was provided while various\n consistencies of barium were administered. Aspiration with thin consistency\n was noted. There was prolonged chewing of solids that had to be washed down\n with thin consistency to be cleared from the oropharynx. There is no\n aspiration with nectar consistency.\n\n IMPRESSION: Aspiration of thin consistency. For further recommendations,\n please consult the speech pathology note available on CareWeb.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-12-05 00:00:00.000", "description": "Report", "row_id": 1432625, "text": "NURSING ADMISSION AND PROGRESS NOTE\nNURSING ADMISSION AND PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA/TRENDS.\n\nADMISSION HX:\n\n61 Y/O MALE WITH PMH METASTATIC MELANOMA, HTN, ANEMIA, DEPPRESSION, HYPERLIPDEMIA AND KIDNEY STONES. PT WOKE UP \"VERY GROGGY\" MORNING OF . 1:30 PM ON WIFE A PROLONGED SZ LASTING APPROX 20-25 MINUTES. RIGHT HAND AND LEFT LEG SHAKING. AFTER EVENT PT LETHARGIC AND VOMITTED. PT TRANSPORTED TO OSH. CT SCAN REVEALED \"SLIGHTLY\" INCREASED EDEMA AND HEMORRHAGE IN AREA OF KNOWN HEMORRHAGIC MET (R-FRONTAL LOBE). PT TRANSPORTED TO FOR FUTHER WORK-UP.\n\nNEURO: LETHARGIC. EASILY AROUSABLE. INCONSISITENTLY FOLLOWS COMMANDS. PERRL. SIGNIFICANT L-FACIAL FACIAL DROOP. LUE +LLE WEAKER THAN RUE+ RLE. TONGUE AND PALATE APPEAR MIDLINE. +WEAK COUGH. DENIES PAIN.\n\nCARDIAC: HCT: BLE WITH +1 PITTING ITTING EDEMA. STABLE. NSR-ST. HR: 90S TO LOW 100S. SBP: 1100'S-120'S/60'S. +RADIAL,FEMORAL,POPITEAL,PT AND DP X2. CLS ON.\n\nPULM: 3L NC. POX: 96-100%. LS: R+LUL CLEAR, DIMINISHED BIBASILAR. NO COUGH NOTED.\n\nGI:POSSIBLE NPO-QUESTION ASPIRATION PNA. ABD:S, +BSX4,S,NT. NO BM.\n\nGU: FOLEY WITH MARGINAL HUO. MD AWARE. K-3.1 AND MAG 1.4 REPLETED. UA +C+S SENT.\n\nENDO: FS QIS COVERAGE PER RISS. BS: 158.\n\nID: T-MAX: 101.2,650MG TYLENOL GIVEN WITH EFFECT. PT IN ED. STARTED ON FLAGYL AND ZOSYN QUESTION ASPIRATION PNA.\n\nIVL: R-CHECT PORTA CATH AND RH PIV. BOTH SITES WNL AND DRESSINGS INTACT.\n\nSOCIAL WIFE AND SISTER IN TO VISIT. UPDATED REGARDING POC. EMOTIONAL SUPPORT PROVIDED. PLAN TO VIST ON .\n\nPLAN: Q 2 HOUR NEURO CHECKS. CLOSELY MONITOR FOR FURTHER SEZIURE ACTIVITY. WBXRT TODAY IF PT ABLE TO TOLERATE. PULM HYGIENE. TITRATE SUPPLEMENTAL OXYGEN AS TOLERATED. SURVAILLENCE LABS PRN. PAIN MANGEMENT. POSSIBLE NPO D/T QUESTION OF ASPIRATION PNA. REPOSITION Q 2. PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY. SOCIALWORK CONSULT.\n" }, { "category": "Nursing/other", "chartdate": "2153-12-05 00:00:00.000", "description": "Report", "row_id": 1432626, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n NEURO: PT W/GARBLED, SOFT SPEECH, A&O X2, ABLE TO MAKE NEEDS KNOWN TO FAMILY & STAFF. PERRL, 2-3MM, SLUGGISH. FOLLOWS COMMANDS CONSISTENTLY, MAES, W/LEFT SIDED WEAKNESS, LUE>LLE. NO C/O PAIN, NO SEIZURE ACT NOTED, DILANTIN GIVEN, ATIVAN GIVEN. ON DECADRON. PT TO START RADIATION THERAPY AM.\n\n CVS: HR 70S-80S, NSR, SBP 90S-110S, AFEBRILE. PALP PP, BLE EDEMA. BLD CX POS FOR AEROBIC NEG RODS PER MICRO LAB. PORT-A-CATH PATENT.\n\n RESP: 3L N/C, O2 SATS 97-99%, LUNGS CLEAR, DIMINISHED AT BASES. IMPAIRED GAG/COUGH, POOR SWALLOWING ABILITY W/PILLS, ? ASPIRATION W/MEDS-DR. AWARE.\n\n GI/GU: NPO EXCEPT MEDS, +BS/FLATUS, NO BM. HRLY U/O>=30CC, HO AWARE.\n\n INTEG: PT TURNED FREQUENTLY, SKIN W/D/I\n\n ENDO: BS COVERED PER RISS\n\n PLAN: PT TO RECEIVE RADIATION TX ON . NEEDS TRANSFER TO EAST TO NOC R/T RN UNABLE TO STAY W/PT ON EAST DURING TX-DR. /NSG AWARE, WILL F/U. NPO, ?NGT R/T ASPIRATION RISK/PROCEDURE. FREQUENT NEURO CHECKS, MONITOR FOR SEIZURE ACTIVITY. PAIN MGMT, FAMILY SUPPORT.\n" }, { "category": "Radiology", "chartdate": "2153-12-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 934906, "text": " 10:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVal of ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with known brain mets and increasing bleed from OSH\n REASON FOR THIS EXAMINATION:\n EVal of ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb TUE 11:12 PM\n 1. Area of white matter edema, soft tissue mass, and acute on chronic\n hemorrhage in the right frontal lobe.\n 2. Smaller area of likely white matter edema and hemorrhage in the left\n frontoparietal lobe.\n 3. Areas of low attenuation adjacent to the left frontal and in the left\n internal capsule and basal ganglia may be areas of lacunar infarction or edema\n from metastases.\n\n Assessment of interval change in hemorrhage cannot be made without prior\n studies. MR would be more sensitive in assessing extent of\n metastatic disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with known brain metastases and \"increasing\n bleeding\" from outside hospital, evaluate intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: Within the right frontal lobe, there is a large\n area of low-attenuation within the white matter, consistent with vasogenic\n edema. Additionally, there are areas of increased attenuation (series 2, image\n 23) and a larger area, which demonstrates layering of blood within a\n surrounding area of low attenuation, suggesting acute-on-chronic hemorrhage.\n There is associated sulcal effacement within the right frontal lobe,\n consistent with some associated mass effect. Adjacent to this area, there is\n a prominent soft tissue component (series 2, image 18), which may correspond\n to one of the patient's known metastatic lesions.\n\n There are areas of low-attenuation adjacent to the frontal of the left\n lateral ventricle, which may represent areas of infarction or associated white\n matter edema. No other definite focal mass lesions are identified. Within\n the posterior right frontal lobe, (series 2, image 20), there is an area of\n low-attenuation with a tiny peripheral margin of increased density, which may\n represent another focus of more acute hemorrhage. There is no shift of\n normally midline structures. Basal cisterns are patent. No definite areas of\n intracranial hemorrhage or mass effect identified within the temporal lobes or\n the posterior fossa, though there is limited evaluation due to streak\n artifact.\n\n There are post-surgical changes overlying the area of abnormality within the\n (Over)\n\n 10:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVal of ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right temporal region. No soft tissue abnormality is seen. No sclerotic or\n lytic osseous lesion is identified. The visualized portions of the paranasal\n sinuses are well aerated.\n\n IMPRESSION:\n 1. There are areas of low attenuation consistent with edema, predominantly\n within the right frontal lobe. Additionally, there are areas of focal\n hemorrhage, some of which appears to be acute-on-chronic in that area, with\n probable soft tissue mass lesion as well. There is a second area of low\n attenuation and probable hemorrhage within the left frontoparietal region.\n 2. Several areas of low attenuation adjacent to the left frontal , and\n within the left internal capsule and basal ganglia likely represent additional\n foci of vasogenic edema or, less likely, infarction. No definite mass lesions\n are identified in these areas.\n 3. Obviously, ithout prior (outside) studies for comparison, the evolution of\n hemorrhage or edema cannot be assessed. Further characterization with enhanced\n MRI would be helpful in identifying the extent of metastatic disease, as well\n as associated edema and hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2153-12-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 934904, "text": " 10:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with MS changes. BS on right\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old man with mental status changes.\n\n CHEST AP: There are low lung volumes on the exam. Accounting for this, the\n cardiac, mediastinal, and hilar contours are within normal limits. Pulmonary\n vasculature is unremarkable. The lungs are clear. No pleural effusions are\n identified. A right IJ Port-A-Cath is noted with the tip in the SVC. Osseous\n and soft tissue structures are unremarkable.\n\n IMPRESSION: Accounting for low lung volumes on the exam, no acute\n cardiopulmonary process is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-12-07 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 935369, "text": " 9:36 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate for abdominal mets, pancreatitis\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Field of view: 37 Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with elevated amylase\n REASON FOR THIS EXAMINATION:\n evaluate for abdominal mets, pancreatitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old man with elevated amylase.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n without and with IV contrast. 100 cc Optiray. Oral contrast was also\n administered. Coronal and sagittal reformatted images were obtained.\n\n CT ABDOMEN: There is mild dependent atelectasis. No focal hepatic lesions\n are identified. Decreased attenuation along the falciform ligament is likely\n related to fatty replacement. Stones are noted in the nondistended\n gallbladder. There is a 4.1 x 3.2 cm mass within the body of the pancreas.\n The distal pancreas is atrophic. Superior to this is an adjacent 6.2 x 5.5 cm\n lobulated mass. The adrenal glands, kidneys, stomach, and bowel loops are\n unremarkable. There are bilateral renal cysts and additional low attenuation\n foci which may represent cysts but are too small to be fully characterized.\n There is no free air or free fluid. An IVC filter is noted.\n\n CT PELVIS: Foley catheter and air are noted in the bladder. The prostate,\n seminal vesicles, sigmoid colon, and rectum are unremarkable. There is no\n free fluid and no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Large mass arising from the body of the pancreas with atrophy of the\n pancreatic tail. There is an adjacent large lobulated mass, which likely\n represents consolidative lymphadenopathy. These findings are most consistent\n with metastatic melanoma. A primary pancreatic neoplasm is less likely.\n\n 2. Cholelithiasis without evidence of cholecystitis.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2102-01-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 947140, "text": " 8:01 PM\n PORTABLE ABDOMEN Clip # \n Reason: Confirm placement of NG tube\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR recent NG tube placement\n REASON FOR THIS EXAMINATION:\n Confirm placement of NG tube\n ______________________________________________________________________________\n FINAL REPORT\n AP UPPER ABDOMEN 8:09 P.M. \n\n HISTORY: AVR. NG tube placement.\n\n IMPRESSION: AP view of the torso centered at the diaphragm shows a feeding\n tube with a wire stylet in place ending in the upper stomach. Pigtail\n catheter ends in the midline abdomen, unchanged in position. Contrast \n is present in nondilated upper abdominal loops, including the splenic flexure.\n There is no free subdiaphragmatic air demonstrated on the supine view. At\n least a small right pleural effusion is present unchanged and there is\n persistent consolidation at the base of the left lower lobe. Heart is\n moderately enlarged. Three epicardial leads emanate from an upper abdominal\n pacemaker, but cannot be traced continuously probably because of technical\n limitations of the study.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-03 00:00:00.000", "description": "Report", "row_id": 1536428, "text": "Respiratory CAre\nPt remains intubated on ventilatory support. Suction for brownand blood tinged thick secretions. BS coarse but clear after Sx. Fair aeration decreased at bases. ABGs with very slight metabolic acidosis good oxygenation on 10 of peep. No vent setting changes this shift. No AM due to peep requirements. No plan to wean from ventilator at this time.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-03 00:00:00.000", "description": "Report", "row_id": 1536429, "text": "Neuro: sedated on propofol, minimal movement of extremities with repositioning or to pain, + gag\nResp: per Flow Sheet, LS coarse throughout and diminished at bases, suctioning thick brown sometimes bloody sputum\nCardiac: SR, no ectopy noted, labs pending\nGI: TF at goal, minimal residual noted, + placement via air bolus test\nGU: foley to gravity draining 10 to 30 cc/hr, team aware\nEndo: SSRI per \nSocial: no calls, no visitor's\nSkin: bilat abrasion on buttocks slightly worse than \nPlan: continue to monitor labs and vitals and treat as indicated and as ordered, VAP protocol, frequent position changes and suction ETT PRN, ? trach and PEG, ? OR Thursday for valve\n" }, { "category": "Nursing/other", "chartdate": "2102-01-04 00:00:00.000", "description": "Report", "row_id": 1536434, "text": "Nursing progress note\nNeuro: not fully awoke this shift, daily wake up done on days. lightly sedated on 20 of propofol. Bilateral soft wrist restraints to protect lines tubes and drains. Strong gag and , 3 brisk. no command following. multipodus boots to prevent foot drop. Primary language is Spanish.\n\nCVS: hr 60's sr with r bbb, see ekg and rythm strip in chart. SBP > 100 via fem art line, no iv agents. R AC picc x 2 lumen patent. Afebrile. Skin warm and dry. Sloughing buttocks and calves continue bilaterally. Pulses palp x 4 ext. On sc heparin and csl on. EKG changes reported and observed by pa , no new orders at that time. Air bed for skin care issues.\n\nResp: LS clear in uppers to dim at bases. >300 cc straw dumping from right chest pig tail while turning. Sats 100, see RT notes. ETT retied on evening shift. Forceful , copious oral secretions, small tan to blood tinged ett secretions.\n\nGI: abd firm, non tender, bs present. No bm no flatus. Brown to green bilious secretions out of t-tube to bulb suction.\n\nGU: Foley cath draining cloudy yellow in scant amounts.\n\nEndo: FS BS not requiring ssri coverage at this time.\n\nPain: no apparent.\n\nSocial: no family contact this shift.\n\nPlan: possible or on thursday, awaiting renal recommendations. Monitor per orders and csru standards.\n\nSee flow sheets and mars for further details and values.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-05 00:00:00.000", "description": "Report", "row_id": 1536441, "text": "See and Carevue for detailed documentation\nNeuro: Rec'd from OR with Pupils 4mm, nonreactive. Through shift remained 4-5mm ? R pupils minimal reaction, sluggish. Patient opened eyes to noxious stim, strong . Remains on low dose propofol. Received standing methadone. Patient with minimal change in VS with stim, sedated.\n\nResp: Rec'd from OR with SAT 88 on 100% FiO2 with a resp acidosis, rate increased with improvement. BS coarse, diminished in bases. Suctioned for small amounts thick plugs. MDIs given. Start PRBC tx without improvement in SAT. Recruitment maneuvers with increase PEEP to 18 with improvement in SAT. Metabolic acidosis improved with PRBC tx. PaO2 remained 80's on 100%, remains on 100% with PEEP. 18. Contact precautions for stentrophonanas in sputum.\n\nCV: Patient with new internal pacer with Ademand, vpaced with rate 70. Patient also with epicardial wires, no apacing, vwires not tested. Old temporary pacer in place-> off. BP initially stable 90-110/50. Rec'd on epi, milrinone, vasopressin. Epi weaned down slowly with stable CO/CI , CI >4. Patient coughing, increase PIP to 50 with drop in BP. Increase epi slightly, increase vasopressin with slow recovery. MV SAT remained 70 thruout. Calcium bolus given. CVVH start with calcium and potassium repletion per protocol. Fluid removal stopped with hypotension.\nOozing at IV sites, dressing reinforced. PICC/ RIJ removed for infection control. CT with 250ml out postop.\n\nGI: OGT to LWS, tube advanced as per xray.\n\nGU: Foley to gravity without urine output. CVVHD started\n\nEndo: RSSI per protocol, none required.\n\nPlan: COntinue cardiopulmonary monitoring. Titrate for BP effect, wean off epi if CO/CI tolerate. Continue vent support. Titrate sedation as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-03 00:00:00.000", "description": "Report", "row_id": 1536430, "text": "NPN: 7a-12n\n\nNeuro: Sedated with prop 30-decreased to 20-light-easily awakens and thrashing with stimulation. Does not follow commands. MAE. Multipodus boots and pneumoboots on.\nCV: 60's SR with BBB, no VEA. K 5.1-4.8. BP 100-110's/30-40's by L fem aline. Palp pedal pulses.\nResp: Lungs coarse and dim. Ventilated on CMV/50%/500/18/10PEEP with RR 20-22. pO2 low 69 in am. Sxn-bloody/small clots secretions. R post pigtail with serous secretions.\nID: T 98.2, Vanco on hold-level 26.4. Gent to be redosed.\nGU: Foley-UO 3-15cc/hr. Cr ^ 3. Renal consult done-awaiting recs. UA and urine lytes sent.\nGI: Abd soft, NT. TF's probalance at 70cc/hr-no residuals. Nutrition following. Bili tube to JP-bilious dng.\nEndo: Glucoses 94-101. No coverage needed.\nSkin: Abrasions to bilateral buttocks-Aloe vesta applied. Cont on kinair bed. Dressings intact to R pigtail and bili tube.\nComfort: Sedated with prop-agitated with stimulation. Remains on methadone for drug h/o.\nActivity: Bedrest-turned side to side with 2 assists-frquently with agitation moves self back to back.\nSocial: Social service- assisting mother with housing and translation.\nA: Rising creat with low UO-awaiting renal input\nP: Renal input, ID following, Send gent level at 1530 today. Cont on CMV-keep light but not agitated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-03 00:00:00.000", "description": "Report", "row_id": 1536431, "text": "Respiratory care: Pt reamins intubated and vented on AC mode. Needed to increse PEEP to 12 per ABG. Breath sounds slightly coarse that cleared with suctioning. Suctioned for thick brown/blood tinged secretions. MDIs given as ordered. will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-03 00:00:00.000", "description": "Report", "row_id": 1536432, "text": "NEURO: Sedated on Prop at 20mcg, MAE when awake, restraints in place, Pt has strong cough, + Gag\n\nRESP: On CMV, PEEP increased to 12 after ABGs showed metabolic acidosis with base excess of -13, repeat ABGs shows improvement (see carevue), Sats in 99%, lung sounds clear at apices/dim at bases, suctioned for mod-copious amounts of blood-tinged/thick secretions, CTs has serous drainage\n\nCV: NSR with HRs in 60-70s, had an episode of freq PVCs with subsequent drop in SBP to 90s, treated with 250mL NS bolus/2 amps of bicarb, currently in SR with widened QRS, pedal pulses palpable\n\nGI/GU: OGT to feeding, plan to change TF to Nutren renal, TF residuals about 20cc, no BM today; Foley in place draining yellow/sediment urine at about 5-10mL/hr, BUN/Creat (2.6/60), renal consulted, ?plan for dialysis, metabolic acidosis as mentioned before, K/Phos was elevated, started aluminum hydroxide, Ca of 0.89 repleted with 2 grams calcium gluconate\n\nENDO: Continues on SSRI\n\nID: Afebrile, Vanco level was 26 today, held vanco dose, pending Genta level, if >2.0 please hold 0400 Genta dose, Bactrim freq changed\n\nSOCIAL: Mother visited Pt today. Phone call from family from . Updated both about Pt status.\n\nPLAN: Continue to monitor resp, hemodynamics, renal function, LABS, replete lytes as necessary, ?change TF\n" }, { "category": "Nursing/other", "chartdate": "2102-01-04 00:00:00.000", "description": "Report", "row_id": 1536433, "text": "Nursing progress note\nat 0305 pt woke coughing violently, bronchospastic. head and chest off of bed. HR 57 SB, SBP 79. Suctioned for thick tan and blood tinged secretions. Lethargic, propofol held, LR 250 bolus. SBP improved, pt woke very aggitated resedated to same dose 20 mcg/kg. Continue current plans.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 1536442, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Attempted to decrease FiO2 to 80% and pt. PaO2=69. Remains on 100%, 18 peep. Fluid overload. Left chest tube placed by MD for small pneumothorax. Patient very agitated and awake at times along w/ hypotension making for difficult balance for sedation. Recruitment manuver performed when SaO2 decreased 86% with moderate affect-SaO2 came up to 91-92%. Sxn for thick tan secretions with some plugs. Plan to decrease FiO2 when/if tolerates.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2102-01-08 00:00:00.000", "description": "Report", "row_id": 1536453, "text": "Neuro: Cont on nimbex and ativan. Pt with mouth movment and slight eye opening with painful stimuli, no with sx so no change in nimbex. Perrla, (? how well sedated) Bp will go up with stimulation. Mso4 x2 for pain and cont on po methadone\nCV: hr 74-76, av paced via permenament pacer. SBP 95-105 most of shift, lower now with sbp 84-90, maps>60 on vasopressin 2.4 units/hr. Dr. aware accepting maps>60. palp pedal pulses. ct dry. no leak noted. PAD 25-30, cvp 15-20. Heparin dc'd from cvvhd due to lowering plt count. HIT sent and pending.\nResp: sats 89-94% ( more ~90% since 1600) no vent mode changes made but Fio2 weaned to 60%, Accepting po2s >60. acid base balanced. sx thick tan. Very slow recovery with sx and turning. Lungs dim at bases lt >rt\nGi: TF FS nutren increased to 35cc/hr which is goal, residulas 50-100cc. Dulcolox supp given with small smear of stool. Abd slightly distended but soft. hypoactive bs.\nGu: Cont on CVVHD, this am running pt 75-100cc negative and hour, this pm with lower BP goal to keep pt even or as negative as possible without needing extra pressors. Pt still postive for day. CVVHd filter right at change of shift and running well throughout day. KCL/Ca gluc gtt runnning per sliding scale. Foley patent UOP<200 cc for day.\nEndo: Bs wnl see flowsheet\nSocial: Mother into visit this am with interperter. Appropriate questions asked and answered.\nID: Tmax 99 while on cvvhd. Sputum cx sent this am per ID request . Gent and vanco held this am due to high levels, recheck in am.\nPlan: cont wean o2 as tolerated. COnt cvvhd per current orders, run pt as negative as possible or at least even in order to maintain MAP>60\n" }, { "category": "Nursing/other", "chartdate": "2102-01-08 00:00:00.000", "description": "Report", "row_id": 1536454, "text": "Addendum: Pt cont to be hypotensive with SBP 80's, filling pressures unchanged as well as co/ci. Dr. no want to increase pressors. Lactate also up to 5 (from 3)--no treatment ordered per dr. . sats 90-91%, with PO@ just 61, no change ordered--continue current plan\n" }, { "category": "Nursing/other", "chartdate": "2102-01-09 00:00:00.000", "description": "Report", "row_id": 1536455, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on full ventilatory support. We increased FIO2 from 60 to 70%. BS are dim t/o bil clear. We are sxtn mod amt thick tan secretions from ETT. ETT retaped & ratated this morning. Plan: Wean as tol & Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-04 00:00:00.000", "description": "Report", "row_id": 1536435, "text": "Resp Care: Pt continues on AC 500x18 50%+10. Pt overbreathing vent by 2-4bpm. LS diminished bilaterally. Sxn'd small to moderate amounts of thick tan/bloody secretions. ABG this am: 7.37/33/111/20/-4/97%. MDI's given MD order. PLAN: continue vent support, wean PEEP as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 1536444, "text": "Resp. care note - Pt. remaines intubated and vented, esophygeal balloon placed, mult. changes made, pt. suctioned for bloody secritiones.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 1536445, "text": "bleeding from left pl ct\nD: a \" pool of blood\" was noted at pt left side- upon inspection noted to be coming from left pl ct site- pt appeared to have a \"cut down for this tube--4 sutures noted. inc line ozzing bright red blood.\npt had receieved 1 unit pc for am hct 26.8.\nA: hct re-checked- ct drsg -done-with \"pressure\"\nR: felt to be a superficial ozz- no futher bleeding noted from this site. min amt of sang drainage noted from left pl ct.\nre-peat hct 26.9-\nA: pt tx with another PC.\nR: hct .30 thereafter.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 1536446, "text": "update\nD: pt improved hemodynamically thoughout day--weaned epi with good svo2, co/ci-off milrinone early this am.-new pacer interrogated- pt with 1 a lead and 2 v leads- set at rate 70-80--a sensing- v pacing most of day, pt did av pace at one point today. sbp remained >90 consistently- weaned levo slightly--goal get epi off first--then wean levo as tol--do not touch vasopressin at this time.\npt oxygenation guarded all day intially able to wean peep from 18- 12--fio2 intially at 100 then down to 80%-- pt sedated and paralyzed-pt abg worsened--requiring peep back up to 16 and fio2 up to 100%. Pip up--changed to pressure regulated ventilation.--pending results. pt receieved 2 units PC today with resultant hct >30. k down slightly (5 range) with replacement fluid of NS- glu intially in 120's presently down to 105.\nneuro: pt mae prior to paralytic, propofol for sedation changed to ativan-- pupils equal and intially rx to light.\ncardiac: pt v paced most of day at rte 70-80--occas av paced and rare nsr beat noted, sbp >100/, co/ci excellent with svo2 >65 throughout the day--re-cal cco this am-ep into interrogate pacer. pt has epicardiac wires connect to pacing box--but off. milrinone to off this am, epi weaning easily-levo cont at .07, vasopressin at 2.4.\nextremities warm and dry. palp pedal pulses bilat.\nresp: as noted resp status worsened. bs inspir/expir wheezes, coarse at times, sx for som,e yellow sputum, abg's initially improved then worsened- pt paralyzed and then changed mode of ventilation--pending futher abg results--pt presently on 100%, 16 peep changed to APRV--\ngi: pt npo, ogt patent-draining bilious material, bs hypoactive, choly tube draining bilious material. no BM noted today.\ngu: foley paptent- min u/o icteric/amber urine, pt cont on ccvh--goal run even.\nskin; abrasion skin integritiy on buttock--no other breakdown noted. pt with 3 sets of ct- no driange noted at this time from sites, midline chect drsg D&I,\nglu: glu tx per sliding scale- last glu 105.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-07 00:00:00.000", "description": "Report", "row_id": 1536447, "text": "neuro-sedated/paralyzed with ativan/nimbex gtts. pt shows no signs of wakefulness although TOF = twitches. @ 3mm/ brisk.no /gag or any bodily movement.\n\ncv- v-paced @ 70 with rare /pvc. lytes wnl-> no repletion needed. hct=28.0 -> transfused 2upbcs with repeat hct=29.0.levo /epi weaned off. hemodynamics improving (actually becoming hyperdynamic).temp trending down-> hypothermic. bed heater temp increased and warm blankets placed over pt with improvement.heparing gtt rate increased to 350u/hr. for ptt < 40.\n\nresp-abg= metabolic acidosis. vent changed to cmv/peep. ( see flow sheet). pt tolerating setting. decompensated to 84% with sxing. with a long recoil time. ls initially with exp wheeze,now dim throughout.ct drg minimal s/s fluid.ct# 2 with pos.airleak. sites c-d, dsgs changed.\n\ngi- abd soft. absent bs. ogt to lcwsx with bilious drg.pt not on tube feeds yet.\n\ngu- crrt to keep pt \"even\" accomplished qh. filter changed x1.replacement fluid bag swithced to d5/ sodium bicarb for metabolic acidosis with iprovement.\n\nlabs- ca+ gtt infusing per crrt orders.no k+ repletion needed. insulin sc x1.\n\nfamily- stepfather call from .\n\nplan- continue to monitor hemodynamics,resp,lab,renal,systems.tx as needed. wean vent as tolerated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-04 00:00:00.000", "description": "Report", "row_id": 1536436, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Had episode of desaturation/hypotension/bradycardia this shift requiring atropine, fluid, and recruitment breaths; recruitment x4 on APRV Phigh=35 Plow=32 Thigh=30 Tlow=0.5. PEEP increased first to +15cm, then to +18cm. Last PaO2=90, slow FiO2 wean now. Current SpO2 98%. ETT advanced 3cm per CXR. BLBS slightly coarse, suctioned for small amounts of thick blood tinged/brownish pluggy sputum. MDIs given as ordered. See resp flowsheet/nursing note for specifics.\n\nPlan: maintain support; monitor oxygenation...\n" }, { "category": "Nursing/other", "chartdate": "2102-01-04 00:00:00.000", "description": "Report", "row_id": 1536437, "text": "Neuro: Rec'd patient eyes open, attempting to sit up, thrashing. Propofol increase with good result. Remained sedated, aroused to stim, open eyes to voice. Propofol off briefly with hemodynamic instabilty, patient became dysynch with vent, restart. Patient again agitated, sitting up, trying to reach ETT. Propofol increased to 35. Patient appears comfortable, sedated.\n\nResp: Patient remains on vent. Initially BS clear out. Suctionewd for thick brown plugs. With decrease HR, BP patient with decreased SAT to 80\"s despite increase to 100% FiO2. ABG acidotic, treated with fluid, inc dopamine. Patient remained with low PaO2, acidosis. Recruitment maneuvers\nwith increase PEEP 10-> 18. ETT retaped, advanced as per CXR. Slow improvement. Decrease FiO2 100-80% with SAT 96%. BS now with exp wheeze s/p MDI without change. Pigtail remains in place with large amounts of drainage. Stripped x1 s/p drainage, leaking onto dressing. Dressing changed.\n\nCV: Rec'd patient in 1st degree block with BBB, converted to BBB, converted to sinus. Rhythm regular with BP stable 110/30's. PRBC tx given for Hct 28/ dopamine started at end of transfusion to improve renal perfusion. Patient then noted to have an irregular rhythm with? wide QRS. ? inappropriate pacing. Atropine, NS bolus given, albumin 5% given, dopamine titrated with good result. Resp slow to recover from instabilty.\nElectrolytes essentially unchanged, Calcium repleted. Sodium remains low, plan to use NS for all fluids.\n\nGI: Continues on feeds, tol well. No BM.\n\nGU: Cr 4.3. Sodium remain low. Attempt dopamine/ volume to increase renal perfusion without result.\n\nEndo: RSSI per protocol.\n\nSocial: Mother updated with interpretor. Phone consent obtained by anesthesia. Mother will visit in am.\n\nPlan: Continue cardiop[ulmonary monitoring. To OR in am. Monitor labs, replace sodium. Wean vent as tolerated.\n\n\n\n\nBP 60-70/20, SAT 80's HR irregular 60's. Pacer inter by epi-> problem found. Backup rate increased to 60. BP treated with\n" }, { "category": "Nursing/other", "chartdate": "2102-01-05 00:00:00.000", "description": "Report", "row_id": 1536438, "text": "Neuro: sedated on propofol, opens eyes to tactile stimuli with good eye contact, no purposeful limb movement noted, pt flacid\nResp: vented.. see Flow sheet for vent change details, LS coarse throughout and diminished at bases\nCardiac: 1st degree AVB rate 60's, rare PVC, left fem aline, RIJ cordis and RAC PICC, renal dopa at 3 mcg/kg/min\nGI: + BS, NPO since MN, no BM\nGU: foley to gravity draining clear yellow urine 10 to 25 cc/hr, changed Foley cath per PA, UA C&S sent\nEndo: no coverage needed\nSocial: no calls, no visitor's\nSkin: buttock's healing well, no drainage noted, aloe cream applied\nMisc: Dr. called and was updated on labs, I&O and vitals\nPlan: to OR today for valve\n" }, { "category": "Nursing/other", "chartdate": "2102-01-05 00:00:00.000", "description": "Report", "row_id": 1536439, "text": "Resp Care: Pt continues on mechanical ventilation. PEEP and FIO2 weaned as tolerated. AM ABG: 7.36/34/104/20/-5. Pt suctioned for small amounts of bloody/tan secretions. Tx's per . PLAN: AVR, wean PEEP as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-05 00:00:00.000", "description": "Report", "row_id": 1536440, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. To OR for AVR, returned to same vent settings. Recruitment breaths x3 on APRV Phigh=35 Plow=32 Thigh=30 Tlow=0.5. See resp flowsheet for specifics.\n\nPlan: maintain support; monitor oxygenation.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 1536443, "text": "Neuro: sedated on Propofol, titrated up to 40 for aggitation and droping SPO2, MAE's sporadically and withdraws to pain\nResp: see Flow Sheet for detailed information.. multiple vent changes, LS coarse bilat dim at bases, suctioning thick tan sputum, left pl. CT placed by PA @ 0530, post CT PCXR done and pending\nCardiac: ASVP, no ectopy noted, multiple drips per flow sheet, recently cut milrinon dose by 50%, epi wires not funtioning appropriately, not to touch until cleared by team, elevated K+ treated with 1/2 amp D50 and 10 units insulin IV with some effect\nGI: OGT currently clamped post medication, to be placed on loq wall suction @ 0700, + BS, no flatus, no BM, NPO\nGU: foley to gravity draining scant amber urine, CRRT replacement changed to NS D/T elevated K+, renal consulted for elevated K+, changed replacement to NS, ordered d-dimer, random cortisol, cortisol stim test and LFT's\nEndo: SSRI coverage per \nSocial: family called X 2 updated X1\nPlan: continue to monitor labs and vitals and treat as indicated and as ordered, needs bed changed if he goes to OR D/T right side controls not functioning, ? to OR for PPM D/C, follow up on epi wires/pace not working right, CRRT with frequent labs\n" }, { "category": "Radiology", "chartdate": "2102-01-28 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 947011, "text": " 7:10 PM\n ABDOMEN (SUPINE ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: feeding tube placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n\n REASON FOR THIS EXAMINATION:\n feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Aortic valve replacement, feeding tube placed, check\n position.\n\n Since the prior film of ten hours ago, the tip of the nasogastric tube has\n advanced a few centimeters and still remains within the stomach. The liver\n appears to be markedly enlarged extending down into the abdomen along _____\n and across to the left side. Left lower lobe infiltrate is present also.\n\n IMPRESSION: Nasogastric tube within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-02-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 947786, "text": " 2:54 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement of left PICC line 57 cm please page I\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement. now s/p trach\n\n REASON FOR THIS EXAMINATION:\n please check placement of left PICC line 57 cm please page IV nurse \n thanks \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left sided PICC line.\n\n Comparison is made to prior radiograph dated .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH.\n\n Since most recent film, a left-sided PICC line has been placed with its distal\n tip within the right atrium. There is stable and appropriate positioning to\n the tracheostomy tube, right-sided subclavian catheter, and Dobbhoff feeding\n tube whose tip cannot be visualized. There has been improvement to previously\n noted pulmonary edema and left lower lobe atelectasis with stable appearance\n to a loculated right-sided pleural effusion. Cardiomediastinal silhouette and\n hilar contours remain unchanged and the patient is again noted to be status\n post median sternotomy and aortic valve replacement. There is no evidence of\n pneumothorax.\n\n IMPRESSION:\n\n 1. Left-sided PICC line tip within the right atrium. Repositioning\n recommended and discussed with IV nursing on date of exam.\n\n 2. Stable appearance to loculated right-sided pleural effusion but\n improvement to retrocardiac atelectasis and pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944122, "text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult ventillation\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Difficult ventilation.\n\n\n FINDINGS/IMPRESSION:\n\n A single AP view of the chest is obtained at 07:20 hours and is\n compared with the study of . Tubes and lines are unchanged in\n position. The small right apical pneumothorax has almost completely resolved\n with a tiny sliver of air visible. There is some increasing density in the\n retrocardiac area on the left side, which may indicate some atelectasis but\n the examination is otherwise unchanged from the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-28 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 946947, "text": " 9:31 AM\n PORTABLE ABDOMEN Clip # \n Reason: feeding tube placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n\n REASON FOR THIS EXAMINATION:\n feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Feeding tube placed, check position.\n\n The tip of the feeding tube lies within the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 946516, "text": " 7:41 PM\n PORTABLE ABDOMEN Clip # \n Reason: ?daubhoff dislodged\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with daubhoff\n REASON FOR THIS EXAMINATION:\n ?daubhoff dislodged\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man with a Dobbhoff tube, question dislodgement.\n\n COMPARISON: Chest x-ray from earlier the same day and fluoroscopy from one\n day prior.\n\n FRONTAL SUPINE ABDOMEN: A Dobbhoff tube is seen with its tip in the proximal\n jejunum. A pacemaker is in unchanged position. The tip of a central venous\n catheter projects over the cavoatrial junction. The heart is stably enlarged.\n There is left lower lobe atelectasis and a small left-sided pleural effusion.\n Opacification of loops of bowel is consistent with recent contrast\n administration.\n\n IMPRESSION: Appropriately placed Dobbhoff.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944239, "text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MT removal CT r/L remain\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult ventillation\n\n REASON FOR THIS EXAMINATION:\n s/p MT removal CT r/L remain\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:12 A.M. ON \n\n HISTORY: Abscess removal.\n\n IMPRESSION: AP chest compared to through 15:\n\n There is no pneumothorax. Small bilateral pleural effusions unchanged.\n Moderate cardiomegaly stable. No new mediastinal widening. ET tube and left\n internal jugular introducer, nasogastric tube, midline and left apical pleural\n drains are unchanged in standard placements. Pigtail catheter still projects\n over the right heart border. Transvenous right ventricular pacer and\n epicardial leads unchanged in their respective positions.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-24 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 946257, "text": " 10:46 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: dobhoff placement post pyloric\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n dobhoff placement post pyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old male status post AVR. Dobbhoff placement post-\n pyloric.\n\n COMPARISON: .\n\n NASOINTESTINAL TUBE PLACEMENT: The patient was placed supine on the\n fluoroscopic table. The previously placed Dobbhoff catheter was removed. The\n oropharynx was prepped with Hurricaine Spray and the right naris with\n lidocaine jelly. Under fluoroscopic guidance, an 8 French 120-cm -\n feeding tube was inserted into the right naris and advanced through the\n esophagus into the stomach. The tube was then advanced through the pyloric\n valve into the proximal small bowel. Injection of approximately 5 mL of\n Conray contrast demonstrates that the tip is located within the third portion\n of the duodenum. The patient tolerated the procedure well without\n complications.\n\n IMPRESSION: Successful nasointestinal tube placement with the tip within the\n third portion of the duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 946491, "text": " 5:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: trach placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement. now s/p trach\n REASON FOR THIS EXAMINATION:\n trach placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tracheostomy placement.\n\n COMPARISON: .\n\n AP SUPINE CHEST RADIOGRAPH: A tracheostomy tube is in standard position. A\n weighted feeding tube tip is not visualized but is below the diaphragm. A\n right subclavian central venous catheter tip is at the cavoatrial junction.\n The heart is stably enlarged. There is bilateral perihilar opacity consistent\n with moderate pulmonary edema. Small bilateral pleural effusions are seen,\n with a loculated component on the right, and persistent left lower lobe\n atelectasis remains. The patient is status post median sternotomy. Pacing\n wires remain in place.\n\n IMPRESSION: Standard placement of tracheostomy. Moderate pulmonary edema\n persists. Small bilateral pleural effusions and left lower lobe atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2102-02-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 948254, "text": " 10:26 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion right\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n evaluate effusion right\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post 23 year status post AVR, evaluate for right effusion.\n\n COMPARISON: .\n\n FRONTAL & LATERAL CHEST RADIOGRAPHS:\n\n Tracheostomy tube again seen with tip approximately 3.5 cm from the carina.\n Median sternotomy wires again noted. Pacing leads again seen in unchanged\n position. Cardiac and mediastinal contours appear stable. No focal\n consolidations are seen within the lungs. Loculated right pleural effusion\n appears relatively unchanged. New small amount of free air is seen under the\n right hemidiaphragm, improving left basilar atelectasis and effusion also\n again noted.\n\n IMPRESSION: Persistent loculated right pleural effusion. A small amount of\n free air noted under the right hemidiaphragm, consistent with patient's recent\n history of PEG placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-23 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 946134, "text": " 4:58 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: assess ogt placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n assess ogt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man status post aortic valve replacement. Evaluate\n placement of orogastric tube.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The right subclavian central venous\n catheter terminates in unchanged position in the mid SVC. The patient is\n status post orogastric tube placement, which descends below the diaphragm and\n past the pylorus, with the tip not visualized. The patient is status post\n median sternotomy. An epigastric pacemaker is in place. The cardiac\n silhouette and mediastinal contours are unchanged. There is increased left\n lower lobe collapse and consolidation. A right-sided effusion is stable in\n size since prior exam approximately seven hours earlier.\n\n IMPRESSION:\n 1. Orogastric tube descends below the diaphragm and past the pylorus with the\n tip not clearly visualized.\n 2. New left lower lobe collapse and consolidation.\n\n COMMENT: Called to at 10 pm on .\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-28 00:00:00.000", "description": "Report", "row_id": 1536399, "text": "Neuro) Pt. sedated with Precedex but additional Propofol required to keep pt. from pulling tubes and having spasmodic coughing. pt. is still able to withdraw to stimuli and has spont. movements. He does not follow commands (language barrier noted). Pt.'s head flops side to side on pillow when sedate and then lifts it off pillow to cough.\n\nCV) NSR 70-80's on Carvedilol; SBP 130-150's. Skin warm and slightly moist over arms and face. Low grade temp.\n\nPulm) CMV ventilation. Pt. has copious secretions at times with strong cough. ABG (resp. alk).\n\nGI) tube feedings at goal rate; no stool.\n\nGU) Good huo after Lasix.\n\nSkin) abrasions over both buttocks. Duoderms not staying on. Sites of skin sloughing and pink. Barrier cream applied.\n\nEndo) SSRI given x2.\n\nPlan) Dr. planning to speak with family (interpreter requested) and will attempt to wake pt. up for discussion re: valve surgery. Planned for Thursday. Continue to diurese and replete lytes.\nMaintain sedation to reduce risk of self extubation. Antibiotics to continue.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-28 00:00:00.000", "description": "Report", "row_id": 1536400, "text": "Respiratory therapy\nPt presents orally intubated on full ventilatory support. BS essentially clear w LLL diminished. Sx for thick pale white to tan secretions. placed on heated circuit. Plan: meeting W family and interpreter\n" }, { "category": "Nursing/other", "chartdate": "2101-12-28 00:00:00.000", "description": "Report", "row_id": 1536401, "text": "Resp Care\n\nPt remains intubated and currently vented on full support with no changes made to parameter settings. ETT retaped and resecured at 24cm at the lip. MDIs ordered and was started this afternoon. BS slightly course sxed for small to mod atms of thick tan/blood tinged secretions. WIll cont with vent support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-28 00:00:00.000", "description": "Report", "row_id": 1536402, "text": "csru nursing update\nNSR, no paced beats all shift. hypertensive to 160s when agitated, continued on propofol and precedex gtts. for avr in am, prop off shortly in order to explain procedure to pt -> pt responded to mother, nods appropriately. no pain but very uncomfortable with ET-> gagging a lot requiring intermittent 1cc boluses of prop-> with good effect. febrile up to 102.6F despite cooling measures/tylenol, pan cultured, atbx unchanged. ET secretions thick tan, lungs coarse, dim bibasally. TF changed to probalance, rate increased. continued on lasix tid, lytes repleted. both gluteal clefts excoriated/broken, allevyn dressing applied. mother visiting all day, requires interpreter for communication\n\na/p: for avr in am -> /anesth consent signed. awaiting further pre-op instructions\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-28 00:00:00.000", "description": "Report", "row_id": 1536403, "text": "add:\nsurgery (AVR) in am cancelled. recent cx revealed gram (+) rods, infiltrates, pneumonia. atbx ->unasyn changed to zosyn. mother informed phone by md re: cancelled surgery. wound rn also made aware of pts skin issues, skin consult done, kinair bed ordered. pt will remain npo at midnight re: ?bronch in am\n" }, { "category": "Nursing/other", "chartdate": "2102-01-21 00:00:00.000", "description": "Report", "row_id": 1536506, "text": "CONDITION UPDATE\n. NSR NO ECTOPY NOTED. AFEBRILE. ALERT. UNABLE TO ASCERTAIN ORIENTATION SECONDARY TO VENT AND LANGUAGE BARRIER. DOES NOT FOLLOW COMMANDS. MOVES ALL EXTREMITIES ON BED. PUPILS ICTERIC, EQUAL AND REACTIVE. LUNGS COARSE THROUGHOUT. NO VENT CHANGES. MIN SUCTIONING FOR THICK, TAN SPUTUM. ABD SOFTLY DISTENDED. POSITIVE BOWEL SOUNDS. TOLERATING TFEED VIA POST PYLORIC FEEDING TUBE W/O INCIDENT. REMAINS ON HYPERAL. JP PUTTING OUT MOD AMT OF ICTERIC DRAINAGE. U/O QS VIA FOLEY. NO STOOL THIS SHIFT.\nCONT CLOSE HEMODYNAMIC MONITOR. AGGRESSIVE PULMONARY TOILET. WEAN FROM VENT AS TOLERATES. CONT CURRENT ICU CARE AND ASESMENTS.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-21 00:00:00.000", "description": "Report", "row_id": 1536507, "text": "Resp: Pt continues on mechanical ventilation. No changes overnight. ABG this am: 7.34/37/81/21/-5. LS: coarse bilaterally. sxn'd for small-moderate amounts of thick tan secretions. Tx's given per . No this am secondary to high PEEP requirements. PLAN: continue to wean PEEP/FIO2 as tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-21 00:00:00.000", "description": "Report", "row_id": 1536508, "text": "BS essentially CTAB; no change with MDI's. Tmax today 102.1. Switched to Vanco and Cipro. FiO2 now at 40% with acceptable oxygenation. Wean PEEP as appropriate (still @ 14cm).\n" }, { "category": "Nursing/other", "chartdate": "2102-01-22 00:00:00.000", "description": "Report", "row_id": 1536511, "text": "Resp: Pt continues on mechanical ventilation. PEEP wean to 11 overnight with acceptable oxygenation. LS coarse bilaterally. Pt suctioned for moderate-large amounts of thick tan secretions. Tx's given per . Plan: continue to wean PEEP as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-22 00:00:00.000", "description": "Report", "row_id": 1536512, "text": "BS coarse crackles; no change with MDI's. Thick tan secretions appear to be increasing again. Tmax 102.8 today. PEEP weaned to 8cm. Continue to wean, keeping SaO2>90%.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-22 00:00:00.000", "description": "Report", "row_id": 1536513, "text": "High Temps Today\nNEURO: Increased Midaz drip to 4mg/hr with Fentanyl boluses for sedation, Pt follows commands inconsistently, MAE, PERRLA (4mm/brisk)\n\nRESP: Continued to wean vent, PEEP at 8, keep O2 Sats >90% MD, lung sounds clear, ETT suctioned when coarse for small-mod tan/thick secretions\n\nCV: Sinus tachy, HR 120s, SBP 110-130s, pedal pulses palpable\n\nGI/GU: TPN discontinued this AM, continues on TF at goal 40cc/hr, small BM of golden/yellow stool, C. Diff screen sent, JP continues to drain bilious drainage at about 50-75cc every 3-4 hours; Foley in place draining icteric/clear urine at >100cc/hr, repleted K with 20mEq KCl MD, repleted Ca with Calcium Gluconate\n\nENDO: On SSRI, last BG was 80.\n\nSOCIAL: Family visited in the morning, concerned about his high temps.\n\nID: Max temp 102.8, last temp 102.4 after Tylenol PR, pan cultured (C. diff/blood/sputum/cath tip), trauma introducer switched to triple lumen over wire\n\nPLAN: ? plan to further wean overnight, continue to monitor temp, neuro, resp, cv, urine output.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-23 00:00:00.000", "description": "Report", "row_id": 1536514, "text": "resp care\nPt remained on a/c 450x30 40% 8peep with peak/plat 22/18. pt overbreathing for a total of 33-40 breaths. BS coarse bil. suct for thick tan sput.Combivent/flovent given as ordered.No further peep wean the night-Pao2 68 on current setting.will cont to follow and wean as tolerated. attempted but rr inc to 40's and pt became agitated.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536412, "text": "RESPIRATORY CARE: PT CHANGED TO PS 12/5 TODAY.\nCT SCAN OF CHEST DONE W/OUT INCIDENT. SX FOR\nTAN. COMBIVENT/ FLOVENT MDI'S GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536413, "text": "CT SCAN TODAY\nNEURO: Pt sedated on propofol at 30mcg and given 100mcg every 2 hours for Pt comfort, started Methadone PO today, MAE, arms remain restrained, PERRLA (4mm/brisk), cough/gag reflex intact\n\nRESP: Pt on CPAP 40%, 5 PEEP, 10 PS, Sats 98%, resp are 15/min and regular, when anxious resp are in 30s, fentanyl helps Pt relax, lung sounds are clear at apices/dim at bases, CT today reveals decreased bibasilar effusions NP, suctioned for moderate tan/thick secretions\n\nCV: NSR with HR in 80-90s, may rise to 100s if anxious, SBP in 150-180s, perm pacer on VVI, pedal pulses present, after CT, given 1L of NS to flush dye at 100mL/hr\n\nGI/GU: Continues on TF at goal per OGT, bowel sounds present, two small BMs of yellow, loose stools; Foley in place draining yellow/clear urine at 100mL/hr, given Lasix TID, good urine outputs, repleted K of 3.0 with 40mEq KCl IVPB\n\nENDO: Continues on Pt's SSRI\n\nSOCIAL: Mother visited throughout the day and updated about Pt's status as far as CT results were concerned\n\nPLAN: Continue to monitor resp, cv, urine outputs, LABS, replete lytes as needed, plan to resedate overnight and rest on vent, ? increase methadone dose tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2101-12-31 00:00:00.000", "description": "Report", "row_id": 1536417, "text": "Neuro: pt weaned off propofol, alert at times and very confused at times per family, has short bursts of energy(moving bilat extrtemities in bed) followed by longer periods of lethargy, fentanyl 25mcg IVP X1 with good results for one period of aggitation around 1515, Tmax 101 BC X2, UA, unable to do sputum CX D/T scant secretions via ETT\nResp: weaned to CPAP 5&5, extubated at 1200, did fine for several hours, needed to be reintubated @ 1615, LS coarse bilat.. dim at bases, see Flow Sheet for complete details, was given propofol and succicoline for intubation\nCardiac: SR/ST most of shift, weened propofol to off, started nicardipine gtt for several hours... on hold just prior to reintubation, became SB in th 50's without BP, code called, given 2 amps epi, 1 amp 1 amp calcium chloride, 200mcg's neo and 500c bolus NS, CPR for @2 minutes, full set of labs, treated K+ 7.3 with 1/2 amp D50 and 5 units regular insulin, 1 amp biacarb post intubation/code with good results, post code EKG, post code ECHO started but interupted D/T code in ED\nGI: NGT currently clamped, NPO for now, + BS, + placement\nGU: foley to gravity with TID lasix with good effect\nEndo: SSRI per \nSocial: family in to visit most of shift\nPlan: keep intubated for now, D/C'd piperacillin, start Bactrim IVPB, incresed carvedilol to 12.5 mg , incresed methadone to 40mg , D/C'd propofol, D/C'd fentanyl PRN(may consider restarting fent if aggitated since ? low BP from propofol during intubation), ? OR on Monday\n" }, { "category": "Nursing/other", "chartdate": "2102-01-23 00:00:00.000", "description": "Report", "row_id": 1536517, "text": "7am-7pm update\nneuro: pt , on bed. spainsh translator into see the pt this am -> pt followed commands when asked simple commands in spanish -> pt was able to wiggle toes on bil feet and the pt was able to make a hand grasp with both hands. . versed gtt dc'd this am. pt given ativan x 2 today.\n\nCV: pt V paced most of the day, HR 90-110's. pt HR up to the the 120's breifly this afternoon -> the pt was in a ST at that time. SBP 100-130's. MAP 80-100's. pt given IV lopressor x 3 for tachycardia and elvated BP. hct 26 this am. repeat hct 31 this afternoon. pp palpable.\n\nresp: LS coarse throughtout. pt placed on CPAP today. pt on 40% CPAP with 8 PEEP and 8 PS. TV in the 400's. RR 20-30's. Pao2 in the 60's - team aware. pt suctioned for moderate/copious amounts of thick yellow sputum.\n\ngi/gu: pt with + hypoactive BS. Dobhoff clogged - team aware - plan for IR in am. attempted to place sodium bicarb + viokase down dobhoff and dobhoff remained clogged. OGT placed for meds only. ogt placement confirmed by CXR. plan to hold TF until new post pyloric Dobhoff placed. (team only wants the pt to be fed post pyloric). pt had smear of stool x 3. pt given bisacodyl. foley draining amber urine with sediment. UO adequate. creatinine reamins elvated although trending down. US of gallbladder and liver done today.\n\nendo: BS wnl.\n\nID: T max 100.8 orally. wbc remain elvated. stool sent for Cdiff and fungal culture sent. vanco and flagyl dc'd today\n\nskin: pt with duoderm on coccxy - report recieved that the pt has a stage II on coccxy. skin care nurse following the patient.\n\nplan: trach and PEG in future, keep NPO overnight except for meds, use OGT for meds, to IR for dobhoff in am, pulm toleit, keep on CPAP overnight - increase PS per team. monitor lytes/abg's,\n" }, { "category": "Nursing/other", "chartdate": "2102-01-24 00:00:00.000", "description": "Report", "row_id": 1536518, "text": "Resp Care\nPt. remains intubated/sedated overnight on PSV w/o change. Vt's 500-750cc with MV ranging from 6-13lpm.\nabgs:within acceptable parameters.\nPlam: Trip to IR for feeding tube placement. Continue current vent support.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-24 00:00:00.000", "description": "Report", "row_id": 1536519, "text": "7p-7a\nNeuro: . Agitated at times, Ativan 1mg iv with effect. Pt also receiving Methadone 50 mg po bid. Following commands...when asked to \"aprieta\" hands pt squeezes hands. PERL. Denies pain.\n\nCV: BP 98-107/60's. Vpaced most of shift 80'-100. SR this am 80's-90's. +palp pp. Venodynes on, heparin given sq.\n\nResp: Pt remains intubated, on cpap with 8ps, 8peep. Peep decreased to 6 @ 6am for abg wnl. Lungs coarse. Suctioned for sm amts thick yellow secretions. Tmax 100. Sats 96-100%.\n\nID: Tmax as above 100. WBC 35.2 (29.6) ?To start antifungal today.\nNeed 3rd Cdiff spec to be sent today.\n\nGI/GU: Abd softly distended. +bs. Meds given via ogt, +placement.\n JP to bulb sxn with large amts out. Small amt soft brown stool x2.\n\nSkin: Multiple areas with sutures, rt side d+i left ota; lt d+i left ota as well. Left shoulder pacer site with steris left ota d+i.\nDuoderm to bottom , skin nurse following. Chest inc ota, approximated, d+i.\n\nSocial: No calls this shift.\n\nPlan: Cont to monitor hemodynamics/rhythm. Follow labs, treat prn.\nCdiff spec today. ?Start antifungal today.\nTo IR today for dopoff repair or placement. ?trach and peg in future.\nOOB to chair.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536414, "text": "Addendum\ngiven prn Fentanyl 100mcg and continues on Prop at 55mcg\n" }, { "category": "Nursing/other", "chartdate": "2101-12-31 00:00:00.000", "description": "Report", "row_id": 1536415, "text": "NEURO: PT. SEDATED ON PROPOFOL, HAS RECEIVED 100MCG FENTANYL IV ONCE, , PT. GAGGS ON ETT OCCASIONALLY WITH MOVEMENT AND POSITION CHANGES. PT. RESPONDS TO PAINFUL STIMULI (I.E. FLEXION AND WITHDRAW UPON PALPATION OF SUPRAPUBIC REGION OF LOWER ABDOMEN), DOES NOT FOLLOW COMMANDS.\n\nCV: PT. NSR, RARE PAC NOTICED, PT. SBP 120-140'S, HR 60-70'S, 6.25 CARVEDILOL GIVEN PO AND TOLERATED. PT. HAS PPM (VVI AT SET RATE 50). PT. AFEBRILE.\n\nRESP: PT. CLEAR IN LUL, SLIGHTLY COARSE IN RUL, DIMINISHED IN LOWER LOBES. PT. SUCTIONED FOR THICK (SOMETIMES THIN), BROWN SECRETIONS. PT. ON CMV VENT SETTINGS PER TEAM. SEE CAREVUE FOR VENT SETTINGS AND ABGS. R POSTERIOR PIGTAIL DRAINING SEROUS, SEDIMENT DRAINAGE. ETT ROTATED.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TUBE FEEDS (PROBALANCE) AT 70CC/HR- NO RESIDUALS. SCANT AMT. OF GOLDEN, BROWN STOOL. ASSESSMENT ABDOMEN PALPATED->PT. SHOWED REBOUND TENDERNESS WITH PALPATION IN SUPRAPUBIC REGION. MD NOTIFIED AND PT. EVALUATED. FOLEY DRAINING MINIMAL AMT. OF URINE- FLUSHED WITH STERILE WATER, AND OUTPUT OF 700CC OBTAINED. TENDERNESS CEASED- AND CURRENTLY ABDOMEN SOFT UPON PALPATION. FOLEY CURRENTLY DRAINING SEDIMENT, YELLOW URINE- GOOD U/O. LASIX GIVEN AT 2400 WITH GOOD RESPONSE. LYTES REPLETED. BLOOD SUGARS TREATED PER PT'S PERSONAL SLIDING SCALE.\n\nPLAN: MONITOR NEURO STATUS, MONITOR SBP AND HR, RESPIRATORY STATUS (?WEAN PROPOFOL AND ATTEMPT CPAP), ASSESS TUBE FEEDS TOLERATION, FLUID STATUS, AND MONITOR WBC COUNT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-30 00:00:00.000", "description": "Report", "row_id": 1536546, "text": "Respiratory Care\nPrior to removing Passey-Muir Valve, patient asked to say \"hello\" forcefully. He was able to repeat the word in a somewhat soft yet clear tone. Returned to trach collar.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-31 00:00:00.000", "description": "Report", "row_id": 1536547, "text": "Resp Care\nPt. remains trached off ventilator t/o shift. CUrrently on 40% TM, tolerating well, with no distress noted overnight.\nBS: coarse bilat. sxn'd q4 for sm-moderate thick tan. Mdis given q4 via spacer/ambu.\nPlaN: COnt. on trach mask,pulm toilet, mdis. Rehab screening.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-31 00:00:00.000", "description": "Report", "row_id": 1536548, "text": "cv: sbp 101-122/ hr 70-74 vp no ectopy\n\ngi: tol tube feed fs impact at 60 cc/hr via doboff and fluid h2o bolus 250 ccq6 hours resiual of 80 cc.small liquid golden stool. diaper on.\n\ngu: foley draining amber urine with sediment adequate amounts.\n\nneuro: pt frequently asking for water. follows simple commands.moves all extremities. restless, pt takes off pneumo boots, throws pillows out of bed and tries to reach up to feeding tube.pupils equal and react to light.\n\nresp: tolerated trach collar 40 % all night. resp rate 8-17. pt appeared comfortable. breath sounds clear upper diminished at bases.\n\nlabs: am labs K= 3.9 20 meq kcl and mag = 1.8 mag 2 grams iv\n" }, { "category": "Nursing/other", "chartdate": "2102-01-25 00:00:00.000", "description": "Report", "row_id": 1536522, "text": "Resp: Pt rec'd on psv 5/5/40%. Ett#8, are coarse bilaterally. Sucitoned for copious amounts of brown thick secretions frequently. MDI's administered as ordered with no adverse reactions. No changes . AM ABG 7.32/35/78/19 with =84. Plan to trach @ bedside this am.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-25 00:00:00.000", "description": "Report", "row_id": 1536523, "text": "neuro- anxious this shift- currently sedated from methadone- vs ok\nresp: remains vented - going for trach today- sputum remains thick and sticky\ncv: v-paced- tachy at times- b/p ok-\ngi/gu: last stool sample sent- results pending-\nendo- bg wnl-\nplan: satrted on d5 for Inc sodium\nplan: trach cont plan of care-\n" }, { "category": "Nursing/other", "chartdate": "2102-01-25 00:00:00.000", "description": "Report", "row_id": 1536524, "text": "Resp Care\nPt was trached today at the bedside with #8 cuffed per-fit and BAL of RLL and LLL obtained and sent to lab. Pt was switched to a rate this morning aft acidotic ABG due to low RR after some medication, pt later became more awake and was then switched back to PSV 5/5, he was switched to A/C for trach procedure where he currently remains due to sedation. BLBS course, suctioned for mod amt of thick tan secretions, MDIs given. Plan to wean back to PSV when his sedation in lightened, and trial trach tomorrow as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-25 00:00:00.000", "description": "Report", "row_id": 1536525, "text": "Neuro: Pt and agitated most of shift, does follow commands. Sedated and paralyzed briefly for trach procedure. Tolerated well. MAE\nCV: afebrile, hr 70-90 , v paced via permeanet pacer. Requiring low dose neo post trach due to sedation, weaning off at present. Palp pedal pulses. Persistent hi NA, d5w at 50cc/hr + free water boluses.\nResp: Trached at 1600 with #8 perfit, by Dr. without difficulty. abd showed slight met acidosis. Planced on imv briefly this am due to apnea post methadone dose this am, and during trach. now on cpap. Sx thick yellow. Bronched post trach by anesth, sputum cx from each lower lobe sent.\nGi: TF off all shift due to awaiting trach. OGT pulled post trach by MD. Awaiting CXR for dobhoff placement to restart TF. Abd soft. Frequent stools, soft pasty yellow. cdiff neg\nGU: voiding 200-400cc/jr amber urine. foley patent\nplan: wean vent as tol. wean neo to off. follow cx.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-26 00:00:00.000", "description": "Report", "row_id": 1536526, "text": "Resp: pt on psv 5/5/40%. Ett #8 portex. BS are coarse bilaterally. Suctioned for moderate amounts of thick tan secretions. MDI's administered Q4 hrs combivent/ with no adverse reactions. =43. AM ABG pending. Plan to wean to T/C trials today.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-31 00:00:00.000", "description": "Report", "row_id": 1536549, "text": "7a-3p\nneuro: awake, , oriented x 2, follows commands, moving all extremites, pt very weak\n\ncv: hr v paced @ 70, no ectopy, sbp stable, po lopressor\n\nresp: on 40 % trach collar, passy muir valve on since 1030, doing well, no resp distress noted, coughing productively, bs+ all lobes, clear, diminished to bases, sat 100, rr 10-20\n\ngi: goal TF tol well, no stool, po prevacid, no stool, free water q 6 hrs\n\ngu: foley patent, clear amber urine, good uo\n\nother: pivot OOb to chair with P.T. today, tol well, back to bed, mother in & updated on pt's condition\n\nplan: continue to monitor resp status, passy muir valve as tolerated, iv antibiotics as ordered, sux as needed\n" }, { "category": "Nursing/other", "chartdate": "2102-01-31 00:00:00.000", "description": "Report", "row_id": 1536550, "text": "Respiratory Care\nPt remains on trach collar as noted in Carevue. Seen by speech therapy.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-01 00:00:00.000", "description": "Report", "row_id": 1536551, "text": "7p-7a\nNeuro: Pt and oriented to self and place, follows all commands, perrla, mae though weakly. Denies pain.\n\nCV: HR 70-90s V pacing via internal pacer. SBP >100. MAP>60. See carevue. + palpable pulses. Lytes repleted prn.\n\nResp: LS clear. Coarse but cleared w/ . Pt expectorates thick tannish secretions via trach. Trach #8 portex, 40% FiO2, tolerated trach collar all . When pt sleeping, RR noted to be intermittently, PA aware, methadone decreased. Sats >98%.\n\nGI/GU: Abd soft, hypoactive BS. No stool. Opium tincture held secondary to no stools during days per PA . Tolerating TF at 60cc/hr, residuals of 100-130cc given back to pt. Foley draining adequate amts of dark yellow urine. See carevue. drain to bulb suction, draining bilious dark brownish green.\n\nEndo: RISS.\n\nSkin: Small swollen area near left breast, continue to monitor. See carevue for further details.\n\nIV: White port of central line unable to draw blood off of. 2 other ports patent, red port flushed w/ heparin to keep line patent.\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate\n" }, { "category": "Nursing/other", "chartdate": "2102-02-03 00:00:00.000", "description": "Report", "row_id": 1536562, "text": "NEURO: , awake, oriented x2, disoriented to time, responds verbally with Passy-Muir valve, able to communicate needs to staff, denies pain, physical therapy visited Pt.\n\nRESP: Trach collar on 35% via 12L flow, Sats 100% with PMV in place, lung sounds clear, suctioned for moderate tan/thick secretions in AM, resp reg/unlabored, given alb/atrovent inhalers\n\nCV: Vpaced HR 70-80s, SBP 100-110s, pedal pulses palpable, afebrile\n\nGI/GU: Remains on NPO, plan for PEG tube placement in evening by MD, BS present, small BM of formed/ colored stools; Foley in place draining amber/sediment urine at 80cc/hr\n\nENDO: Last BG was 136, treated with 4units reg insulin SC\n\nSOCIAL: Mother visited Pt throughout the afternoon\n\nPLAN: PEG placement in the evening, maintain NPO status until after surgery, continue to monitor resp, cv, urine output, increase activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-03 00:00:00.000", "description": "Report", "row_id": 1536563, "text": "Respiratory Care Note\nPt is on 35% trach mask - water refilled. Pt has a #8.0 per-fit trach in place. Passy muir valve in place. Pt has a strong slightly congested . Plan to continue to follow per airway protocol.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-02 00:00:00.000", "description": "Report", "row_id": 1536426, "text": "Respiratory CAre: Pt remains intubated and vented on AC settings. Pt was weaned to PS for approx 1 hr, ABG showed non-compensated metabolic acidosis. Pt pleced back on AC. Pts breath sounds clear/ diminished at bases. Suctioned for moderate thick brown secretions. MDIs given as ordered. will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-27 00:00:00.000", "description": "Report", "row_id": 1536530, "text": "7am-7p update\nneuro: pt . MAE on bed, follows commands inconsistently. . pt aggitated - ativan given - little effect noted. pt uncooperative with care.\n\nCV: pt remains A sensing and V paced, (via PPM). HR 80-90's. BP 110-130's/60-70's. MAP 70-80's. hct 24.9 this am. pp palpable. lytes replaced. NA has been elvated the past few days -> pt recieving d5W at 100 cc/hr and free water bolus q6hr d/t elvated sodium. NA level 144 this am. LFT's still remain slightly elvated.\n\nresp: LS coarse throughout. pt on CPAP 40% with 5 PEEP and 5IPS overnight. TV 400-500's. RR wnl. pt suctioned for moderate amount of thick tan sputum. trach care done. abgs continue to show met acidosis - md aware - no treatment overnight.\n\ngi/gu: pt with + hypoactive bs. pt continues to have frequent loose golden brown stool. pt recieving impact at 60 cc/hr (goal) via dobhoff. foley draining amber urine with sediment. UO ~ 100-200 cc/hr. Creatinine 1.1 this am and BUN 24 this am.\n\nskin: pt with 2 stage II ulcer on -> initally clean, duoderm gel placed over ulcer and covered with allevyn dressing. although dressing off this am d/t pt stooling frequently. cleaned with soap and water.\n\nid: pt afebrile. wbc 26.1 (down from yesterday) pt continues on caspofungin, cefepime and cipro.\n\nplan: trach collar on days, pulm toleit, skin care, continue TF, monitor wbc's, antiobiotics, monitor lytes/hct, monitor renal status, monitor LFT's, monitor abgs\n" }, { "category": "Nursing/other", "chartdate": "2102-01-27 00:00:00.000", "description": "Report", "row_id": 1536531, "text": "Resp: pt on psv 5/5/40%. Pt has #8 portex. BS are coarse bilaterally. Suctioned for moderate amounts of thick tan secretions. MDI's administered as ordered combivent/flovent with no adverse reactions. AM ABG 7.32/46/120/25. =24. Plan to continue with T/C trials as tolerated today.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-27 00:00:00.000", "description": "Report", "row_id": 1536532, "text": " 7a-7p\nneuro: trached, mouthing words (unable to discern spanish/english), follows commands inconsistently, perrlaa, mae, standing transfer to chair by pt, returned to bed by \n\ncv: sr 70-87 no ectopy, sbp 91-127 art line pulled by pt (new art line not inserted per team), afeb\n\nresp: trach collar since 0800, coughing up moderate amounts thick tan secretions q 1-2hours, occasionally requires suctionning to clear trach, inner cannula changed, 02 sat >98% all day, coarse breath sounds to bases, clear upper lobes\n\ngi: tube feeds at goal, no residuals, fingersticks ssri (no coverage today), hypoactive bowel sounds, tube draining 60ml/3-4h, 1 small loose gold stool\n\ngu: foley draining adequate amounts amber urine with sediment\n\nlabs: repleted K+, Io Ca++, Na+ sent\n\nassess: stable\n\nplan: trach collar as long as tolerated, to chair by /standing transfer, continue to restrain while trying to pull lines\n" }, { "category": "Nursing/other", "chartdate": "2102-01-28 00:00:00.000", "description": "Report", "row_id": 1536533, "text": "0400 pt increasingly agitated pulled NGT. pulling at CVL. smacking staff. unable to reposition pt off of back at this time. methadone IV admin. with improvement. pt now resting calmly.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536564, "text": "Resp Care\nPt currently on 35% trach mask. Pt requied to be on vent for a few hours after placement. Sucitioned for mod amt of blood tinged secretions. All equipment @ bedside. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536565, "text": "NEURO: pt , speaking with PM valve. appropriate answers to questions. rec'd from OR paralyzed and sedated on propofol. woke 0400, oriented and following commands. . medicated for pain with morphine IV.\nCV: sinus rhythm/Vpaced. SBP 100-110's. skin warm, dry. DP/PT palp.\nRESP: lungs clear with diminished bases bilat. on trach collar in eve. briefly on vent on return from OR. now on trach collar. sats 100% resps . PM valve on 0600. had flex bronch in OR.\nGI/GU: abd soft, +bowel sounds. NPO/NGT. J tube placed with open approach overnoc to gravity draining bilious. JP with bilious drainage. shortly after arrival from OR abd incision bleeding. pressure held and dressing reinforced. MD 'd, placed pressure dressing. now with small amt serosang drainage, dressing . had small smear of stool.\nENDO: no RISS required\nSKIN: duoderm to changed. wound healing compared to last weekend. abd J tube incision with staples, JP drain site CDI, L chest sutures and steri strips CDI. on airbed.\nA/P: continue to monitor cv, resp, continue trach collar and PM valve as tol. NPO/NGT. monitor J tube incision. continue PT. ?transfer to F2 today.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536568, "text": "please disregard above note, written on wrong patient\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536569, "text": "Respiratory Care Note\nPt received on 35% trach mask - water refilled x2. BS coarse bilaterally which clears with suctioning. Pt suctioned for small to moderate amts thick, tan secretions. MDI's given via spacer a/o. Cuff deflated with Passy muir valve on. Pt vomited at 4:30pm - trach suctioned with no secretions or vomit noted. Cuff reinflated and Passy muir valve taken off. Emergency equipment at bedside. Plan to continue to follow per airway protocol. Plan to transfer pt to 2 at 6pm.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-02 00:00:00.000", "description": "Report", "row_id": 1536427, "text": "PICC Line In Today\nNEURO: Continues on Prop drip at 20mcg, PERRLA, arouses to voice, PERRLA, MAE, does not follow commands, pain assessed with grimace/vital signs\n\nRESP: Current on CMV 50% & 10 PEEP, earlier was on PS but ABG was metabolic acidodid with base excess -11, last ABG 7.35 38 97 -5 21 and shows improvement after Pt was put back on current CMV settings, lung sounds clear at apices/dim at bases, suctioned for moderate brown, thick secretions\n\nCV: NSR without ectopy, HRs in 80s, SBP 110-120s, pedal pulses palpable, afebrile (low temps earlier during shift, current temp 99.6), PICC line (double lumen) placed at the bedside today. Discontinued R subclavian central line, cath tip sent . Plan for AVR on Thursday .\n\nGI/GU: TF continues at goal with TF residuals of 30mL/40mL, abd soft, bowel sounds present, no BM today; BUN/Creat/potassium elevated, Lasix discontinued, urine outputs low despite Lasix, , Foley draining yellow/sediment urine at no greater than 30mL/hr, last K was 4.3\n\nENDO: Continues on SSRI every four hours.\n\nID: WBC was 13.7, currently on Doxycycline, Genta, Bactrim, Vanco; R ear had moderate amounts of exudate, irrigated by NP, perforated tympanic membrane per EENT consult, Ciprodex ear drops started to R ear, ear culture sent .\n\nSOCIAL: Mother visited throughout the afternoon. Pastoral services provided a prayer and provided baptismal certificate to mother.\n\nPLAN: Continue to monitor neuro/resp/BP/renal function, LABS, replete lytes as necessary, check results of cultures, plan for AVR Thursday.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536390, "text": "BS CTAB. Extubated this AM but failed in 20-30 minutes - tachycardia, tachypnea, diaphoresis. Reintubated 7.5 ET, 24 @ the lip. Weaned back to CPAP. Will attempt to wean to extubate again when family is present due to pt's anxiety component.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-29 00:00:00.000", "description": "Report", "row_id": 1536538, "text": "NEURO: . inconsistently following commands. at times nodding approp. to questions. . MAE. periods of agitation through . ativan 0.5 mg IV with some effect. restrained per protocol.\nCV:sinus rhythm/Vpaced. no ectopy noted. SBP 90's-low 100's. skin warm, dry. DP/PT palp. pt removing pneumoboots. receiving sc heparin injections.\nRESP: received on trach collar. remained on trach collar until midnoc pt began having apneic periods, then placed back on vent. ABG on trach collar with increased CO2. lungs coarse/diminished clearing with suctioning. suctioned for tan, thick secretions.\nGI/GU: abd soft +bowel sounds new dobhoff in stomach confirmed by XR. tubefeeds restarted. held at midnoc for high residual. restarted at 30cc. opium tincture added to tubefeed for liquid BM. had loose BMx2 overnoc. drain with bilious drainage. foley with amber urine with sediment.\nENDO: elevated blood gluc. treated with CSRU RISS.\nSKIN: sternal wound healed. steristrips and sutures to L chest CDI. drain site no drainage dsd changed. with stage II. wound cleanse spray, duoderm gel and dsd applied. on air bed.\nSOCIAL: no calls this shift.\nA/P: continue to monitor cv, resp, skin care, advance tubefeeds as tol., trach collar as tol. monitor mental status.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-29 00:00:00.000", "description": "Report", "row_id": 1536539, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 Portex percutaneous trach tube. Tube patent. Stayed on 40% trach mask for 16.5 hours, then starte having periods of apnea and was placed on vent with MMV to rest for night. ABG drawn prior to placing on vent showed mild respiratory acidosis and good oxygenation. Will wean on trach mask again in AM.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2102-01-29 00:00:00.000", "description": "Report", "row_id": 1536540, "text": "RESPIRATORY CARE\nPT GIVEN PRIOR TO BEING PLACED ON TRACH COLLAR. SUCTION FOR SCANT AMOUNT OF PALE TAN SECREATIONS. BREATH SOUNDS DIMINISHED. SETTINGS NOTED IN CAREVUE.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-29 00:00:00.000", "description": "Report", "row_id": 1536541, "text": "NEURO- AWAKE,,APPROPRIATE,COOPERATIVE ALL SHIFT. CONCISTENTLY FOLLOWS COMMANDS. DOING ACTIVE ROM AND FOLLOWING INSTRUCTIONS FOR ANKLE PUMPS. LOOSELY RESTRAINED WITH NO ATTEMPTS TO PULL AT TUBES. OOB-VIA - TO CHAIR X 5HRS. MOM INTO VISIT FOR 3 HRS. PT MOUTHING WORDS AND POINTING TO CUP OF H20 ALL THE TIME.ATIVAN IVP X1 FOR SLIGHT RESTLESNESSS.\n\nCV- V-DEMAND WITH RARE A SPIKES. HR/BP STABLE. AFEBRILE.SKIN WARM,DRY,JAUNDICE. PLATELETS 715. TIBC,IRON,SED RATE DRAWN. NO EDEMA.BOUNDING PEDAL PULSES.\n\nRESP- 40% TRACHE COLLAR.LSC->BECOMING MORE RHONCHOROUS EARLIER THIS EVENING. FREQUENTLY SXING THICK YELLOW SPUTUM. TRACH CARE DONE.\n\nGI- ABD. SOFT. + BS. 1 SMEAR GOLDEN STOOL.BUTTOCKS CARE AND DIAPER CHANGED. JP WITH LARGE AMOUNT BILIOUS DRG.\n\nGU- FOLEY DRG ADEQUATE AMOUNT AMBER URINE WITH SEDIMENT.\n\nLABS- RESULTS PENDING.\n\nPLAN- CONTINUE WITH PLAN OF CARE. MONITOR NEURO,RENAL,RESP,GI,GU SYSTEMS. ADVANCE TUBE FEEDS AS TOLERATED. METHADONE IV A/O.\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536391, "text": "Resp: pt on psv 12/5/40%. Ett 8.0, retaped and secured @ 24 lip. Alarms on and functioning. Ambu/syringe @ hob. BS are clear bilaterally with diminished bases.Suctioned for small to moderate amounts of thick yellow secretions. Notable ^ in wob, bp, hr then placed on a/c 18/500/+5/40% with improvement noted. ABG 7.43/36/166/25. Sedation lightened to perform =100. Pt's hr, bp, rr increased immediately when placing on psv 5/0. Returned to rate and sedation. Pt is scheduled for or on wed for procedure. Will continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536392, "text": "Nursing Progress Note\nNeuro: sedated on propofol at 50 mcg/kg/min, while off for became very aggitated. Coughing, lifting head and chest off bed, hypertensive to 170 sys, hr 108, sats fell from 100 to 93. Opening eyes spontaneously while off. Now resedated, bilateral ue wrist restraints for safety of lines tubes and drains. primary language is spanish.\n\nCVS: t max 99.5 po, HR 90's sr, no pacing noted. SBP 118-170 (noted above). Pulses palp x 4 ext. Skin warm and dry. RSC cvl patent x 3 ports, left femoral a line dressing changed for drainage, intact with waveform transduced and blood return. Skin sloughing on bles, buttocks sheared off first layer of skin. Multiple areas of redness and continued sloughing on buttocks, duoderm placed but having difficulty sticking in moist environment. Generalized edema, worst in Bilateral feet to +2. Multipodus boots applied for early signs of foot drop. Electrolytes repleted md orders. right groin drainage bag with scant serous fluid from old stick site.\n\nResp: LS clear in uppers to dim and crackles at left base, now resolved after scheduled lasix dose. Sats on 0.4, 100. See above for event while RT doing . Suction for varying amounts of thick white to yellow secretions in ett, copious oral secretions. VAP protocol, HOB 30, SUBglottal sxn before ett retape and reposition. teeth brushed, q 4 hour mouth care, on sc heparin and ppi.\n\nGI: abd soft non tender, flat, bs positive. Tube feeding at goal 50 cc hour ensure via ngt. placement confirmed by air bolus. no flatus, no bm.\n\nGU: Foley cath with clear yellow urine.\n\nPain: no apparent.\n\nEndo: FS BS not requiring ssri coverage at this time.\n\nSocial: no contact from family this shift.\n\nHepatic: T tube draining thick golden bile, dsd applied to site after cleansing.\n\nPlan: attempt extubation vs. leave down untill OR on weds. Wean vent as tolerated, Tube feed, blood sugars, sedation control.\n\nSee carevue flowsheet and mars for further details and values. Continue to monitor per csru standards.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536393, "text": "weaning\nPt placed on cpap 7 ips, 0 peep--pt hr >114, sbp >180/, sat dipped to 95%- resp rate >40.\nA: ptplaced back on cpap 5 peep 10 ips\nR: cont with elevated resp rate >40, hr >110, sbp >170\nA: plan put back on ac until presedex/labatolol obtained then will re-attempt wean.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536394, "text": "wean attempt x 2\nD: pt placed on precedex at .5 with propofol at 30 mcq, labetalol started.\nA: pt placed on cpap with -0 peep 7 ips\nR: hr immed >110, resp rate >40 and labored, sbp to 150/\nA: pt therapist placed pt back on original settings immed thereafter.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536395, "text": "wean attempt x 3\nD: pt placed on cpap with 0 peep and 7 IPS-pt cont on precedex .7 and prpofol 10, labateloll to off maintaining sbp 130's/, resp rate from 24 up to 40's labored.\nA: decision made--place pt on cpap with inc ips to allow weaning. ips up to 15.\nR: tv .400, resp rate remained 30's, less labored.\nA: abg sent--pt appeared more labored at this time\nR: abg;s as noted, pt more alkalotic- blowing off co3- pt resp rate cont to slowly inc to 40's appeariung more labored, sat > 98% at this time\nD: dicussion with Dr place pt back on A as needed, wean to precedex alone of possible-plan family meeting tomorrow at 9am at which time translator should be available to discuss possible options for patient--including pt and family.\nsocial work aware and discussing plans with pt mother.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536396, "text": "update\nD: pt remains intubated on a/c 40%, 5 peep tv 500cc- pt changed from propofol to precedex- Dr want pt to wake enough to discuss surgical intervention. pt on precedex .7- very irritable--attempting to sit up in bed, gag with the ET tube. yet does not follow simple commands at this time. please refer to previous notes in regards to weaning attempts x 3. temp up to 101 this afternoon, wbc down slightly today.\nplan: family meeting with Dr at 9am - wed am-mother aware. hope to have pt awake enough to discuss surgical options/plans.\nneuro; pt had been sedated on propfol 50mg- weaned and changed to .7 precedex- pt irritable- gagging at tub-attempting to sit up in bed to pull at ET tube--yet pt much like a \"ragdoll\"--head flopping when pt attempting to sit up in bed. pupils equal and slightly rx to light. does not follow commands at this time. does respond to stimuli.\nCardiac: pt in sr rates 80-120-depending on agitation/restlessness- when weaning from vent hr >120. when sedated down to 80's, sbp correlates as well elvated with restlessness- down with sedation. pt started on labatelol in hold to control HR/SBP when weaning- pt sbp to 110/30--lababelol to off--with lower sbp- lower u/o- ? related to decrease renal perfusion. extremities warm and slightly diaphorectic- esp when associated with work of breathing.\nadded po-carvegilol- pt tol well- infact sbp >150/- added esmolol to hope to control hr/sbp with weaning--eventually turned to off.\npalp pedal pulses easily.\nresp: as not in previous notres, bs coarse, dim in bases bilat- tx for mod amt thick clear secretions. plan will keep intubated due to poor performance with weaning today.\ngi: tol tf well, no bm today- residual 15cc-t-tube draining brown/bilious fluid- 200cc this shift. ultrasound of abd done- \"looks okay\" per team- Surgery blue team following(GI)\ngu; foley draining yellow to amber colored urine--responds to lasix- u/o did dip in afternoon to 5cc/hr- ? due to lower bp- did not inc with inc in sbp - lasix changed to pt responded to dose nicely.\nskin: pt with \"slothing\" of skin on buttock- duodern will not stay on due to Hairy surface- pt kept off buttock as much as possible. underside of calfs also \"slothing\"\nPLan: or possibly thursday- team to discuss with family at 9am tomorrow- need trasnlator present.\nsedate pt on precedex only--pt cont to attmept to toongue tube out--remains restrainted.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536397, "text": "update\nD: pt mother in to see him- despite not following simple commands in english- pt listened to mother and appeared to nod approp. focused on mother. pt cont to cough \"aggressively\" _(lifts entire trunk off bed with coughing)-pt given intermittent bolus of propofol to aid in relaxation. pt has also attempted to tongue ET tube out.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 1536398, "text": "BS coarse crackles. Suctioned for mod amounts thick yellow secretions. Attempted and failed SBT x 4 with tachypnea, tachycardia, agitation. Rest on AC for night. Sedation will be lightened in AM and meeting will be held with family/patient with translator available to discuss options for future care.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-01 00:00:00.000", "description": "Report", "row_id": 1536552, "text": "Resp. Care:\n Pt. with #8 portex trach. Seen x 2 last night. Changed inner cannula once - coated with sm. amt. dried brown secretions. Pt. continues on 40% cool aerosol trach. mask. BS- bilat. coarse. Sx'd thick tan sputum in sm-mod. amt. Pt. can also and raise on own. Cuff inflated with approx. 7ml to achieve press. of 23cmH20. Rx with combivent MDI and flovent as ordered. Will cont. to follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-01 00:00:00.000", "description": "Report", "row_id": 1536553, "text": "7a-7p\nneuro: pt , oriented to person and place. MAE with equal strength. talking with mother in . +.\n\ncv: remains v-paced without ectopy. sbp 100-120. lytes repleated prn.\nOOB with PT this am, tolerated well, back to bed via . team aware that one of the ports (the white one) on the tripple lumen clotted, awating picc line placement.\n\nresp: tolerating trach collor well. ls coarse, dim at bases. o2sats>98%.\n\ngi/gu: indwelling cath draining sufficient mats amber color urine. tube feeds at 60cc/hr, 60 cc residual when checked. no stool.\n\nendo: RISS\n\nplan: continue to monitor. continue physical therapy, continue pulm toilet. continue search for rehab. picc line/j-tube\n" }, { "category": "Nursing/other", "chartdate": "2102-02-01 00:00:00.000", "description": "Report", "row_id": 1536554, "text": "Respiratory Care:Pt seen for trach care today. Lung sounds coarse that clear with suctioning, Pt also expectorates specially when PMV on. Suctioned for thick yellow/tan secretions.PMV on cuff deflated. Pt tolerating well. Emergency equipment at bedside. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-02 00:00:00.000", "description": "Report", "row_id": 1536555, "text": "Resp Care\nPt trached with 8 portex. Received pt on 40% cool mist with pmv, @ 2130 pmv removed and 7 mls of air placed cuff to maintain a cuff pressure of 25. Pt was suctioned for tan secretions. Cool mist weaned down to 35%. All emergency equipment at bedside. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-02 00:00:00.000", "description": "Report", "row_id": 1536556, "text": "7p-7a\nNeuro: Pt and orientedx2, mae weakly, perrla, follows commands, anxious at times. Methadone dose increased for anxiety and c/o incisonal pain.\n\nCV: HR 70-120s ( 120s w/ anxiety). V pacing via internal pacer. SBP >100. MAP>60. + palpable pulses.\n\nResp: LS clear diminished. Sats 100%. See carevue. Tolerating trach collar FiO2 35%, #8 Portex, trach care done. Suctioned for thick tan scant amts, also expectorates thick tannish via trach.\n\nGI/GU: Abd soft, +BS. Colace has been held for 3 days, dose given at 2100. Opium dc'd from TF. No BM this shift. Tolerating TF at goal 60cc/hr, no residuals. Foley draining dark amber color urine. drain to bulb suction draining clear bilious drainage.\n\nSkin: See carevue.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-09 00:00:00.000", "description": "Report", "row_id": 1536456, "text": "ekg vpaced via internal pacer, low 70s, no ectopy. sbp stable, 100s mostly, occ drop to high 90s. filling pressures stable, cco/ci, svo2 stable and hyperdynamic. remains on vasopressin at 3.6. afebrile. scant uo. glucose stable, k and ca repleted per sliding scale. wbc up to 22 this am. breath sounds clear, decreased at bases. ett suctioned for small to mod amts very thick tan pluggy secretions, but suctioned infreq because of unstable oxygenation. fio2 increased to .7, no other changes made. abd soft, distended, very few bowel sounds heard, small smear of stool x 1. tolerating renal tf at 35cc/hr with 50-70cc residuals. scant amts ct drainage, no air leaks noted tonight sternal incsion dry, , small amt serous drainage at pigtail site, l ct site dry. skin warm and dry, abraded areas on buttocks unchanged, small amt serous drainage, aloevesta applied. sedated with ativan, paralyzed with cisatracurium, has 4 twitches on .3, no gag, no , no spont movement except for slight movement of tongue with mouth care. morphine given for pain in addition to scheduled methadone. family called x 1, updated. plan to continue cvvhd, negative if tolerated, monitor hemodynamics, labs. support family.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-09 00:00:00.000", "description": "Report", "row_id": 1536457, "text": "Resp Care\nPt remains sedated, intubated on CMV. Fio2 changed to keep pao2>60. Plan to wean fio2 as tolerated per abg's.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-09 00:00:00.000", "description": "Report", "row_id": 1536458, "text": "Neuro: remains sedated and paralyzed on ativan and nimbex. some tongue mvmt with mouth care. 4 twitches but no spontaneous breaths or . ROM done. PERRLA. Ms04 intermittently for pain\nCV: Swan dc'd this am per Dr. . Remains paced via internal pacer at rate 75-80. Epicardial wires secured. no ecopty. BP 90-110, more 90's since 1600. cont on vasopressin 3.6 units/hr. maps>70. palp pedal pulses. plt down to 80, HIT from still pending. Heme consulted and addtional labs sent. No heparin in lines or CVVHD. Mediastinal CT with minimal drng, left in.\nResp: Required increase oxygenation this am due to O2 sats~87-89% and PO2 56. Continues on CMV , peep increased from 14 to 16 and Fio2 ^ to 80% from 70%, oxygenation improved with sats>90% and P02>70, Fio2 weaned again to 70% with no change in oxygenation. No further changes made. Sx for thick tannish sputum. Lung sounds essentially clear and slightly dim lt base. B/l pleural CT left in due to high peep per Dr. , minimal drng. Some serous drng around Rt CT site.\nGi: continues on trophic TF nutren at 35cc/hr (goal) residuals 40-60cc/hr. Team aware feeding via OGT sump in abdomen, asked for post pylorid dobhoff, ? on . abd soft, absent to hypoactive BS, small smear of golden soft stool on pad. JP in biliary stent, patent with brown drng\nGu: Essentially anurinc. continues on CVVHD, trying to maintain pt negative if possible. Pt tolerating 50-70cc/hr negative difficult to maintian at times due to quantitiy of antbiotics, Volume for antbx taken off over many hours. Acid base balanced, lytes repleted well via k+ and Ca gtts\nID: WBC^ 22 (from 18) Pan cx. Vanco/Gent levels low so pt recieved dose of each today will need it checked in am. Temps 98-99 on cvvhd with only thin blanket. Pt pan cx. Pt growing gram neg rods in sputum cx from --awaiting sensitivities. ID following. Plan to remove old pacemaker in cath lab tomorrow.\nSocial: mother in with interperter. Update on pt progress given, and mom signed consent for cath lab procedure with cardiology fellow\nPlan: cont cvvhd and run negative if possible. cont assess cardio/resp status. Will need dobhoff placed in am. ? reline in am if WBC ^. Plan procedure in cath lab tomorrw for old pacemaker removal, pt on call for afternoon case--? stop TF in am for procedure. Follow CX and HIT screen. Cont supportive care and wean o2 as tolerted slowly.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-10 00:00:00.000", "description": "Report", "row_id": 1536459, "text": "shift cover 2300-0700\n\nneuro: remain paralyzed and sedated on cisatracurium/ativan. tof on 20mA. raised eye brow & min tounge movement w mouthcare.no overbreathing/movements. gave scheduled methadone. morphine ivp prn. perl.\n\nid: low grade temp. wbc ^25 today. pan cx ->urine and blood pnd. sputum r/s gram negative rod. see ccc. on multi abx iv. id follow. sent daily level for both genta & vanco.\nLabs: HIT still pnd. na & lactaid acid & liver fnc improved. see careview\n\nrenal: cvvh machine initiated at b/g of shift. goal -50 or more as tol. hemodynamic stable &acid base balanced w increasing PFR. replete k/calcium per ss. creatine improved. anuric.\n\nresp: remained on AC .70/450x22/peep 16. sat 90->96. gas acid base balanced & pao2 mid 60s. ls cta, yet diminish both bases more L>r. MT, R apical pigtail CT & L pleural CT to sxn-min serosang drg- no leak/crepitus. sxn sm-mod amt tan secretion from lung and lrg amt subglotally x2. vap protocol.\n\ncv: av paced 100% via perm pacer. rate 70s-80s w/o ectopies. sbp 90s-110s/60s w map 70s-80s. No change in vasopressin gtt overnoc per team. skin w/dry. 2As/3Vs wires secured. pneumo boots and multipodus boots to les. palpable pulses.\n\ngi: npo. tf at goal via ogt. stopped at 0500 for tx to OR for perm pacer removal today. no residual. ruq drain to bulb sxn-mod amt of bilious-color drg.\nendo: bs wnr\nwound: skin periphral very dry/scaly. buttock w pressure sore stage 1. reposition as tol. applied vesta creams. heels . sm pressure sore on exterior r ear.\ncomfort: no family call yet/visit overnoc. support pt prn\n\na/p: tolerating goal -50 and more. hemodyn stabled. no changes in vent and gtts over night.\nNPO for OR today for perm pacer removal. Need dobhoff today. F/u vanco &gentamycin level. F/u HIT and labs/cx.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536420, "text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Respiratory rate decreased to 18BPM d/t respiratory alkalosis. Continues on A/C ventilation w/ PIP/Pplat = 26/23. MDIs given as ordered; minimal blood tinged secretions suctioned from OETT. SpO2 90s. ETT secure/patent. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2102-01-07 00:00:00.000", "description": "Report", "row_id": 1536448, "text": "update\nD: pt continues to do well hemodymnamically- off alld rips except vasopressin--will keep on per team- svo2 >70, ci >3 consistly. pt weaned to 80on vent, rate to 22 and tv to 450cc-\nchanged dialysis x 2-from ns to d5w with bicarb back to prismate.- appears to be better controlled.\nPlan: cont to attempt to wean fio2 slowly--pt with little reserve--\"baby steps only\", if pt tol remove fluid via cvvhd--0-100cc/hr- attempted 25cc- pt tol--will cont to titrate removal upward.\nneuro: pt paralyzed on cisatricurium-4 twitches noted yet proper effect noted--pt no gagging , coughing or working against vent. pupils 3mm- equal.\nresp: bs coarse, wheezes inspir/expir throughout, sx for yellowsputum in mod amts at times. weaned fio2 to 80%, pao2 60's sat >93% consistently. did tv to 450cc, and rate 22 with adeq response.\nas noted pt paralyzed to aide in oxygenation.\ncardiac: pt av paced at times, v paced at times- he appears to a sense and v pace most of the time- pt internal pacer firing and caputing well- pt satill awaiting to have old temporary pacer removed. pt cont with epicardiac leads attached to pacer box yet turned off. sbp .100- as noted vasopressin only. svo2 .70 with excellent co/ci.\ngi: abd soft, hypoactive bs--(pt cont on paralytic) written to restart tf via ogt at 35cc/hr- started at 10cc/hr at present will inc slowly. residual 25cc. cont on ppi, no bm today.\ngu: foley driang very small amt amber yellow urine, pt cont on ccvhd- goal to remove 0-100cc/hr- depending on hemodynamcis, changed filter x 1. creat 3.2 this afternoon, creat down to 2.8 this am--with replacement and changing od replacement fluid back up to 4.0 reange. pt met alkalosis- tx with changing replacement fluid. abg at 1600 noted to have elevated bicarb--(found dialysate fluid to not fully have emptied into solution) will recheck .\nskin: , reddened area on buttock (previos irritation) no drainage noted, pt turned side to side to keep off area. inc , all drsg .\nglu; glu elevated when replacment fluid d5w--started insulin drip--when changed to prismate--glu down to 50- tx with 1/4 amp d50 - drip to off- glu coming up 66-70.\nplan: support resp status--slow moves on vent.\ncvvhd- remove fluid carefully (start small then work upward in amts)\nkeep pt paralyzed and sedated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-07 00:00:00.000", "description": "Report", "row_id": 1536449, "text": "Resp Care\nPt remains sedated and intubated on CMV. Able to wean as noted per abg's. Plan to continue to wean slowly as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-08 00:00:00.000", "description": "Report", "row_id": 1536450, "text": "Respiratory Care Note:\n\nPt remain orally intubated & paralyzed on full ventilatory support. We weaned FIO2 from 80 to 70%, this morning after ABG look promising. BS are dim mildy and clear. Wea re sxtn mod to cop thick yellowisk plug. Plan: Wean as tol slowly & Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-11 00:00:00.000", "description": "Report", "row_id": 1536463, "text": "Neuro) Pt. sedated with Ativan and NM blocked with Cisatracurium. No change in infusion rates this shift. TOF checked q2-3hrs.\n\nCV) Pt. a-sensing and v-pacing without any interruption. BP improving to allow for Pitressin weaning to 1.2u/hr this morning. Skin warm and dry with palp. pedal pulses. Afebrile.\n\nPulm) CMV mode with increase need for Fio2 to 90% after PO2 54. PO2 improved to 70's. Rate down to 22 due to resp. alkalosis. No secretions when sx. BS clear to auscultation.\n\nGI) Tube feedings resumed at goal rate 35cc/hr Nutren Renal. Will need Dobhoff placed today. Very subtle bowel sounds. No stool.\n\nGU) Pt. to be straight cathed QD. CRRT in progress.\n\nSKin) Abbraised area over right buttock with tiny open sore. Drainage is serous. Cleaned with soap & water with skin barrier cream applied. All wound dressing sites documented on AFS. Scleral jaundice noted.\n\nID) started on Meropenem; ID to approve by morning. 1st dose given at 2400. Pt. on genta, vanco & bactrim. Afebrile. WBC 20 today.\n\nPlan) dobhoff placement. Continue CRRT with goal 50cc hourly removal. Wean Pitressin as ordered. Monitor gas exchange in view of high FIO2 requirements. Follow up with pending cultures. Continue to keep family informed.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-11 00:00:00.000", "description": "Report", "row_id": 1536464, "text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. BS clear bilaterally, Sx scant secretions. RR decreased to 22 FiO2 increased to .9. plan: continue to follow and adjust settings as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-11 00:00:00.000", "description": "Report", "row_id": 1536465, "text": "Respiratory Care Note\nPt received on AC as noted. PEEP weaned to 12 from 16 with initial increase in PaO2 from 61 to 71 - then PaO2 dropped to 58-65. Pt taken to CT Scan for chest secondary to ? PE - results pending. BS clear bilaterally, but diminished in LLL. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-11 00:00:00.000", "description": "Report", "row_id": 1536466, "text": "7a-7p\nNeuro: Pt sedated and paralyzed on nimbex and ativan gtts, goal of twitches w/ train of four, see carevue, titrating btw 0.4-0.45mg/kg/hr. Perrla. No spontaneous movement. No coughing w/ mouthcare.\n\nCV: HR 80-90 A sensing V pacing via permanent pacer. SBP >90. MAP>60. Vasopressin dc'd, pt tolerating thus far, goal keep MAP>60. +palpable pulses.\n\nResp: LS clear diminished left base. Sats 89-95%. PaO2 57-71, Np aware. See carevue. NP aware of ABGs. Present settings CMV 90% FiO2, rate 22 peep 12,tv 450, pt not breathing over vent rate. Travelled to CT, uneventful, sats 100%. SBP 100s, HR 80s.\n\nGI/GU: Abd softly distended, hypoactive BS. At beginning of shift, TF residual 120cc, NP aware, continue w/ tube feeds NP , reglan 5mg ivp q6 hours started. Ducolax suppository daily started today. drain, draining bilious brownish drainage, see carevue. OGT + placement Nutren FS Renal at 35cc/hr as ordered. At beginning of shift, CVVHDF filter clotted, changed filter x2, dialysis cath very positional. Disconnected at 1230, to travel to CT, deaccessed and accessed per protocol. Goal to -100cc/hr as BP can tolerate NP . See carevue. Straight cath for 40cc amber cloudy urine.\n\nID: Vanco held, d/t level 23. Gentamycin given and dose will be increased for tommorrow. Meropenem dc'd, cefepime started d/t results of cultures, see orders and CCC for details. Low grade temp 99.6 Ax, WBC 19.\n\nEndo: Glucose 70-80s. No coverage needed.\n\nSocial: Mother updated by NP ( mother in w/ friend ). Mother updated w/ plan of care.\n\nSkin: Small purple area to pt's right lower ear lobe. Cushion applied as pillow to try to keep pt off right ear. 2 abrasions on buttocks, see carevue. Wound care nurse aware and to see pt ?tomorrow. ? change bed to auto turn bed and vibrating air bed.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. Continue CVVHDF, goal -50 to -100cc/hr as pt can tolerate. Follow labs and treat as appropriate. Take daily vanco and genta levels. Staright cath daily. Need ua and uc ? to start diflucan.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-12 00:00:00.000", "description": "Report", "row_id": 1536467, "text": "Respiratory Care\nPt remains intubated on full vent support. Pt began overbreathing vent slightly this morning. Sedation increased to decrease pt's WOB. BS coarse bilaterally and throughout. Pt suctioned for moderate amounts of thick yellow secretions. MDIs given as ordered. ABG continues to show hypoxemia (PaO2=50's). Peep and FiO2 increased accordingly. Spo2=96%. not completed (PEEP>10). See CareVue for details and specifics.\nPlan: Wean PEEP & FiO2 slowly as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-12 00:00:00.000", "description": "Report", "row_id": 1536468, "text": "Neuro: sedated on Ativan gtt, paralyzed on Nimbex gtt, -of-four goal was 2... plan changed to keep totally paralyzed for continued poor ABG, no purposeful movement noted, pupils 4mm and sluggish\nResp:LS clear, vented, poor ABG's most of shift, did several adjustmets to Nimbex and vent with some results, see flow sheet for details\nCardiac: V paced, no ectopy noted, CVVH with good results, goal of -100cc/hr with good resluts\nGI: TF at goal via OGT, moderate residuals, + placement, no BM, no flatus\nGU: str cath X 1 for 50cc concentrated urine, CX sent\nEndo: no SSRI needed\nSocial: family called X1 and updated\nPlan: continue CCH goal, monitor labs and vitals and treat as indicated and as ordered\n" }, { "category": "Nursing/other", "chartdate": "2102-01-12 00:00:00.000", "description": "Report", "row_id": 1536469, "text": "Resp Care\n\nPt remains intubated and on full vent support; poor oxygenation entire shift; multiple attempts of increasing and decrease peep; Esophgeal data obtained; pt bronched; cxr L pneumo and chest placed.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536410, "text": "Respiratory Care\nPt remains intubated on ventilatory support. Pt. rested on CMV for most of the shift due to escalating RR and decreased Vt with decreasing SpO2 to 89%. AM 135, mode of ventilation changed to PSV, PS titrated to pt. comfort with good Vt and RR. PT does well until any intervention is performed such as hygiene, suctioning or even dressing changes, then RR escalates to 40's and pt slowly recovers with gradual improvement in RR and Vt but this process takes greater then 15 minutes. BP increases to 150's but this also improves to 130's with rest. Pt sx numerous times for thick blood tinged/tan secretions, BS coarse and with exp wheezes at times, clears with suction and MDIs. Plan is to continue with weaning process as pt. tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536411, "text": "NEURO: PT. LIGHTLY SEDATED ON PROPOFOL, AROUSES TO STIMULI, BECOMES EXTREMELY AGITATED WITH ANY STIMULI, PROPOFOL INCREASED WITH VENT SETTINGS FROM CPAP TO SIMV. PERRL. DOES NOT OBEY COMMANDS APPROPRIATELY, DOES RESPOND TO PAINFUL STIMULI-SPANISH SPEAKING.\n\nCV: PT. NSR, DOES HAVE PPM (VVI AT RATE OF 50), NO ECTOPY NOTED. HR 70-80'S,BLOOD PRESSURE 120-150- PT. BECOMES HYPERTENSIVE WITH AGITATION AND GAGGING ON ETT- PA NOTIFIED.INCREASE IN PROPOFOL REQUIRED AS WELL AS DECREASE IN STIMULI- IMPROVEMENT (DECREASE) MADE WITH SBP. 3.125MG CARVEDILOL GIVEN WITH NO SIGNIFICANT DECREASE IN BLOOD PRESSURE. PULSES STRONG PALPABLE.\n\nRESP: PT. LUNG SOUNDS COARSE THROUGHOUT, PT. SUCTIONED MULTIPLE TIMES FOR THICK, TAN/BLOOD-TINGED SECRETIONS. PT. ORIGINALLY ON CPAP- PLACED ON SIMV DUE TO TACHYPNEA AND DECREASE IN TIDAL VOLUMES. PT. PLACED BACK ONTO CPAP IN PT. BECAME TACHYPNIC, DECREASE IN TIDAL VOLUMES,SBP IN 180'S- PLACED BACK ON SIMV. PIGTAIL DRAINING LARGE AMTS OF SEROUS DRAINAGE- PA NILLSON NOTIFIED FOR OUTPUT AMT.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, TUBE FEEDS AT 70CC/HR, FOLEY DRAINING SEDIMENT, YELLOW URINE- LASIX GIVEN WITH GOOD U/O, LYTES REPLETED. BLOOD SUGARS TREATED PER PT'S SLIDING SCALE.\n\nID: TMAX 100.0- WBC 13, PAN CULTURE SHOWED GRAM NEGATIVE RODS IN SPUTUM.\n\nPLAN: WEAN VENT, BLOOD PRESSURE CONTROL, MONITOR RESPIRATORY STATUS AND PULMONARY HYGIENE, REPLETE LYTES, AND CONTINUE TO CURRENT PLAN OF CARE.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-21 00:00:00.000", "description": "Report", "row_id": 1536509, "text": "NEURO: Sedated on 2mg Midaz drip while Pt on CMV with 14PEEP MD, Pt follows commands, PERRLA (4mm/brisk), MAE, Gag/ \n\nRESP: Weaned vent from 50% to 40%, plan to continue wean with PEEP of 14, keep PaO2 >60, lung sounds clear, ETT suctioned for large amount of tan/thick secretions earlier in the shift\n\nCV: Sinus tach with HR in 120s, MD aware, SBP in 110-140s, pedal pulses palpable\n\nGI/GU: Continues on TF Nutren renal at goal 40cchr, Dobhoff post-pyloric, also on TPN, small liquid/ stools, held Dulcolax/please hold Colace, JP draining bilious at 50-75cc every 3-4 hours; Foley in place draining icteric/clear urine at >100cc/hr\n\nENDO: Continues on SSRI\n\nSOCIAL: Family visited in the afternoon.\n\nID: WBC was 26. Max temp 101.7, gave Tylenol and cultured blood/urine, last temp 100.8, changed abx (please see )\n\nPLAN: Wean vent as tolerated (keep Pa02 >60), continue to monitor fevers, neuro, resp, cv, urine output, LABS, replete lytes as needed\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536421, "text": "Neuro: pt sedated on propofol with good results, breakthrough aggitation X1.. medicated with fentanyl IVP X1 iwth good results, MAE's to painful stimuli\nResp: LS clear and diminished at bases bilat, decreased rate to 18 for resp Alk with good results, see Flow Sheet for details, minimal thick tan secretions, CXR X2 for ETT placement and NGT placement\nCardiac: SR, no ectopy noted\nGI: Probalance FS @ 70cc/hr, TF residulas < 70cc, PCXR for NGT placement, advanced X 2(7cm then 3 cm), + BS all 4 quads\nGU: foley to gravity drainage draining clear yellow urine with some sedimentation, UO >30cc/hr\nEndo: SSRI coverage X1, 4 units for regular insulin SC for BS 166 @ 1600\nSocial: pt's mother in to see pt several times today for short visits @ 10 minutes\nPlan: continue to monitor, follow labs and vitals and treat as indicated and as ordered, VAP per protocol, frequent repositioning, ? to the OR for AVR\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536422, "text": "dose changed on Vanco and Gent D/T elevated levels.. give next scheduled dose of each MD as directed by ID\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536423, "text": "OR cancelled for D/T elevated WBC, family aware, pt's mother, via pt's stepfather, questioned vent and TF status, reviewed plan with potential need of GT and trach, also updated on change in OR plans\n" }, { "category": "Nursing/other", "chartdate": "2102-01-02 00:00:00.000", "description": "Report", "row_id": 1536424, "text": "Nursing 7p-7a\nNeuro: Sedated on prop gtt. PERRLA. MAEs to painful stimuli & occasionally spontaneously. Add'l ivp fentanyl x1 for agitation. On po methadone.\nCV: NSR 60-70s. No ectopy. SBP 110-130. +PP. Lytes repleated.\nResp: CMV. No vent changes made this shift. Suctioned for mod amt dk brown sputum. Decrease in sat to 88%, sx'd lg plug x1. Lungs coarse throughout, dim in LLL. R pigtail w/lg amt serous drainage.\nGi: TF @ goal rate. BS x4. Abd soft & nt. No stool.\nGu: Min-adequate HUO. Mod diuresis from ivp lasix. Creat/BUN pnd.\nEndo: RISS.\nSkin: Sm abrasions in bilat buttocks. On airmattress. Aloe vesta cream applied.\nSocial: No call/visit from family or friends.\nID: Hypothermic. Warm blankets applied. On four different iv antibiotics. WBC pending. PM vanco dose held. Vanco trough to be drawn in am.\nPlan: ?daily wake up. Continue current poc. No OR today per team. f/u w/antibiotic dosing- id/pharm recommendations.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-02 00:00:00.000", "description": "Report", "row_id": 1536425, "text": "Respiratory Care\nPt remains intubated on ventilatory support. No vent setting changes made this shift. Experienced an episode of significant desaturation measured via pulse oximetry at which time pt was suctioned but unable to obtain any secretions, pt. then began coughing and was able to dislodge a large plug of thick blood tinged secretions up into ETT afterwhich oxygenation immediatly improved. No AM due to peep requirements. Plan is to continue to adjust ventilator settings as needed and not wean from ventilator at this time.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-08 00:00:00.000", "description": "Report", "row_id": 1536451, "text": "ekg av and vpaced via implanted pacer, rate 70s, no ectopy. epicardial wires attached but never used. sbp stable, 100-110, remains on vasopressin at 2.4. filling pressures stable, svo2, cco/ci are hyperdynamic. afebrile, cools down when uncovered. no urine output. glucose stable, calcium and k repleted per sliding scale cvvhdf continuous all night, no problems with access or equipment, some clot visible in top of filter now. breath sounds clearer, decreased at bases. ett suctioned for moderate to large amt thick yellow pluggy secretions. fio2 weaned to .7 with acceptable abgs, no other vent changes. chest tubes and pigtail draining scant amt, mediastinals still have air leak. abd soft, slightly distended, tolerating tf at 30cc/hr now, goal is 35cc. small smear of stool. sedated and paralyzed with ativan and cisatracurium, 4 lid twitches, but no movement, or gag. pupils equal, sluggish. family called x 2 for update. plan to continue cvvhdf, monitor electrolytes and hemdynamics, try to wean fio2 and peep as tolerated, provide family support.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-08 00:00:00.000", "description": "Report", "row_id": 1536452, "text": "Resp Care\nPt remains sedated, intubated on CMV. Able to wean fio2, plan to continue to wean slowly, follow abg's.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536385, "text": "Resp care note\n\nPlan has been to rapid wean and extubate pt this A.M. and this was attempted. Pt became increasingly more tachypneic and then diaphoretic. Using accessory muscle with marked supraclavicular contractions. Pt was put back onto PSV, temporarily 15/+5 with 50% Fio2. Sx frequently t/o the night for mod amts of thickish tan secretions. Plan to put pt back to 10/+ 5 when he is stabilized.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536386, "text": "NEURO-SEDATED ON PROPOFOL,NO PURPOSEFUL MOVEMENT OR TRACKING TO VOICE/STIMULI. PRECEDEX INTITATED WITH WEANING OF PROPOFOL TO ATEEMPT EXTUBATION IN AM. FENTANYL GTT @25MCG/HR.\n\nCV- NSR/ST NO ECTOPY SEEN. SITUATIONAL HTN/TACHYCARDIA. 5MG IVP LOPRESSOR X 1 WITH EFFECT. AFEBRILE. WBC=15.3 CONTINUES ON QUAD ABX COVERAGE.\n\nRESP-INTUBATED ON CPAP 40% 5/10 WITH SATS=96%. SPONTANEOUS EPISODES OF PROLONGED COUGHING REQUIRING SXING FOR COPIOUS AMOUNTS OF THICK TAN SPUTUM VIA ETT AND THICK WHITE IN ORAL CAVITY. ATTEMPTED X 2 TO WEAN SEDATION AND EXTUBATE. PT BECOMES TACHYPNEIC,TACHYCARDIC,RESTLESS,GAGGING, AND THRASHING IN BED.UNABLE TO TOLERATE PRECEDEX WEAN. PT .\n\nGU-MARGINAL BUT ADEQUATE HOURLY U/O. RESPONDS TO LASIX X 1HR THEN SLOWS DOWN.\n\nGI-ABD SOFT,HYPOACTIVE BS. NUTREN AT 50CC/HR. NO RESIDULE.NO BM\n\nLABS- K+,CA+ GLUCOSE LEVELS COVERED.\n\nPLAN- ATTEMPT EXTUBATION LATER TODAY. CONTINUE TO MONITOR HEMODYNAMICS,RENAL,LABS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536387, "text": "Abd: T tube draining bile. Site WNL\n\nSkin: Right groin w/wound drainage collection bag draining serous fluid from old groin puncture site.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536388, "text": "Abd: T tube draining bile. Site WNL\n\nSkin: Right groin w/wound drainage collection bag draining serous fluid from old groin puncture site.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-14 00:00:00.000", "description": "Report", "row_id": 1536477, "text": "Resp Care: Pt remains intubated via #8 ETT rotated and re-advanced back to 27cm MD . BS rel clear bilat. Sx'd for scant amt clear sputum in AM, and mod amt thick tan sputum in PM. MDI's given as ordered. Conts on 20 ppm of iNO (PAP= 30/27, 33/22 respectively). Conts to be paralyzed and sedated. No vent changes made this shift. Plan: cont vent support and iNO. Please see carevue for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-14 00:00:00.000", "description": "Report", "row_id": 1536478, "text": "update\nD: pt o2 requirements down to 50% , nitric oxide at 20 ppm- pao2 70-80- sat's 98-100%, et inserted 2 cm per team- inc amt of yellow sputum sx- sats dipping as day progressed to 93-94%-pt with ph 7.33- 7.30. bicarb wnl. pt paralyzed on nimbex - weaned to .4- 4 twitches noted out of 4--yet effect continues- pt not working against vent-no -no gag noted. ativan at 2mg/hr and pt on methadone. pt appears to have been incont of urine for past 3 days- when str cath-10cc oly obtained- thus cath inserted today- pt draining 10-15cc/hr thereafter- pt has yeast in urine- fluconazole added. hemodynamically pt stable- hr up to 120 at times- wonder if related to inc temp- pt temp 99.9 on cvvhd--\nplan; cont to pull off 50cc/hr if possible via cvvhd- wean cisatricurium if possible- labs obtained per renal protocol for cvvhd-\n? need for oxyhemaglobin while on nitric oxide.\nneuro: pt paralyzed on nimbex--4 twitches out of 4--yet pt not competing with vent-ativan cont. pupils 5mm-rx to light.\ncardiac; pt a sensing- v pacing- rates 98-118- ? elevation due to temp. sbp intially 120/50 dipping down to 90's as day progressed. extremties warm, dry- palp pedal pulses, svo2/co/ci- good.\nresp: pt cont on 50%-nitric oxide 20ppm-sat initally 99-100%- dipping to lower 90's with pao2 to 70's- bs coarse, bronchial on right side, ET tube inserted 2 cm--inc production of yellow sputum.\ngi: no tf today- residual 100cc this am- ogt remains clamped, ppi cont, abd soft, hypoactive BS to absent BS at times. suppository given - no stool at this time.\ngu: pt incont of urine intermittently- foley inserted for 10-15cc/hr of yelow/amber urine. creat 1.8 today- pt tol cvvhdf-\nskin: buttocks area remians unchanged- 2 small opens- protectorant applied-open to air.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-22 00:00:00.000", "description": "Report", "row_id": 1536510, "text": "ekg st, rate 110-120s, no ectopy. sbp stable, mostly in 120s. febrile to 103, tylenol given, temp down to 100.9 and now 101.6. was cultured on previous shift. uo 140-220cc/hr, icteric. k and mg repleted, glucose rx per protocol. breath sounds iniyially clear, now coarse throughout, ett suctioned for large amts thick tan secretions. remains on cmv, .40, peep weaned slowly from 14 to 11 overnight. abgs are acceptable, but spo2 relates to activity level; drops to 90 when active/agitated. abd slightly distended, soft, bowel sounds present, mod amts green thin liquid stool and small amt loose yellow stool x 1. tolerating renal nutren at goal, 40cc/hr, and remains on tpn at 33cc/hr. biliary stent draining large amts, bile. chest inciaion and ct sites dry, l neck and axilla dressings dry. skin hot, dry, jaundiced. l gluteal and coccyx sites pink, draining small amts serous,rx with double guard cream. cs in place and multipodus splint are on. opens eyes spont and to voice, squeezed hands to command, but inconsistent, mae spont. continues on versed gtt at 2mg/hr, supplental fentanyl x 1. plan to continue to wean peep as tol, maintain nutririon, follow labs and hemodynamics, support family.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-23 00:00:00.000", "description": "Report", "row_id": 1536515, "text": "ekg initially sinus tach, rate up to 120s, now 96, vpaced, no ectopy. rate dropped when pt defervesced. sbp 120s when awake, low 100s asleep. cvp 10 down to 5. temp max was 103, aspirin supp given with out effect, tylenol given per ngt and temp finally came down to 99. adequate uo, icteric, some sediment. glucose monitored, ca repleted. hct down to 26 this am. breath sounds coarse, ett suctioned for large amts thick tan secretions with plugs. no vent changes overnight. remains on cmv, .40, 8 peep. overbreathes vent to a total rate 28-34. ph has improved after one amp of bicarb, po2 is greater than 60. abd soft, distended, bowel sounds present, tolerating nutren renal at goal, 40cc/hr. small amt soft yellow stool x 1, but able to feel stool when giving suppository, so fleets enema given, no results so far. biliary stent draining large amts bile. sternal incision dry, , old ct sites covered with dressing, l pacer removal site dry. skin warm and dry, jaundiced. l gluteal and open areas pink, scant serous drainage, covered with duoderm. lip has small ulcerated area, slight bleeding during mouth care, but unable to see source. pupils 4mm, equally reactive. moves all extrem spont and occ to command, shook head approp to simple questions (\"do you have pain, are you cold\"). remains on versed at 4 mg, when not asleep, is restless, bangs knees against siderail for attention, can be soothed, but fentanyl 50 mg given x 2 for comfort. mother and friend visited, updated via interpreter. plan to monitoe labs and hemodynamics, follow culture results, have wound nurse and gluteal breakdown.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-23 00:00:00.000", "description": "Report", "row_id": 1536516, "text": "Respiratory Care\n\n Pt received on A/C placed on CPAP/PSV as documented in NARD. ABG acceptable. B/S sl coarse sx'ing mod to large amount thick yellow. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-26 00:00:00.000", "description": "Report", "row_id": 1536389, "text": "ROS:\n\nNeuro: Propofol gtt for sedation. Fentanyl gtt dc'd. Propofol off this afternoon x's 30 min, when off communicates w/family by nodding head yes/no to questions. Blinked eyes,looked side to side, wiggled toes, grasped and released hands all to command. PERRLA.\n\nCV: RSR/ST w/o ectopy. VSS. Has right subclavian central line. ABP line pulled out this AM prior to this nurse accepting patient assignment. Multiple attempts made for radial abp line w/o success. Left femoral ABP line placed. Peripheral pulses palpable w/ease.\n\nResp: Extubated this AM, became tachycardic (120's) and tachypnec (50s-60's). Reintubated w/in 30 min of extubation. Back on Vent and rate until this afternoon when back on CPAP and tolerating it w/o any resp distress, = rise and fall of chest and normal VS. Lungs clear. Sx tan secretions via ETT. Sats 98-100%. SQ heparin for DVT prophylaxis.\n\nGI: Ensure infusing at goal via sump via right nare w/minimal residuals. Abd soft w/active Bowel sounds. Protonix for GI prophylaxis.\n\nGU: Foley patent draining clear amb urein in QS. Lasix dose ^ to 40 mg w/fair response.\n\nID: Tmax 100.1 po. Remains on Vanco, gent, unasyn, and doxycyline.\n\nEndo: FSG covered w/RSSI.\n\nSocial: Mother, Father, Aunt, and in to visit. translates effectively.\n\nPlan: Obtain ABP line, wean vent as able. Wean sedation in AM w/family present and attempt extubation again then w/family present to offer support and comfort for patient. Pulmonary toileting, mobilization, Monitor, tx, support, and comfort. OR ?? Wednesday\n" }, { "category": "Nursing/other", "chartdate": "2102-01-16 00:00:00.000", "description": "Report", "row_id": 1536484, "text": "vpaced in 70s to 80s via internal pacer, no ectopy. sbp a little more labile tonight, vasopressin titrated between 1.2 and 3.6 to maintain map > 60. sbp may rise to 140s when awake. filling pressures stable. cco/ci stable and hyperdynamic. afebrile now, temp dropped from 38.8 to 37.7 immediately upon resumption of cvvh. uo 25-30cc/hr, yellow with sediment. new dialysis line placed by , xray confirmed, cvvh restarted at 2200, running close to even, no problems with new line. ca and k rx per sliding scale, glucose per protocol after insulin gtt stopped for low glucose of 77. breath sounds clear, diminished at bases, ett suctioned for small to mod amts thick tan secretions. ph down to 7.19 while dialysis on hold, 1 amp biacrb given. oxygenation improved overnight, peep dropped to 14 and nitric dropped to 15ppm. abd softly distended, no bowel sounds heard, no stool. ogt to lws, irrig several times, but no drainage at all. tpn continues. r pleural tubes draining scant serosang, 50cc from biliary stent.small serous drainage from l axilla wound. left ij dialysis cath site oozing steadily. remains off nimbex, fent continues at 50mcg, receiving methadone for maintenance. pupils 4mm, brisk, opens eyes to voice, moves all extremities spont, but does not follow speaker with eyes or follow any commands. no family contact tonight.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-16 00:00:00.000", "description": "Report", "row_id": 1536485, "text": "Resp Care\n\nPt remains intubated and on full vent support in the A/C mode. MV is being maintained in the 11-12L range with good ventilation. Nitric oxide weaned for 15 to 5. Plan is to wean to 0 by increments of 1. BS with scattered rhonchi and suctioning small amts of thick tan sputum.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-16 00:00:00.000", "description": "Report", "row_id": 1536486, "text": "update\nD; pt hemodynamically stable, a sensing-v pacing rate 80-90- no ectopy pt on vasopressin- sbp 80-120/50-able to wean vasopressin to 1.2 today- bs clear to coarse- able to keep fio2 at 50%, 14 peep-weaned nitric oxide to 5 ppm- with good abg's sat -100%. due to persistent elevated wbc and temp - cardiac echo done- \"looks good\" according to cardiology. pending final results.\nplan: cont cvvhd- when pt off pressors-? remove fluid. weaned nitric oxide slowly-according to team.\nneuro: pt responds to noxious stimuli- opens eyes to stimulation- does not follow commands, has mae on bed. pupils 5mm and sluggish rx to light. pt sedated on ativan 1.5 and fentanyl at 50- cont on po methadone.\ncardiac: as stated a sensing-v pacing. svp 80-120/50- titrating vasopressin as needed- presently on 1.2. extremities warm, dry, co/ci/svo2 hyperdynamic. cardiac echo done- \"looks good\"per cardiology team- no vegatation noted-no clots noted.\nresp: bs coarse throughout- sx for mod amt thick yellow- as noted weaning nitric oxide and pt appears to be hanling well, ct -in right pl space- draining min amts.\ngi: pt with ogt-clamped most of day with no residual- bs present, small soft stool noted- spec sent to lab for c.diff.-ppi cont- plan to place post pyloric ft- then restrt feedings. pt cont on TPN.\ngu; foley with amber urine with sediment noted in small amts- approx 20cc/hr. pt cont with cvvhdf- tol well- plan run even until pt pressor requirements off.\nskin: no futher breakdown noted, small scab noted right ear lobe- unchanged, 2 small areas on buttocks- double bond applied- skin looks better.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-24 00:00:00.000", "description": "Report", "row_id": 1536520, "text": "Resp Care\nPt remains intubated on PSV 8/6 40% no vent changes made this shift. BLBS very course, suctioned for copious thick tan secretions this morning and smaller amt of brown secretions this afternoon, sputum sample sent to lab for culture. MDIs given as ordered. Pt taken to IR this morning for feeding tube placement without incident. Plan to continue to wean as tolerated and possible trach tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-24 00:00:00.000", "description": "Report", "row_id": 1536521, "text": "UPDATE\nCV: A-SENSING, V-PACING 90'S-LOW 100'S. SBP DIPPED TO 80'S WHEN ASLEEP , THEN 78'S AFTER ATIVAN GIVEN FOR IR. BP RESPONDED WELL TO 200ML FLUID BOLUS. EXTREMETIES /DRY. SCD'S AND MULTIPODUS BOOTS ON LE'S.\n\nRESP: COARSE BS BILAT. SUX Q 2-3 HRS FOR THICK, TAN SECRETIONS. SPEC FOR CX SENT. VENT DOWN TO 5/5 @ 1830 THIS EVE; TOL WELL SO FAR, SPO2 MID 90'S. BEDSIDE TRACH POSTPONED TODAY DUE TO SURGEON UNAVAILABILITY.\n\nNEURO: PT W/ EYES OPEN SPONTANEOUSLY MOST OF SHIFT, OCC WATCHING TV(SPANISH SPEAKING STATION TURNED ON). DOES ATTEMPT TO REACH TUBES NEAR FACE WHEN ABLE. ATIVAN PRN FOR RESTLESSNESS. , SOC.WORK, SPOKE TO PT ABOUT NEED FOR TRACH, POSS TO BE DONE TOMORROW. SHE FELT THAT PT WAS ATTENDING AND SEEMED TO UNDERSTAND. DENIED PAIN WHEN ASKED IN SPANISH.\n\nG.I.: TO IR AGAIN TODAY TO REPLACE CLOGGED FT. TF RESTARTED THIS AFTEROON. SMEAR OF SM AMTS OF SOFT STOOL X 2 TODAY. T.BILI DOWN TO 17 RANGE. CONT TO DRAIN DK, THICK BILIOUS FLUID VIA T-TUBE.\n\nG.U.: 100-200ML/HR AMBER UO VIA FOLEY. CREAT 1.5, K+ REPLACED.\n\nI.D.: WBC UP TO 35. BUT AFEBRILE. CAPSOFUNGIN STARTED IV FOR YEAST.\n\nENDO: GLUCOSE WNL. NEED INSULIN ONCE TF RATE INCREASED.\n\nSKIN: ABRASION OF R EAR APPROX 2X2MM TX W/ ALOE VESTA SKIN CREAM PER SKIN CARE R.N.\n\nSOCIAL: MOTHER HERE TO VISIT AND SIGNED TRACH CONSENT. SHE WAS NOTIFIED OF POSTPONEMENT BY .\n\nA/P: NO PAIN BUT OCC RESTLESS, APPARENTLY FROM ETT IRRITATION. ATIVAN PRN. CONT WRIST RESTRAINTS FOR SAFETY. CONT TO SUX ETT FREQUENTLY TO CLEAR AIRWAYS. FLUSH FT Q 6 HRS TO MAINTAIN PATENCY. MONITOR GLUCOSE CLOSELY NOW THAT TF RESTARTED. RECHECK ABG ON NEW VENT SETTINGS. TRACH POSS TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-26 00:00:00.000", "description": "Report", "row_id": 1536527, "text": "Neuro: Pt is , follwing commands inconcistently; MAE's, UE lift & hold bilat; not cooperative with care; multiple attemtpts to pull trach, played with any tubes in reach, intructed pt not to pull any tubes\n\nCV: DDD perm pacer, v paced all shift, no ectopy; SBP 110's-130's; afebrile; AM hct 25; K & Ca repleted\n\nResp: #8 trach, on CPAP all night, , 40% FiO2, 43; lung sound clear bilat, suctioned with thick tan sputum; improved ABG\n\nGI: Abd soft, bowel sound x4, TF restarted post trach placement, impact @ goal 60ml/hr, no residual; dobhoff tube OK to use MD , abd X-ray done to confirm tube placement; T tube to JP in RLQ, draining copious amount billious clear drainage; multiple yellowish brown pasty stool\n\nGU: Foley draining huge amount amber clear urine\n\nInteg: Jaundice all over\n\nSocial: No call overnight\n\nPlan: ?trach collar attempt; OOB to chair; skin care; monitor hemodynamcis; monitor labs, repleted PRN\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536492, "text": "RESP CARE: Pt remains intubated/on full vent support. No changes in vent settings though NO weaned to 1PPM this am at 0615. SEE CAREVUE. Lungs coarse bilat,few wheezes. MDIs per . SXd mod amts thick yellow/tan sputum. Pt overbreathing vent 1-2 breaths at times with stimulation. ABGs this am reveal slight increase met acidosis. No this am due to high PEEP. Continue full support.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536493, "text": "RESP CARE: Methemoglobin level 0\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536494, "text": "Respiratory Care Note\nPt received on AC as noted with 1ppm of nitric oxide (NO) in line. BS coarse bilaterally. Pt suctioned for moderate amts thick secretions. MDI's given with improved aeration - slight coarseness persists on R side. Pt placed on 100% at 11:30am in preperation for turning off NO. NO turned off at 12noon. Follow up ABG's reveal metabolic acidosis with good oxygenation. FiO2 slowly weaned throughout afternoon. ETT repostioned and retaped without incident. Plan to continue on current settings at this time and wean FiO2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536495, "text": "Neuro: Pt sedated on 1.5 ativan & 25 fentanyl @ beginning, no response to stimuli, discontinued fentanyl @ ~0900, ativan decreased to 1, open eyes to stimuli, MAE's, lift&hold on UE bilat, LE move on bed bilat; 4mm, brisk; not following commands, look @ nurse when name was called\n\nCV: T max 38.5 C, no tylenol given d/t elevated liver enzymes, ice pack applied; V paced 90's-100's, no ectopy; SBP 90's-110's, MAP >60; SvO2 60's-70's, CI>4, PAD 30's; Ca & K repleted\n\nResp: Intubated on CMV 14 PEEP, weaned off nitric oxide @ 1200, FiO2 set to 100% for support, ABG post nitric oxide turned off revealed metabolic acidosis, ABG improving as FiO2 weaning, now on 80% FiO2; lung sound coarse, suctioned with thick tan sputum; bed percussion turned on for chest PT with improvement; CT to water seal, draining minimal drainage\n\nGI: Abd soft distended, hypoactive bowel sound; TF Vivonex advanced to goal @ 60ml/hr, residual 5-120 ml; TPN @ 66.7 ml/hr; tiny loose brown stool x1 post PR ducolax; abd xray done to confirm dobhoff tube placement, tube @ anthropyloric region; RLQ JP draining bilious drainage; reglan q6h IV changed to renal dose\n\nGU: Foley draining clear ambner urine, UO >100 ml/hr\n\nInteg: Coccyx area breakdown with yellowish white wound base, cleansed with soap & water, double guard cream applied; L axillary incision with suture, moderate amount serous drainage, see carevue for detail assesment\n\nEndo: Cover per CSRU protocol\n\nID: Febrile; receivng IV bactrim, flagyl, meropenem, cipro,doxycycline; AM vanco dose held d/t high trough level\n\nSocial: Mother visited & updated through interpretation by social worker \n\nPlan: monitor hemodynamics; replete lytes PRN; wean FiO2 as tolerated; cont IV antibiotics; wound care\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536496, "text": "Addendum:\nPlan to have g-tube placed at the time general surgery take out the pigtail tube & cholectomy, if not, will get post pyloric dobhoff placement in IR per team; stopped TF after midnight for possible procedure in AM\n" }, { "category": "Nursing/other", "chartdate": "2101-12-29 00:00:00.000", "description": "Report", "row_id": 1536404, "text": "Nursing Progress Note:\nNeuro: Pt sedated on propofol gtt. Opens eyes to tactile stimuli. MAE. Localizes to painful stimuli. Cough and gag intact. Perl 4mm brisk.\n\nResp: Lungs coarse. Sats 100% on AC 15/5/500/40% Suctioned for moderate amount of thick, tan secretions.\n\nCV: SR w/ BBB. HR 60's. Occasionally HR decreases to 56-58. MAP >60. ABP 130/40's. Low grade temp. Pulses palpable. Skin abrasion noted to coccyx and left calf area. K 2.7, repleted.\n\nGI/GU: Abdomen soft, flat. NPO since MN. Fecal bag intact. JP with brownish drainage. Foley cath. Good diurese with lasix.\n\nID: Vanco, Gent, zosyn\n\nEndoc: RISS\n\nPlan: To OR today for avr? Pulm hygiene. Wean vent.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-29 00:00:00.000", "description": "Report", "row_id": 1536405, "text": "Respiratory Therapy\nPt presents orally intubated on full ventilatory support. BS coarse bilaterally clear after Sx. Sx for moderate amounts thick tan secretions most of night. This AM produced a more rusty colored secretion, spec sent to lab. MDI's as ordered no change in BS or aeration.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-29 00:00:00.000", "description": "Report", "row_id": 1536406, "text": "RESPIRATORY CARE: PT W/ AN 8.0 ORAL ETT IN PLACE.\nCHANGED TO PS 5/5. 103. BRONCHOSCOPY FOR A\nBAL. CHEST TUBE FOR RIGHT PLEURAL EFFUSION. WILL\nREMAIN INTUBATED OVER NIGHT. SX TAN. COMBIVENT\nAND FLOVENT MDI'S GIVEN.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-26 00:00:00.000", "description": "Report", "row_id": 1536528, "text": "Respiratory Care\nPt placed on trach collar for approximately six hours before increased shortness of breath. Suctioned for small amounts of thick tan secreations. MDI's administered as ordered. Placed back on mechanical ventilation as indicated in Carevue.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-26 00:00:00.000", "description": "Report", "row_id": 1536529, "text": "shift update:\n\nneuro: . follows commands but . turned s->s inbed frequently. oob->chair via , required total lift back to bed d/t off pad. tolerated well. tylenol x1 for abd pain w/fair effect. wrists restrained d/t pt frequently pulling off vent.\n\ncv/skin: vpaced. no vea. bp stable. k+ & ca repleted see flow sheet. jp w/lg amt drainage. areas ota d/t frequent stooling & skin care. perineum red w/small amt ss drainage noted. +pp bilat.\n\nresp: lungs coarse. expectorated & suctioned for lg amts thick tan secreations. tolerated trach collar for 5 1/2 hrs. abg's acceptable on trach collar.\n\ngi/gu: +bs. tolerating tf. frequent stooling. able to visualize hard stool in rectum, aware mg citrate & fleets enema given w/only liquid return. aware of results & need for probable disimpaction. lg uop.\n\nendo: bs wnl no ssri given.\n\nsocial: mother into visit update given.\n\nplan: cont current plan of care. replete labs prn. rest on vent overnight, trach mask in am. ?disimpaction by pa/md.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-28 00:00:00.000", "description": "Report", "row_id": 1536534, "text": "NEURO: . . following commands inconsistently. at times nodding to questions, at times not responding, agitated. ativan 0.5 mg IV for agitation with some result. MAE. restrained per protocol.\nCV: sinus rhythm. with some V pacing. few PVC's noted. SBP 90's to low 100's. tolerating 12.5 mg lopressor po dose. CVP transduced off CVL. skin warm and dry. PT/DP palp.\nRESP: on trach collar at beginning of shift tiring with apneic episodes so placed on vent overnoc to rest. suctioned for thick tan secretions. lungs clear upper fields with diminished bases bilat. pulling at trach overnoc, disconnecting from vent several times.\nGI/GU: abd soft + bowel sounds. tolerating tubefeeds at goal with no residual. opium tincture added to tubefeeds for mult. liquid golden stools. foley with amber urine with sediment.\nENDO: blood glucose elevated treated with CSRU RISS\nSKIN: with open area scant serosang drainage. covered with duoderm gel and dsd d/t frequent soiling and changing. sternum approximated open to air. abd JP with bilious drainage dsd changed. R chest steri strips, sutures CDI. open to air. on special bed. freq skincare/turn and position.\nSOCIAL: no calls this shift.\nA/P: continue to monitor cv, resp, tubefeeds at goal. plan trach collar today as tolerated. freq skin care. orient prn/restraints per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-28 00:00:00.000", "description": "Report", "row_id": 1536535, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with 8.0 Portex Percutaneous trach tube. Placed back on vent to rest d/t periods of apnea >30 seconds. Placed on MMV with back-up Vt=500, RR=10. Tolerated well. Airway patent. Inner cannula changed. Sxn for thick tan secretions moderate amount. completed on PS 5=29. Will place back on trach mask this AM.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2101-12-25 00:00:00.000", "description": "Report", "row_id": 1536381, "text": "neuro/resp: sedated on propofol, arousable to voice but no purposeful tracking or following commands. ?language barrier vs. sedation? attempted vent wean with precedex but pt became extremely tachypneic,tachycardic,htn,agitated,thrashing with uncontrollable gagging.sxd for copious amounts thick white secretions via ett and oral cavity. multiple vent settings made with no change in pt response. pt re-sedated on propofol until AM. ls course continued to sx thick white-> clear secretions. abg wnl. sats=99%.\n\ncv- tachycardic/htn tx with 5mg ivp lopressor with effect then became tachycardic/htn in response to vent/sedation wean. no change in vitals while on precedex. propofol re-started & vital signs normalized.t-max=100.1, 3+ pedal edema. ck-mb x3 for previous elevated st segment on EKG.\n\ngi- abd soft,+ bs,large soft mushy stool x1. c-diff spec.sent.t-tube draining mod.amount clear bile.Nutren FS started @50cc/hr(goal) via ngt.\n\ngu- foley patent drg clear amber urine. 20mg ivp lasix for dwindling u/o with little response. lasix order.bun/cr 28.0/1.0\n\nlabs- no repletions given. wbc=15.3\n\nsocial- family is spanish speaking only. mother stayed in waiting room last night. visited x2. nephew is spokesperson.\n\nplan- needs central access for triple abx tx.repeat echo today. attempt to wean/extubate. continue assessment of hemodynamics.labs.renal systems.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-20 00:00:00.000", "description": "Report", "row_id": 1536501, "text": "NPN 7p-7a\nSee carevue for specifics:\nAlert, PERRLA at 3-4mm with brisk reaction, follows simple commands , squeeze hands upon command, but does not wiggle does ? able to, does move both legs to the side. Anxious at times, attempts to lift self off bed. Appears comfortable at rest. Tmax 100.0. HR 80s-low 100s V-paced no ectopy, ST with activity. SBP low 100s-120s. HCT stable at 26.3, WBC trending up 25.1, LFTs trending up. Intubated on AC 450x30, PEEP 14, FIO2 60%, repeat ABGs showed metabolic acidosis with good oxgenation. LS coarse & diminished at bases, sxn'd multiple times for mod amts of thick, brownish sputum. Rotataion & percussion q2hrs as tol. ABD, softly distended, (+)BSX4, JP with sm amts of bilious drng. TFs tol at 30cc/hr, goal 40cc/hr pedi tube on hold for ? testing today (check patency of drain). OGT clamped. Foley with adequate dark u/o 160-220cc/hr, creatine stable at 2.4. Sternum staples c/d/i, L shoulder/upper chest steri strips , LUQ sutures c/d/i. Coccyx stage 2, with mod amt of cream diff to assess. No family contact over-.\nA/P-Stable, continue to monitor hemodynamics closely, wean from vent as tol, pulm toileting, monitor lytes & hct, TFs on hold for ? drain testing today (IV dye), monitor skin integrity obtain skin care consult, rotation q1-2hrs as tol, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-20 00:00:00.000", "description": "Report", "row_id": 1536502, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. FI02 weaned to .50/02 sats 96%. Lungs coarse with wheezes, sl dim R lung. Sxd mod amts thick brown sputum. ETT retaped. No due to high PEEP level. Continue to wean PEEP as tol.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-20 00:00:00.000", "description": "Report", "row_id": 1536503, "text": "NPN Addendum\nAttempted to wean FIO2 placed on 50%, ABG showed worsening Acidosis with poor oxgenation 7.28/69. Placed back on 60%, will repeat ABG. Vanco trough to be drawn at 0600. Very sm loose BM, ? need for enema. Will continue to monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-20 00:00:00.000", "description": "Report", "row_id": 1536504, "text": "BS coarse crackles; no change with MDI's. Sx'd for mod amount blood-tinged brown secretions, less than yesterday. Continued slow improvement, much more cooperative. Temp to 102.1. Able to wean FiO2 to 55%, continue as tolerated. Cholangiogram today; preliminary no stones, ducts clear.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-29 00:00:00.000", "description": "Report", "row_id": 1536407, "text": "csru nursing update\nSB-NSR, no ectopies. hypertensive to 180s when agitated, sbp ~120s when calm. afebrile today. abg/sao2 wnl on cpap pps, but pt unable to tolerate ET per mother -> gagging and agitated. on/off prop/precedex, fent bolus also given with short effect. rt pigtail also inserted, drains >100cc/hr serous fluid. ET secretions tan/thick initially requiring hourly suction, bronched -> no significant amount of secretions per IP. easily rousable with prop 40, requiring occassional 1cc bolus. pt and mother non-english speaking -> requires spanish interpreter. obeys some commands, nods/shakes head when asked. appears to mouth words at times, able to lift head and shoulder off the pillow. kept npo today. diuresis excessive with lasix tid, k+ remained low despite repleting regularly. pressure areas per carevue, wound rn informed of pt's skin issues. mother visited most of the day, soc worker to interpret mostly for her.\n\nplan: keep on cpap overnight - titrate propofol\n pulmonary toilet\n cont plan of care\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536408, "text": "Respiratory Care\nPt continues to experience episodes of coughing and congestion requiring aggressive suctioning, RR remains evelvated in the high 30's to low forties with increased BP. Mode of ventilation changed back to CMV with immediate positive response with decreased RR and decreased BP.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-30 00:00:00.000", "description": "Report", "row_id": 1536409, "text": "Respiratory Care\nPt continues to experience episodes of coughing and congestion requiring aggressive suctioning, RR remains evelvated in the high 30's to low forties with increased BP. Mode of ventilation changed back to CMV with immediate positive response with decreased RR and decreased BP.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-10 00:00:00.000", "description": "Report", "row_id": 1536460, "text": "A Shift\nNeuro: Pt paralyzed on nimbex, continuing to get 4 twitches out of 4 w/ MA 10, NP aware, Nimbex parameters increased. Pt attempting to open eyes w/ oral suctioning. Perrla 4mm-5mm brisk. No evidence of pain. Ativan gtt decreased to 3mg/hr NP .\n\nCV: HR 70s pacing AV a sensing v pacing. SBP 90s. MAP>60. Vasopressin decreased to 2.4units/hr, tolerating thus far keeping MAP>60. + palpable pulses. To go to cath lab and get old perm. pacer removed. HIT pending.\n\nResp: LS clear diminished. See carevue. ABGs showing PO2 50s, NP aware, rate increased, fio2 to 80-90% increased, gradually weaning as pt tolerates to keep sats >92%. Right and left pleural CT to suction w/ scant drainage.\n\nGI/GU: Abd softly distended, hypoactive BS. TF on hold d/t going to cath lab. drain draining bilious tannish. Foley dc'd at 0900 per team, to be straight cath daily. CVVHDF w/ goal -50cc/hr, see carevue, for 7am and 8am outputs together, see carevue. Filter clotted on hold at present since going to cath lab. Deaccessed per protocol, use heparin NP .\n\nEndo: No coverage.\n\nPlan: Monitor hemodynamics. Monitor resp. status. To cath lab for old pacer removal. Restart CVVHDF when pt back from cath lab. Line changes. Restart TF once pt back from cath lab. Keep pt paralyzed for oxygenation issues.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-10 00:00:00.000", "description": "Report", "row_id": 1536461, "text": "Resp Care\nPt remains sedated and intubated on CMV. Esophageal Balloon was reinserted, measurements done, pt is at correct peep level. Fio2 adjusted to keep sats >92. Pt traveled to cath lab without incident. Plan to wean as tolerated and follow abg's.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-28 00:00:00.000", "description": "Report", "row_id": 1536536, "text": "Respiratory Care\nPt placed on trach collar for prolonged period of time, out of bed much of the morrning. Suction for small amount of pale tan secreations. MDI's given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-28 00:00:00.000", "description": "Report", "row_id": 1536537, "text": "See and Carevue for detailed documentation\n\nNeuro: Rec'd patient agitated, combative. Pulled self off vent, pulling at trach. Trying to hit staff. Haldol given with good result. Ativan also given. Inconsistently responding to commands. Responding ? appropriately to mother. and mother updated with interpretor.\n to chair, tolerated OOB well with mother present. Again pulling at tubes in afternoon, s/p methadone. Ativan given, with some improvement. Patient remains restrained, uncooperative.\n\nResp: On trach collar 40% day. Tol well with Resp , SAT 100%. BS coarse-> clear, good aeration. Venous pH 7.33. Suctioned every 2 hours for mod amounts thick yellow secretions.\n\nCV: Vpaced, HR 70's,occassional tachy to 120's with agitation. BP stable 100-110/40. Afebrile. CVP discontinued. Potassium and calcium repleted.\n\nGI: Tube feeds into stomach, residual 30ml. Tol well. Small BM x2.\n\nGU: Foley draining large amounts amber urine with sediment.\n\nSocial: Mother in, keeps patient calm. Updated with interpretor.\n\nPlan: Continue cardiopulmonary monitoring. Xray for NGT-> restart tube feeds. Continue on trach collar-> keep sat >95%. Follw venous pH.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-30 00:00:00.000", "description": "Report", "row_id": 1536542, "text": "RESP CARE: Pt remains trached with 8.0 Perc trach, cuff pressure 25cmH20.On TC until 2am, periods of apnea while asleep, placed on MMV, Vts 300-800/RR 4-20. Lungs coarse bilat. Sxd thick yellow/tan sputum. MDIs per . Tol well. Pt asking for H20. this am on 0 PEEP/5 PS was 22. wean to 24 hrs on TC/? swallow ..\n" }, { "category": "Nursing/other", "chartdate": "2102-01-30 00:00:00.000", "description": "Report", "row_id": 1536543, "text": "NEURO: . nodding appropriately and mouthing responses to questions. able to make needs known. constantly asking for water. denies pain. napping on and off slept total 3 hrs. calm most of shift with few periods of agitation. restrained per protocol.\nCV: sinus rhythm/Vpaced no ectopy noted, some A spikes noted. SBP 90's 100's skin warm and dry, DP/PT palp. k and mag repleted.\nRESP: on trach collar until almost 0230. tiring, placed on vent to rest. lungs coarse with dim bases. improved with freq suctioning while on trach collar tan thick secretions. upper lungs clearing somewhat. improved from assessment sat .\nGI/GU: abd soft. +bowel sounds. pt pulled NGT at beginning of shift. reinserted by md. in stomach place confirmed by XR. feeds restarted, pt tolerating. golden loose BMx2. opium tincture added to feeds. foley with amber urine. drain with bile draining. NPO but requests water freq. mouth swabs done.\nENDO: blood glucose elevated. treated with CSRU RISS.\nSKIN: see careview for details. stage II , drain site, L chest sutures/steristrips. turned and positioned freq. air bed.\nSOCIAL: no calls this shift.\nA/P continue to monitor cv, resp, mental status, blood gluc and lytes, skin care and positioning. advance tubefeeds to goal 60/hour as tol. ?OOB to chair. trach collar today as tol.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-25 00:00:00.000", "description": "Report", "row_id": 1536382, "text": "Resp Care: Pt continues on mechanical ventilation AC 600 x14 30%+5. ABG: WNL. Attempted to wean pt to CPAP/PS at 2330. Pt became extremely tachypnic, tachycardic, and agitated. PS increased to 15 without improvement. LS generally clear. sxn'd large amounts of thick white/clear secretions. pt with large amounts of clear oral secretions. this am: 112. During pt became tachypnic and tachycardic. pt continues on AC. PLAN: wean and extubate.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-25 00:00:00.000", "description": "Report", "row_id": 1536383, "text": "Significan events: Right subclavian placement, TEE, throacentesis (1600 cc removed)\n\nROS:\n\nNeuro: Sedated on propofol gtt, fentanyl gtt for pain mngt. Strong cough and gag reflexes. Lighter at times then others, during those times has eyes open at times and random movements. Consitantly withdraws to pain. PERRLA.\n\nCV: RSR w/o ectopy. Noted ST ^ on bedside monitor. Serial CPK/MB done. VSS. Right subclavian placed today. Has right radial ABP line. Peripheral pulses palpable w/ease. TEE also done today.\n\nResp: Remains orally intubated and on vent, currently CPAP 10/5 no resp distress noted, = rise and fall of chest. Lungs clear. Sx ETT for small clear secreations.\n\nGI: sump via left nare w/TF infusing w/minimal residual. Abd soft w/active BS. PPI for GI prophylaxis.\n\nGU: Foley patent draining clear amb urine in QS. Lasix this AM w/fair response.\n\nID: Afebrile. Remains on 4 different ABx.\n\nSocial: Mother in to visit several times today. Speaks only spanish, interp used.\n\nPlan: Pulmonary toileting. Mobilize. Wean sedation as able, wean vent as able. Monitor, tx, support, and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-25 00:00:00.000", "description": "Report", "row_id": 1536384, "text": "BS generally CTAB. Weaned to PSV 5/5 without incident. Will continue as tolerated and weaning sedation as tolerated. Extubate tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-10 00:00:00.000", "description": "Report", "row_id": 1536462, "text": "Addendum\nRemains paralyzed 1/twitch w/ 20MA w/ nimbex at 0.6mg/kg/hr. Not moving any extremeties. Perrla.\n\nBack from cath lab, see cath lab notes for details. Uneventful. Dsg CDI to left upper chest. Trauma lines and dialysis cath in process of being changed to different sites, d/t high wbc. Epicardial wires dc'd at bedside at 1645, see carevue.\n\nContinues on CMV PEEP 16 rate 24, fiO2 75%, pt not breathing over vent settings.\n\nCT dc'd at bedside at 1700. drain still , draining bilious brownish green drainage.\n\nPlan: To restart CVVDHF once lines established. Restart TF.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-12 00:00:00.000", "description": "Report", "row_id": 1536470, "text": "shift update:\n\nneuro: remains paralyzed & sedated on nimbex & ativan. ativan decreased to 2mg/hr per dr & . no spontaneous movements. 0/0 twitches on ma 10. no gag or reflex. pearl but sluggish. minimal turning d/t decompensated resp status.\n\ncv/skin: vpaced w/pvc's noted. hr ^ low 100's started on coreg. sbp dropped to high 70's low 80's->ns 250cc bolus given & albumin x1 w/improvement noted. k+ & ca gtts cont w/cvvhd. dsg's d&i. coccyx wounds ota->wound nurse unable to assess d/t resp compromise, she will be into first thing in the morning. ns w-d dsg only, no duoderm per wound nurse. +pp bilat.\n\nresp: lungs coarse. abg's acidotic, pao2 50-60's on 100% fio2. sat's 81-94. peep increased w/dropp in sat. rate increased w/no effect. pressures checked by resp->needs only peep of 10. sat's dropped to low 80's->bronch done tolerated poor. cxray showed lg right pneumo->ct inserted w/130cc out initially. repeat cxray=pneumo resolved. sat's slowly improving currently 97%. suctioned for scant thick tan. tanish bile secreations suction from mouth team aware.\n\ngi/gu: tf via og. +placement. residuals>50cc & suctioned tan/bile colored secreations from mouth team aware. very hypo->absent bs. tf off for abd us. restarted vivonex at 10cc/hr do not advance. tpn to start tomorrow. no uop. st done overnight.\n\nrenal: cvvhd cont. goal currently to run even. replacement fluid changed to bicarb for acidosis. heparin infusing via syringe pump at 500u/hr.\n\nendo: no ssri coverage needed per protocol.\n\nid: temp 95.5 bedwarmer on->temp now 97. multiple ivabx. meds adjusted per id.\n\nsocial: step father called & updated. mother & friend into visit update given. social worker called to speak with family. priest into visit but unable to see pt at that time d/t ct insertion.\n\nplan: cont current plan of care. remain sedated/paralyzed. monitor resp status closely. cvvhd to run even.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-13 00:00:00.000", "description": "Report", "row_id": 1536471, "text": "Respiratory Care\nPt remains intubated on full vent support. FiO2 decreased to 90%. Last ABG shows partially compensated metabolic alkalosis with hypoxemia. MDI's given as ordered. BS coarse bilaterally, suctioning for small amounts of thick yellow secretions. not completed (PEEP>10). See CareVue for details and specifics.\nPlan: Wean FiO2 & PEEP as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-13 00:00:00.000", "description": "Report", "row_id": 1536472, "text": "Neuro) Pt. continues to be sedated with Ativan and neuromuscularly blocked with nimbex. Nimbex weaned until 2 twitches obtained. Dose currently at .6mg/kg/hr. No gag, no , PERL.\n\nCV) Pt. V-paced appropriately and BP stable off pressors. Afebrile. Skin warm & dry with palp. pedal pulses.\n\nPulm) Oxygenation poor and continues to require high levels of FiO2 90-100%. Peep at 16cm. ABG's showed met. alk. (pt. on bicarb in replacement fluid for CRRT). Renal fellow notified and replacement fluid changed back to Prismasate solution. ABG continues to be alkalotic with PH 7.51 and bicarb 40's.\nNegligable amount of pulm secretions. Right pleural CT drng minimal ~30cc q4hours. Right chest tube site very oozy requiring extra stitch.\nBleeding now controlled.\n\nGI) tube feedings vivonex at 10cc; residuals 100cc x2. feedings stopped at 0400 in view of lactic acid 6.8. Repeated (6.2).\nno stool as yet. Reglan 10mg IV q6, colace and dulcolax being admininstered. Very scarce BS.\n\nGU) incontinent x1 of mod. yellow murky urine w/sediment.\nCRRT in progress.\n\nSKin) buttocks with small open sores. Skin care nurse to see pt. today for . Skin barrier cream appplied after washing. All wounds and dressings documented on AFS. Scleral jaundice.\n\nEndo) sudden increase in BS's tp 300-400's. Large discrepancy with fingersticks and lab values. insulin drip started and titrated as needed.\n\nID) afebrile. WBC down today. Merepenam, Cipro, Doxicycline started.\nVanco per levels.\n\nplan) insulin titration due to sudden rise and fall after treatment.\nMonitor acid-base balance due to worsening alkalosis. monitor BP in the face of rising lactic acid. Wean FiO2 if possible. monitor HCT.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-13 00:00:00.000", "description": "Report", "row_id": 1536473, "text": "Respiratory care\npt on the vent changes made tol poorly. see respiratory page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-13 00:00:00.000", "description": "Report", "row_id": 1536474, "text": "update\nD: pt initally lookd better thia am- able to weaned fio2 to 80% and peep down to 12--abg okay.. due to pt hypotension and tenuous status- a cco was inserted via right subcl- placed easily, post cxr revealed inc ? pneumothx- abg worsened-ct which was placed yesterday appears to have clotted--ct sucked out for mod amt thick clot- no improvement noted, another curved ct placed right ant chest(pleural) for 250cc dark red material-pt INR 2.0- pt given 1 ppf prior to ct insertion. in the meantime pt receivied 1 unit pc- repeat hct unchanged--additional pc ordered thereafter- infusing now. pt hr remained v paced 90-100--sbp liable 110/50 to 70/40--pressors did not have to be started--bp up on own -- cvvhdf-cont- goal neg 50cc- pt appeared to tol- when able to pull off fluid-low K+ and altered bicarb- changed prismisate to solution with 4-b22-k4. cco placed- initial svo2 40--up to 65 eventually then as oxygenation dropped- svo2 dropped to mid 50's--pt does have adeq co/ci via thermodilution and .\nplan for thoracic ct today-pt oxygenation worsened- thus scan on hold.\nneuro: pt sedated on ativan, paralyzed on cisatricurium- .6- pt has 4 twitches out of 4-pupils 4mm- rx to light.\ncardiac; pt a sensing v pacing with own internal pacer- sbp liable 70-110/50-pt did not require any pressors at this time--tx with vol.\nor slowed fluid removal as well as stimulation to obtain improved hemostasis--pt very sensitive to all changed physical as well as fluid and drips. co/ci adeq svo2 45-65--depending on o2 status.\nresp: pt resp status improved as noted then dropped--presently back on 100% and 16 peep- pt with hemothx-tx with ct- sats dipped to low 80's with any change--recover slowly. bs brochial on right side, cl upper left, dim in bases. sx for nothing.\ngi: pt tol ft at 10cc only reglan given x 1, pt with no audible bs- pt on paralytics. ppi cont. no stool today- dulcolax not given due to compromised o2 status. started tpn today.\ngu: str cath for 5cc dk yellow urine, \"curd type yellow secretions noted as well- pt appeared to be incont of some urine--but when cath--no urine evident. creat 1.8 today--pt cont on cvvhdf- replacement fluid changed to B22-K4--all labs improved.\nskin; skin nurise in to see pt--visualized buttocks- cont o clean and apply double bond lotion. no other breakdown noted. when cco placed with trauma cordis--ozzing mod amt bloody fluid.\nplan; monitor closely--abg freq--please draw labs for ccvh- q 4-6 hours- keep and eye on the bicarb. if pt o2 status imrpoves may go to CT....\n" }, { "category": "Nursing/other", "chartdate": "2102-01-30 00:00:00.000", "description": "Report", "row_id": 1536544, "text": "Respiratory Care\nPatient placed on trach collar with cool aerosol early in the shift. Speeach evaluation today with Passey-Muir Valve. Noted that valve could be left in place but his swallowing was suspect.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-30 00:00:00.000", "description": "Report", "row_id": 1536545, "text": "7A-7P\nNEURO: . PERRLA. Cooperative. Nodding appropriatley to questions. P/M valve trial tolerated x2 hours. Faint weak voice. Failed swallow study today, remains NPO. No c/o pain. Methadone continues . Afebrile. Soft limb bilat wrist restraints in place, continues to pull at Dophoff. OOB to chair with lift today.\n\nCV: Vpaced @ 70. Underlying NSR. No ectopy. Lytes repleted as needed. SBP 100-110's drops to 80-90's while asleep. Metoprolol . Palpable pulses bilat. Skin warm and dry.\n\nRESP: Trach collar 40% since this am. Suctioned for small amounts thick yellow sputum. Strong productive . See above P/M valve trial. LS clear diminshed at bases. O2 sat 100%.\n\nGU/GI: Foley to gravity, amber colored UO with sediment. JP bulb with bilious drainage. +BS Abd snt. TF @ 60cc/hr. Residual this am 160cc NP notified, TF continued as ordered. Free H20 flushes Q6. Liquid BM x1. Failed swallow today.\n\nENDO: FSBS coverage per CSRU protocol.\n\nPLAN: Continue to monitor CV status. Pulmonary toileting, P/M valve trials. Continue TF as ordered at goal & monitor residual.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-02 00:00:00.000", "description": "Report", "row_id": 1536557, "text": "Neuro: A&O x2; 3mm, brisk; MAE's, follows commands consistently; able to use call light & voice out needs\n\nCV: Afebrile; V paced 70's-100's, SBP 110's-120's; palpables pulses x4; double lumen PICC placed in L AC @ bedside, placement confirmed with , pulled out excess length by IV nurse , OK to use per IV team; K repleted\n\nResp: Lung sound clear, #8 portex trach, on trach collar all shift, 35% FiO2, sat 100%, expetorated & suctioned small amount thick tan sputum; tolerating PMV\n\nGI: Abd soft, bowel sound x4; TF impact FS @ goal 75 ml/hr via L nare dobhoff tube; G-tube placement in AM, NPO after midnight; RLQ tube draining copious amount billious drainage, tube clamped for several hours per PA , total bili checked, tube unclamped after lab test; ducolax suppository x2 given, awaiting effect\n\nGU: Foley draining amber clear urine, UO adequate\n\nInteg: See carevue, jaundice overall\n\nEndo: Cover per CSRU protocol\n\nSocial: Mother visited most of shift, relatives called; surgery consent for g-tube obtainied by Dr \n\nPlan: NPO after midnight for g tube placement in AM; keep triple lumen CVL for OR tomorrow; fleet enema if no results from ducolax suppository; monitor hemodynamcis & labs\n" }, { "category": "Nursing/other", "chartdate": "2102-02-02 00:00:00.000", "description": "Report", "row_id": 1536558, "text": "Respiratory Care\nPt wearing pmv and aerosol t/o shift without complications.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-02 00:00:00.000", "description": "Report", "row_id": 1536559, "text": "Type & screen sent\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536418, "text": "Respiratory care\nPt. intubated on ventilatory support. Vent adjustments made accordingly, based on ABG values. Curently ABG values with in normal ranges. Suctioned for large amounts of bloody tinged secretions. BS coarse and decreased but improved with suctioning. not performed due to peep requirements. Plan to continue and adjust ventilator support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-14 00:00:00.000", "description": "Report", "row_id": 1536475, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings this. Started on nitric oxide 40 ppm, FiO2 100%, Peep 16 at 2200. Immediate effect noted on SaO2, PAP. SaO2 went from 85% to 98-100%. PaO2 went from 55 to 193. This 0600 patient is currently on nitric oxide 20 ppm, FiO2 50%. Plan to wean peep as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2102-01-14 00:00:00.000", "description": "Report", "row_id": 1536476, "text": "Nursing progress Note\nCVS: patient initially hemodynamically unstable, with falling svo2 46, CVP 12, PAD 33, CO 6.4, CI 3.37, sats on 100 % fi02 85, internal DDD vpaced. Patient placed on nitrous oxide via ventilator MD' and . Immediately patients vitals and oxygenation improved, BP 107/61, CVP 6, PAD 23, CO 6.8, CI 3.58, sats 100, PO2 on ABG rose from 55 to 193. Currently patient is afebrile, bleeding from trauma line site, surgicell applied when dressing changed. Pulses palp x 4 ext, skin very dry, jaundiced, tan. RSC CCO through trauma cordis, Left IJ dialysis cath, Left radial a line, all patent and transduced with adequate waveforms.\n\nResp: lungs remain dim throughout, coarse in left upper lobe. CT x 2 right anterior with serosang to old brown drainage. Dressing changed, no leak no crepitus. Sats 95-98 not on .60 fio2 and nitrous at 20 PPM. Sxn x 1 for thick yellow, does not tolerate suction or activity. PCXR done x 1.\nSee rt note and carevue for vent specifics.\n\nNeuro: paralyzed and sedated with nimbex and ativan, attempt to wean paralytic resulted in overbreathing ventilator. Currently has 3 twitches of left eyelid.\n\nGI: abd soft, unable to auscultate bs. OGT clamped after emds, TF shut off during distress, not restarted.\n\nGU: No catheter, occasional incontinence of small yellow to icteric urine with blood clots.\n\nCRRT: Continues with no order changes at this time. CVVHDF, with goal -50 per hour as tolerated. Calcium and KCl infusing per scale orders, heparin at 700 units hour via crrt machine. Pressures remain within limits.\n\nPain: morphine 2 mg iv x 1 for tachycardia and overbreathing ventilator.\n\nEndo: FS BS not requiring insulin coverage at this time.\n\nSocial: no family contact this shift.\n\nActivity: not tolerating turns or rotational bed.\n\nPlan: wean nitrous as tolerated, awaiting md rounds for further direction\n\nSee carevue flowsheets and for further details and values.\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-15 00:00:00.000", "description": "Report", "row_id": 1536479, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated, paralyzed and fully ventilated on AC settings. Nitric oxide remains on at 20 ppm. If PaO2 continues to improve peep will be decreased slowly.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2102-01-15 00:00:00.000", "description": "Report", "row_id": 1536480, "text": "a sensed and v paced via internal pacer, rate 100-116, no ectopy. sbp stable off vasopressin, 100-120s, very rare dip to high 80s. filling pressurs stable. cco/ci hyperdynamic, svo2 mid 60s. lowgrade temp, 99.4. small amt yellow urine, cloudy. ca and k managed per standing orders, no insulin requirement tonight. ptt remains subtherapeutic despite increased heparin. cvvh continues, running close to even at this time per dr. due to continued acidosis, 1 bicarb given with minimal effect. filter changed x 1, unable to access via red port,read high pressures, so ports switched, system is running, but with higher return and filter pressures. breath sounds clear, dimished at bases, ett suctioned for small to mod amts thick tan secretions. continues on nitric at 20 ppm, no other vent changes, see flow sheet for abgs. abd soft, no bowel sounds heard, ogt placed to suction, no drainage so far. r pleural tubes to suction, scant serosang drainage. 70cc bile from biliary stent. small amt clear liquid rectal drainage x 2. skin warm, dry, abarasions on buttocks unchanged, doubleguard cream applied. sedated with ativan, paraluzed with cisatracurium, intermittent morpine for comfort and maintenance methadone given. no family contact tonight. plan to continue cvvh, monitor electrolytes and ph, abgs. maintain paralytic and sedative meds. support and update family.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-15 00:00:00.000", "description": "Report", "row_id": 1536481, "text": "Resp. care note - Pt. remaines intubated with # 8 OET 30 at the teth, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-15 00:00:00.000", "description": "Report", "row_id": 1536482, "text": "7am-7pm update\nneuro: pt initally on nimbex gtt. nimbex gtt of per team at 1030 am. pt remains sedated althouth noted to MAE on bed after turning side to side. pt not following commands. pt moving mouth and biting down with mouthcare. . pt continues on ativan gtt at 2.0 mg/hr. pt started on fentanyl gtt at 50 mcg/hr.\n\nCV: pt remains A sensing and V pacing via PPM. HR 90-100's. approximately 0730 am the pt was hypotensive -> SBP in the 70's with MAP in the 50's. -> vasopressin gtt restated at that time per team. Vasopressin gtt started at 1.2 u/hr. vasopressin gtt up as high at 3.6 u/hr mid day. vasopressin gtt titrated to keep MAP > 60. vasopressin gtt currently at 2.4 u/hr. see flowsheet for vasopressin titration and BP. SBP 70-130's. MAP 50-70's. svo2 66-73. CI > 3.0. SVR 500-800's. hct stable. pp palpable. Lactate up as high as 4.0 -> lactate currently trending back down.\n\nresp: LS coarse -> clear with suctioning. no vent changes made today. pt continues on AC 50% with 16 PEEP. pt continues on nitric at 20 ppm. abgs show met acidosis -> team aware -> replacement fluid changed in attempt to correct acidosis (bicarb ^ in replacement). this am ETT rotated and noticed resistance -> ETT felt as though it was push out forward. team notified. Dr into room and evaulate ETT placement with laryngescope. ETT advanced by Dr to 30 at this teeth. pt was also bronch at that time -> moderate amount of sputum removed and sputum sent to lab. CXR done post and showed ETT in proper position per NP. CT drining minimal serousanginous fluid, no airleak noted.\n\ngi/gu: BS remain absent. ogt with no drainage today. continues on reglan q6h. duclox supp given -> no stool. foley draining yellow urine with sediment. UO 10-35 cc/hr. TF remain on hold. pt recieving TPN.\n\nendo: BS elvated this afternoon -> pt started on inuslin gtt. insulin gtt titrated per protocol\n\nID: T max 100.6. pt continues on multiple antiobiotics. vanco level 15.0 today -> pt given 1 gr vanco per team. Sputum cx sent to lab.\n\nCVVHD: pt continues to have met acidosis. replacement fluid changed today (bicarb increased). CVVHD ran even today. ~ 1515 CVVHD machine alarming for negative access pressure. quinton line position. line flushed. unable to draw off red port and slightly difficult to infused into red port. blud port able to draw off of and infuse althouth very position. team aware. TPA placed in red port per team. TPA dwelled x 1 hr and still unable to draw off of red port. team notified -> plan to change line. plan to restarte CVVHD once new line placed\n\nplan: continue CVVHD, antiobiotcs, monitor hemodynamcis, monitor abg's/lytes/wbc's, ??? TEE in am d/t elvated wbc, ?? CT tomorrow d/t elvated wbc, monitor neuro status, BP control\n" }, { "category": "Nursing/other", "chartdate": "2102-01-16 00:00:00.000", "description": "Report", "row_id": 1536483, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Increased RR to 26 d/t acidosis. Decreased peep to 14. Nitric Oxide decreased to 15 ppm at 0400. ABG shows adequate ventilation and good oxygenation. Plan to wean peep and NO as tolerated. Sxn for thick tan secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2102-01-17 00:00:00.000", "description": "Report", "row_id": 1536487, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on full ventilatory support. No vent changes done /or wean in NO. Sometimes he overbreathes, get agitated with string actuve /or when bet get rotated. BS are coarse b bil, No wheezes. not done due to high PEEP. Wea re sxtn for small to mod thick whitish to yel secretions from ETT and thick whitish orally. Plan: wean NO to off as tol & Continue present ICu monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-03 00:00:00.000", "description": "Report", "row_id": 1536560, "text": "neuro: pt a&ox2, to self & place. dozes on/off this shift. received pt w/pm valve on, communicates needs effectively. calm, weakly maes to command. mouthes words to communicate, once on trach collar, nods approp to questions. no c/o pain. cv: vpaced 70s-90s via internal pm. bp 100s-110s. palpable pulses. pneumo boots & sc heparin for dvt proph. afebrile. hct 25. wbc 14. repleted K & mag.\nresp: received pt on pmv-tolerates well; tolerated trach collar overnight. lscta. o2sats >95% on 35% fio2. resp rate 10s. sxn'd trach for scant thk tan sputum, pt expectorates mod amt thk tan sputum. mdi's given.\ngi/gu/endo: initially receiving tf FS Impact via left nare doboff @ goal 75cc/hr~npo after 2400 for g-tube placement . rt j-tube to bulb sxn, mod bilious drainage noted overnight. +bs, +flatus, sm soft brown bm x1; adequate huo, clr amber. creatinine wnl; bs per ss protocol; covered w/rssi x1 overnight.\nsocial: pt's family called, updated; will call on days.\nplan: continue monitoring cardioresp status. monitor labs. pulm toilet. trach collar on days. prepare pt for g-tube placement. update family. transfer to 2 if appropriate.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-03 00:00:00.000", "description": "Report", "row_id": 1536561, "text": "Resp care\nPt remains on 35%% trach mask. # 8 portex trach tube. Suctioned for mod amt of tan secretions. All equipment a @ bedside.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536566, "text": "NEURO/MUSC: , awake, oriented x3, PMV on since 0600 and Pt able to communicate needs to staff, c/o pain in abd incision , given 2mg Morphine SC, pain . Pt 2 person transfer from bed to chair at 1000, tolerated activity well.\n\nRESP: On trach mask 35%, Sats 100%, lung sounds clear, trach suctioned once for mod tan/thick secretions\n\nCV: Vpaced HR 90s, SBP 100-110s, pedal pulses present, afebrile.\n\nGI/GU: Abd dsg changed with pressure dressing, J-tube draining bilious. Pt to remain NPO, may give meds with minimal fluids per NGT or J-tube, plan to restart TF tomorrow, bowel sounds present, small BM this AM; Foley in place draining amber/sediment urine at >40-50cc/hr\n\nENDO: On SSRI\n\nSOCIAL: Mother has been in to visit Pt since this AM. interpreter stopped by and notified mother of plan for transfer to floor either this afternoon or tomorrow. Pt needs private room/?sitter.\n\nPLAN: Increase activity as tolerated, plan to restart TF tomorrow, ?transfer to 2, continue to monitor trach/resp status, cv, urine output, abd incision, pain.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-01 00:00:00.000", "description": "Report", "row_id": 1536419, "text": "ekg nsr, no ectopy, rate 70s, rises to 80s when awake. sbp stable in 120-150 range, occ up to 160s when agitated, no nicardipine tonight. temp up to 101.5 at beginning of shift, 98.3 now. adequate uo, dark yellow, cloudy, moderate response to lasix. glucose rx per protocol, was 27 at , confirmed by fingerstick, rx with 25 gm d50w. k repleted. breath sounds coarse to clear now, ett suctioned freq for large amts thick bloodtinged secretions. vent settings weaned from fio2 1.0 to .5 and peep from 14 to 10 overnight with acceptable abgs. r pleural pigtail drain draining moderate serous fluid, no air leak. abdomen soft, flat, bowel sounds present, no stool. tolerating fs probalance at 70cc/hr with small residuals. biliary stent draining moderate amt bile. skin arm and dry, feet warm, dp and pt pulses palp bilat. site dressings at stent and pigtail dry and intact. bag removed from r groin site - it was dry and coming off - and dsd in place, dry. abrasions on buttocks pink, small amt serous drainage, protective ointment applied. pupils equal, brisk, opens eyes to uncomfortable stimuli and sometimes to voice. mae spont, did follow any commands, but did nod head occ to questions \"can you hear me\" and do you have pain\". resedated early in shift with propofol, had one dose of fentanyl for serious agitation requiring propofol up to 50mcg to control. stepfather called for update on behalf of mother. plan to monitor hemodynamics, labs, maintain sedation, support and update family.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-24 00:00:00.000", "description": "Report", "row_id": 1536379, "text": "23yr male with hx of IVDA and Hep C admitted from OSH with 8.0 ET in place, 24 @ the lip. Pt seen here previously for incompetent aortic valve but not a surgical candidate at that time due to bleeding issues. Returned to OSH for abx therapy. Today returns following mental status changes and new sepsis, possibly uremia. Intubated for airway protection and transferred here. CT of abdomen pending. Preliminary read of head CT shows no bleed. After CT will wean Diprivan and wean to extubate this evening or tomorrow AM.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-17 00:00:00.000", "description": "Report", "row_id": 1536488, "text": "Neuro: pt openeing eyes with stimulation and movement of bed, becomes slightly hypertensive with waking. Pt did focus on nurse when name called and when asked to squeeze hands both right and left at different times pt did obey command, but when asked tomove feet he did not. Pt does move both lower extremities on own bending at knees. Pupils equal and reactive.\nResp: No vent changes made ABG's good on 50% FIO2 and Peep of 14 with 5ppm of nitric oxide. Suctioning for moderate amounts of thick yellow secretions every hour this am. O2 sats 94-97%.\nC/V: pt remains off Vasopressin with SBP ranging from 98-140 depending on level of consciousness. Hemodynmics good SVO2 70's pt received and additional 2 units of PRBC for Hct of 23 after 2 units earlier in day. Hct this am 29. pt continues on the CA gluconate and Potassium Chloride Gtts for CVVH titrating per protocol and labs.\nGI: pt npo except meds to have feeding tube placed today and start on tube feeds. Continues on hyperal for now.\nEndo: blood sugars treated with sliding scale.\nGU: pt passing 30-50cc/hr of yellow urine with sediment.\nSkin: no changes in skin abrasions on coccyx Double Guard Cream applied. pt on rotation air bed turning every 10mins\nPlan: feeding tube, wean off nitric Oxide. Continue to slowly wake.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-17 00:00:00.000", "description": "Report", "row_id": 1536489, "text": "UPDATE\nRESP: LUNG SOUNDS COARSE. SUX FOR MOD AMT THICK, YELLOW SECRETIONS. NITRIC OXIDE WEANED SLOWLY. CARDIAC AND RESP PARAMETERS WNL UNTIL DOWN TO 1PPM, THEN SPO2 DROPPED TO 93%(FROM 95-96%) AND PAS UP TO 60'S FROM 40'S. PAO2 DROPPED TO 78 FROM 89. RATE INCREASED BACK TO 2PPM PER DR. W/ IMMEDIATE IMPROVEMENT IN ABOVE PARAMETERS. REMAINS ON 14 OF PEEP AND CMV 26, FIO2 .50. ONE PLEURAL CT D/C'D THIS EVE.\n\nCV: HR 90'S-LOW 100'S A-SENSING, V-PACING INTERNALLY. NO ECTOPY SEEN. SVO2 70'S, C.I. 3-4 RANGE: NO CHANGE NOTED ON THESE W/ ADJUSTMENTS OF NITRIC AMT; FILLING PRESSURES WERE EFFECTED(SEE ABOVE).\n\nNEURO: PT OPENS EYES TO VOICE BUT DIFFICULT TO TELL IF HE FOCUSES ON SUBJECT. GRASPS W/ BILAT HANDS BUT DIDN'T MOVE FEET TO COMMAND(ONLY SPONTANEOUSLY) UNTIL REQUEST MADE IN SPANISH-THEN HE MOVED BOTH FEET IMMEDIATELY. APPEARED TO NOD HEAD SLIGHTLY \"NO\" WHEN ASKED ABOUT PAIN THIS AFTERNOON, BUT NO RESPONSE THIS EVE. FENTANYL DRIP ADJUSTED ONCE CVVHD OFF.\n\nG.I.: NEW FT PLACED VIA R NARE REPORTEDLY INTO STOMACH BY CXR. VIVONEX STARTED @ 20ML/HR. HARD, FORMED STOOL FELT IN RECTUM WHEN TYLENOL SUPP GIVEN->DULCOLAX GIVEN ALSO. NO B.M. YET. T-BILI RISING, ETIOLOGY UNCLEAR @ PRESENT.\n\nG.U./RENAL: CVVHD D/C'D THIS EVE PER RENAL TEAM PLAN. IV MED DOSING ADJUSTED ACCORDINGLY. CONTINUOUS CALCIUM/KCL INFUSIONS OFF-TO BE DOSED INTERMITTENTLY PRN. PT MAKING 70-90ML/HR SL CLOUDY, AND SL ICTERIC URINE VIA FOLEY. I&O +77ML.\n\nSKIN: SM SKIN TEAR NEAR DIALYSIS CATH SITE CAUSING MOD AMT OOZING OF BLOOD. PRESSURE DRSG . COCCYX WOUND W/ SL YELLOWISH BASE, NO DRNG NOTED, DOUBLEGUARD CREAM APPLIED.\n\nENDO: GLUCOSE WNL. INSULIN IN TPN.\n\nSOCIAL: MOTHER HERE AND UPDATED BY DR. .\n\nA/P: OFF PRESSORS. PT BECOMING SL MORE RESPONSIVE, ABLE TO FOLLOW SIMPLE COMMANDS. RESP STATUS STILL BENEFITING FROM SM AMT NITRIC, DETERIORATES WHEN LOWER THAN 2PPM: PLAN TO KEEP @ SAME O/N PER DR. . CVVHD OFF, RENAL TEAM TO ASSESS FOR HD NEED TOMORROW. MONITOR FLUID BALANCE AND LYTES CLOSELY. NEED MORE INSULIN NOW THAT TF STARTED. ADVANCE TF RATE PER ORDERS. NEED ENEMA IF NO B.M. TONIGHT.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-17 00:00:00.000", "description": "Report", "row_id": 1536490, "text": "Patient remains on mechanical ventilation and Nitri oxide therapy.Patient vital signs as well as saturation improves with nitric oxide therapy.MD would like patient to remain on set up of 2PPM overnight.Suctioned for small amount of thick yellow secretion,remains on cvvhd;will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-18 00:00:00.000", "description": "Report", "row_id": 1536491, "text": "NEURO: Continues on 25mcg Fent/1.5mg Ativan, arouses to verbal stimuli, inconsistently follows commands, grasps fingers to commands, bilat upper ext lift/hold in bed, R leg moves in bed/no movement noted on L leg, PERRLA (4mm/brisk), Gag impaired, when ETT suctioned\n\nRESP: Nitric oxide decreased to 1 ppm, continues on CMV with 14 PEEP, Sats in 97-98%, lung sounds clear, suctioned for moderate tan/thick secretions\n\nCV: Vpaced, HR in 90-100s, SBP in 90-110s, no pressors, pedal pulses palpable, plan to discontinue PA cath when nitric oxide is weaned off\n\nGI/GU: Continues on TPN & advanced TF Vivonex through Dobhoff at 40mL/hr (goal 60mL/hr), +BS, small loose BM after enema; Foley in place draining yellow/sediment, plan for renal consult about HD today. Repleted Ca of 1.08, last Ca 1.13\n\nENDO: Continues on SSRI, last BG was 140.\n\nSOCIAL: No family visit or phone call during shift.\n\nID: WBC 21, max temp was 38.7, treated with Tylenol, current temp 38.3, pan cultured for sputum, urine, blood, C. diff\n\nPLAN: Continue to monitor neuro, resp, cv, renal status, LABS, replete lytes as necessary, advance TF as Pt tolerates, wean nitric oxide off/dc PA catheter, ? HD consult\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-01-19 00:00:00.000", "description": "Report", "row_id": 1536497, "text": "RESP CARE: Pt remains intubated/on vent on settings per carevue. Attempting to wean FI02 this shift. ABGs remain acidotic, oxygenation acceptable. Lungs coarse on L, dim with wheezes noted R lung. MDIs given per with little effect noted. Sxd mod amts thick yellow sputum. ETT rotated/retaped at 29 lip. Continue full vent support at this time.No this am due to high PEEP/FI02 requirements.\n" }, { "category": "Nursing/other", "chartdate": "2102-02-04 00:00:00.000", "description": "Report", "row_id": 1536567, "text": "S/P CABG x3 and MVR.\nGeneral: Pt x3. Calm and cooperative. Denies pain.\nNeuro:Equal motor strength bilat. Gait steady.\nENT: , MMM.\nCardiac: SR to ST 90-105, with occasional PVC's. SV02 60-80's with CI >2.2. Ambulated to with assist of 2, tolerated well with some SOB. SV02 upon return to room in 70's. Milrinone decreased from .2 to .1 mcq.\nLungs: CTA, diminished in bases. Denies SOB. Nonproductive -needs a lot of encouragement for /deep breathing exercises. Teaching regarding IS. IS 500-750. O2 sats 96-98% on RA.\nAbd: soft, NTND. BS +4 quads. No BMs. Good appetite.\nGU: Foley d/c this am, pt voided x3 since. Clear, yellow urine.\nPV: PP+ Left leg incisions CDI. Extremeties warm and dry.\nF/E: K+ 3.9-20 mEq given @ 1530, to recieve additional K+ after.\nEndo: BS 136 @ 1200, given 4 units Reg insulin coverage.\nSocial: Mother, wife and son in to visit today. Wife updated.\n\nA: Pt stable and doing well. Tolerating Milrinone wean presently.\n\nP: Pt needs consistant encouragement on IS. Monitor fluid intake, and urine output. Monitor SBP, SV02, and CI while weaning off Milrinone. Check BS before meals and give coverage if indicated. Monitor labs including K+. Assess incision sites for any changes. As per orders.\n" }, { "category": "Nursing/other", "chartdate": "2101-12-24 00:00:00.000", "description": "Report", "row_id": 1536380, "text": "Pt readmitted from for further w/u of endocarditis. Pt has been at since , pt was on the regular floor until getting IV antbx until pt developed SOB and was intubated (ef 15% per report) pt then had increase in LFT's and had a stent placed in CBD and JP placed on . Per report from OSH pt LFT trending down. Pt arrived on propofol on CPAP 10/5 fio2 30%. Assessment is as follows:\n\nNeuro: Sedated on prop--to be awaken post CT, PERRLA. Head CT done, results pending(per OSH has MS changes)\nCV: Aline bp with fling--low diastolics. Hr 80-90 with BBB. No ectopy. palp pulses.\nResp; on CMV overbreathings. ABG WNL. lungs coarse. O2 sat>95% on fio2 30%. Sx t hick whitish/tan\nGI: nGT clamped at present for getting po contrast for abd CT. then to start TF ensure . + BS. Arrived with FIB bag on dc'd.\nGu: UOP>30cc/hr , foley cath from OSH patent\nENdo: BS wnl\nID: Iv antbx, and blood cx sent.\nPlan: Abd ct at 1730 then wake and wean vent if appropriate. start TF md order. Begin IV antbx. follow cx. cont current plan of care\n" }, { "category": "Nursing/other", "chartdate": "2102-01-19 00:00:00.000", "description": "Report", "row_id": 1536498, "text": "neuro- pt sedated on ativan gtt @1. responsive to stimuli-i.e blinks eyes to name by rn but doesn't follow commands or have purposeful movement.body is completely flaccid.perrla 4mm.\n\ncv-t-max 101.8 ice paks to bilateral axilla & groins. no tylenol given d/t increasing liver enzymes.hyperdynamic hemodynamics. K= repleted x1. cco re-calibrated.\n\nresp-intubated on cmv. 14 peep. fio2 weaned to 60%. ABG= metabolic acidosis-> 1 amp bicarb. ls course/clea/dim. sxing thick tan sputum.\n\ngi-abd softly distended. TF shut off @ 2400 for testing in AM. tpn infusing. no stool. bed pad wet with light amber colored staining. ( urine leaking from catheter vs. liquid seeping from bottom.t-tube drain with increased bile drg. lft's rising.\n\ngu- auto diuresing large quantities cloudy amber urine. u/o > 200cc/hr.\n\ninteg- coccyx with sage decutitus with yelow center base & reddish raw edges. drg yellow fluid. ct site dsg changed.\n\nid- febrile. continues on bactrim,flagyl,meropenum,cipro,doxycycline,\n\nplan- dc swan. ? ct to check placement of t-tube and to assess gallbladder. IR to position dobhoff. montor resp. temp.coccyx wound.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-19 00:00:00.000", "description": "Report", "row_id": 1536499, "text": "BS rhonchi, coarse crackles; no change with MDI's. Sx'd for large amounts of blood-tinged tan secretions with occasional clots. After trip to IR for feeding tube, pt's PIP's increased with desats requiring PEEP to 16 and FiO2 to 100. After vigorous repeated lavage, ambuing and suction, copious amount of thick secretions raised. PIP's back to normal and also able to wean PEEP and FiO2 to prior settings. Continue to wean both as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-19 00:00:00.000", "description": "Report", "row_id": 1536500, "text": "UPDATE\nNEURO: ATIVAN DRIP OFF THIS AFTERNOON. PT SL MORE ALERT. OPENS EYES TO VOICE AND OCC SPONTANEOUSLY AND LOOKS AROUND. GRASPED X1 IN A.M. WHEN ASKED IN SPANISH. WOULD NOT NOD HEAD WHEN ASKED ABOUT PAIN. MOVES LE'S BUT NOT TO COMMAND TODAY.\n\nCV: A-SENSING, V-PACING RATE ~100 RANGE. NO ECTOPY SEEN. SWAN D/C'D AND TIP SENT FOR CX. (TRAUMA LINE) CATH REMAINS. BP WNL. EXTREMETIES /DRY. TRANSFUSING 1UNIT PRBC FOR HCT 24.4.\n\nI.D.: TMAX 101.5. PR TYLENOL GIVEN X 1 W/ MILD EFFECT. CONT MULT ABX COURSE.\n\nRESP: THIS AFTERNOON, AFTER RETURN FROM RADIOLOGY, HAD DIFFICULTY PASSING SUX CATH ENTIRE LENGTH OF ETT. HAD PT FOR COPIOUS THICK, TAN SECRETIONS IN RADIOLOGY. PT DID NOT APPEAR TO BE BITING TUBE. SPO2 DRIPPED TO MID 80'S AND SVO2 TO 50'S. PEEP AND FIO2 INCREASED TEMPORARILY AND ETT SUX/LAVAGE AND AMBU MULT TIMES FOR THICK BLOOD TINGED SECRETIONS AND PLUG. EVENTUALLY ABLE TO PASS CATH LENGTH OF ETT. SPO2/SVO2 IMPROVED AND VENT PARAMETERS RETURNED TO BASELINE. PAO2 WNL. PT DOES TEND TO DESAT SLIGHTLY ON L SIDE. REMAINING CT ON L SIDE D/C'D THIS AFTERNOON.\n\nG.I.: JP TUBE CONT TO DRAIN DK BILIOUS. HEPATOLOGY AND GEN HERE TO SEE PT. PLAN FOR POSS TUBE STUDY OF ABOVE FOR TOMORROW TO ASSESS PATENCY. PT WENT TO IR FOR PLCMT OF PPFT. TF RESTARTED THIS AFTERNOON. CONT ON TPN (@ LOWER RATE) FOR NOW. OGT TO STAY IN FOR NOW. FORMED STOOL FELT IN RECTUM ON ADM OF SUPP.\n\nG.U./RENAL: CREAT 2.4 TODAY. CONT TO MAKE 100-250ML URINE Q HR. FOLEY CATH CHANGED W/O DIFFICULTY. RENAL ACIDOSIS ON ABG; NO TX FOR NOW. P.M. K+ 3.6 NOT TX DUE TO INCREASED KCL ADDED TO TPN TODAY. IONCA+2 REPLETED.\n\nSKIN: SM ULCER NOTED TO BE FORMING R EXT EAR. PT TENDS TO KEEP HEAD TURNED TO R SIDE. WILL TRY FOAM PAD TO REDUCE PRESSURE. NO CHANGE IN COCCYX WOUND; DOUBLEGUARD CREAM APPLIED.\n\nSOCIAL: MOM IN TO VISIT AND UPDATED BY BY PHONE(W/ K. M.D.).\n\nA/P: HEMODYNAMICALLY STABLE. CONT TO SUX Q 2-3 HRS AND USE PERCUSSION ON BED PERIODICALLY AS WELL AS BED ROTATION FOR PULM TOILET. NEED ENEMA IF NO B.M. TUBE STUDY TOMORROW. INCREASE TF TO GOAL RATE OF 40ML/HR. CONT TO MONITOR LYTES, ABG AND FLUID BALANCE CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2102-01-20 00:00:00.000", "description": "Report", "row_id": 1536505, "text": "npn 0700-1700;\nevents to ir for cholangiostomy study for tube patency, tube is patent gall bladder appears normal.on unofficial read,\n\nneuro; opens eyes spontaneously and to voice inconsisently squeezes hand moves both legs spontaneously but not to command ? due to language barrier. 3-4mm.\n\nresp;lungs coarse upper diminished at bases suctioned q2 for mod ammounts thick tan secretions. remains on cmv fio2 weaned to 55% x30 abgs metabolic acidosis started bicarb drip at 100 mls/hr for 1litre.\n\ncvs; tmax 102.4 po received aspirin 600 mgs pr with fair min. effect.\nppm at 70.st and short of afib some pac's. bp stable 118-130/60.\n\ngu; auto diuresis greater than 150 mls/hr. following lytes.\n\ngi; belly soft distended restarted on t/f goal of 40 mls/hr ducolax supp with small amount stool no cover on riss.\n\nskin;wounds dsd cdi stage 2 on coccyx duoderm gel and dsd per skincare nurse. rt ear with press sore. foam toreleive press in place,\n\nsoc; mother into visit and updated wiwthtranslation by liwsw,\n\nap ; continue to wean fio2 to 50%. for sats greater than 95.continue pulmonary toilet contiue lytes during autodiuresing stage.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2101-12-31 00:00:00.000", "description": "Report", "row_id": 1536416, "text": "Respiratory Care\nPt. remains intubated on ventilatory support. BS improved over last 24 hours, better aeration and less congestion Left base diminished. Sx for moderate amounts tan and blood tinged secretions, no wheezes noted. Rested overnight on CMV ABG's W/I normal values. AM 106, ventilation mode changed to PSV 5 peep / 15 PS at 0:500. PS titrated to give pt. 400-500 cc Vt and keep WOB low as well as RR in mid teens to low 20's. Pt appears to be tol well. ABG will be obtained on these settings. Plan is to continue to progress with slow wean from ventilatory support as pt. tol.\n" }, { "category": "Echo", "chartdate": "2102-01-16 00:00:00.000", "description": "Report", "row_id": 82336, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Evaluation for abscess. Left ventricular function. Right ventricular function.\nHeight: (in) 72\nWeight (lb): 190\nBSA (m2): 2.09 m2\nBP (mm Hg): 101/56\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 14:14\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated and sedated with infusions of midazolam and fentanyl\nduring the procedure.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Severely dilated LV cavity. Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR well seated,\nnormal leaflet/disc motion and transvalvular gradients. No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Local anesthesia was provided by benzocaine topical spray.\nThe patient was sedated for the TEE. Medications and dosages are listed above\n(see Test Information section). No TEE related complications. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion.\nThe patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in cavity size. No atrial septal defect is seen by\n2D or color Doppler. The left ventricular cavity is severely dilated with\nsevere global hypokinesis. There is severe global right ventricular free wall\nhypokinesis. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. A bioprosthetic aortic\nvalve prosthesis is present. The aortic prosthesis appears well seated, with\nnormal leaflet motion. No masses or vegetations are seen on the aortic valve.\nTrace aortic regurgitation is seen. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. No mass or vegetation is seen on the\nmitral valve. The pulmonic valve leaflets are thickened. No vegetation/mass is\nseen on the pulmonic valve. Significant pulmonic regurgitation is seen. There\nis no pericardial effusion.\n\nIMPRESSION: Well seated aortic valve prosthesis with no echo evidence of\nabscess or vegetation. Severely dilated left ventricular cavity with severe\nglobal hypokinesis. Severe right ventricular free wall hypokinesis.\n\nCompared with the post-operative images from the prior study (images reviewed)\nof , the findings are similar.\n\n\n" }, { "category": "Echo", "chartdate": "2102-01-05 00:00:00.000", "description": "Report", "row_id": 82337, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Intra-op TEE for AVR.\nHeight: (in) 61\nWeight (lb): 157\nBSA (m2): 1.71 m2\nBP (mm Hg): 105/24\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 10:03\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Moderate to severe spontaneous echo\ncontrast in the body of the LA. Good (>20 cm/s) LAA ejection velocity. Cannot\nexclude LAA thrombus.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal interatrial septum. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Severe global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. No AS. Severe (4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The rhythm appears to be A-V paced. Results were personally\nreviewed with the MD caring for the patient. See Conclusions for post-bypass\ndata\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is moderately dilated. Moderate to severe spontaneous echo\ncontrast is seen in the body of the left atrium. A left atrial appendage\nthrombus cannot be excluded.\n2. A catheter/pacing wire is seen in the right atrium and/or right ventricle.\nThere are echogenic lesions on the right atrial segment of this catheter,\nprobably consistent with mass or thrombus. No atrial septal defect is seen by\n2D or color Doppler.\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis severely dilated. Overall left ventricular systolic function is severely\ndepressed.\n4. Right ventricular chamber size is normal. There is severe global right\nventricular free wall hypokinesis.\n5. The aortic valve is bicuspid. The aortic valve leaflets are severely\nthickened/deformed. The coronary cusp appears endocarditic and is flailing\ninto the LVOT. There is no aortic valve stenosis. Severe (4+) aortic\nregurgitation is seen.\n6. An erosion is seen in the LVOT below the non coronary cusp adjacent to the\nanterior mitral valve. It appears to communicate only with the LVOT.\n7. The mitral valve leaflets are structurally normal. Trivial mitral\nregurgitation is seen.\n8. Episode of PEA intra-operatively, with worsened biventricular function,\nresponded to chest compression and epinephrine. Echogenic mass on the RA\npacing wire still seen.\n\nPOST-BYPASS: Pt is being AV paced. Pt is on an infusion of epinephrine,\nNorepinephrine, vasopressin and milrinone.\n1. A bioprosthesis is well seated in the aortic position. Leaflets appear to\nopen well. No significant AI is seen. Mean gradient between 20- 30 mm of Hg is\nnoted, CO is 6.5 l/min.\n2. Biventricular systolic function is slightly improved.\n3. Other findings are unchanged\n4. Aorta is intact post decannulation.\n5. Thrombi are still noted on the RA pacing wire\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-31 00:00:00.000", "description": "Report", "row_id": 82338, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. S/p cardiac arrest\nHeight: (in) 68\nWeight (lb): 150\nBSA (m2): 1.81 m2\nBP (mm Hg): 120/30\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 22:53\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. The IVC is >2.5cm in diameter with no change with\nrespiration (estimated RAP >20 mmHg).\n\nLEFT VENTRICLE: Severely dilated LV cavity. Moderate global LV hypokinesis.\n[Intrinsic LV systolic function likely depressed given the severity of\nvalvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Large vegetation on aortic valve. Severe (4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe estimated right atrial pressure is >20 mmHg. The left ventricular cavity\nis severely dilated. There is moderate global left ventricular hypokinesis.\n[Intrinsic left ventricular systolic function is likely more depressed given\nthe severity of valvular regurgitation.] Right ventricular chamber size and\nfree wall motion are normal. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are moderately thickened/deformed with\nbilateral leaflet flail with a large vegetation involving the anterior\nleaflets. Severe (4+) aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is a\ntrivial/physiologic pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2101-12-25 00:00:00.000", "description": "Report", "row_id": 82339, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 190\nBSA (m2): 2.09 m2\nBP (mm Hg): 123/36\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 12:01\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated and sedated with propofol during the study.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate to severe spontaneous echo contrast in the body of the\nLA. No mass/thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of\nthe RA or RAA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Severely dilated LV cavity. Moderate-severe global left\nventricular hypokinesis.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Large vegetation on aortic valve. Aortic root abscess. No AS. Severe\n(4+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion.\n\nGENERAL COMMENTS: Local anesthesia was provided by benzocaine topical spray.\nNo TEE related complications. Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nModerate to severe spontaneous echo contrast is seen in the body of the left\natrium. No mass/thrombus is seen in the left atrium or left atrial appendage.\nNo spontaneous echo contrast is seen in the body of the right atrium or right\natrial appendage. No atrial septal defect is seen by 2D or color Doppler. The\nleft ventricular cavity is severely dilated. There is moderate to severe\nglobal left ventricular hypokinesis. The ascending, transverse and descending\nthoracic aorta are normal in diameter and free of atherosclerotic plaque. Of\nnote, the thoracic aorta has significant pulsations seen, consistent with\nsevere aortic regurgitation.\n\nThe aortic valve is bicuspid. The aortic valve leaflets are severely\nthickened/deformed. There are two large vegetations on each of the two cusps\nof the bicuspid aortic valve. The anterior vegetation measures approximately\n1.5cm in length while the posterior measures approximately 1.2 cm in length.\nThese are probably slightly larger than on the prior study. An aortic annular\nabscess is seen, this is located in the interfibrosal tissue (best seen at the\nbase of the anterior mitral valve leaflet). This is similar in size and\nappearance than before. fibrous tissue between the mitral valve . There is no\naortic valve stenosis. Severe (4+) aortic regurgitation is seen. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. No mass\nor vegetation is seen on the mitral valve. There is a small to moderate sized\npericardial effusion. The pericardial reflections are prominent and contain\nmore fluid than is usually seen.\n\nCompared with the prior study (images reviewed) of , there is now\nspontaneous echo contrast in the left atrium/left atrial appendage. The\nanterior aortic valve tissue appears more thickened and edematous than on the\nprior study. This may be an abscess. The vegetations on the aortic valve may\nbe slightly larger. The left ventricular chamber size and function are similar\non both studies.\n\n\n" }, { "category": "ECG", "chartdate": "2102-01-06 00:00:00.000", "description": "Report", "row_id": 209276, "text": "Atrial and ventricular sequential pacing. Compared to the previous tracing\npacing is now present.\n\n" }, { "category": "ECG", "chartdate": "2101-12-27 00:00:00.000", "description": "Report", "row_id": 209277, "text": "Probable sinus rhythm\nPossible right atrial abnormality\nLow lead voltage\nMarked left axis deviation\nConduction defect of LBBB type, consider left ventricular hypertrophy\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2101-12-24 00:00:00.000", "description": "Report", "row_id": 209278, "text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , probably no significant change\n\n" }, { "category": "Radiology", "chartdate": "2102-01-23 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 946112, "text": " 3:00 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Please do duplex to assess for thrombosis\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p avr with fevers and elevated t bili, and t tube\n REASON FOR THIS EXAMINATION:\n Please do duplex to assess for thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Doppler of abdomen and pelvis.\n\n INDICATION: Status post AVR with fevers and elevated total bilirubin.\n\n COMPARISON: Comparison was made with the previous ultrasound from .\n\n FINDINGS: The liver is visualized and is of normal echogenicity. No focal\n liver lesions identified. The portal vein is patent with normal centripetal\n flow. The divisions into the left portal vein and right anterior portal and\n left and right posterior portal vein are patent. The hepatic veins are\n patent. The hepatic artery is patent with normal waveform. The gallbladder\n is contracted and contains some areas of increased echogenicity with some\n shadowing, which may represent sludge or gallstones. The cholecystostomy tube\n is not clearly identified within the gallbladder, the CBD is not dilated.\n There is increased echogenicity in relation to the right kidney.\n\n IMPRESSION:\n 1. Patent liver vasculature.\n 2. Contracted gallbladder with echogenic material, which may represent\n sludge/gallstones. Cholecystostomy tube in situ not clearly identified in\n gallbladder.\n 3. Incidental note made of increased echogenicity in relation to the right\n kidney, which likely reflects renal disease..\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944958, "text": " 9:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT position.\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe ARDS.\n REASON FOR THIS EXAMINATION:\n Eval ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n HISTORY: ARDS, ET tube position.\n\n One view. Comparison with the previous study done . The left\n costophrenic sulcus is not included. There is continued evidence of a right\n pleural effusion. Mediastinal structures are unchanged. Two right chest\n tubes, endotracheal tube, nasogastric tube, Swan-Ganz catheter, and multiple\n wires remain in place.\n\n IMPRESSION: No significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943755, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR w/hypoxia-r/o PTX\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure\n REASON FOR THIS EXAMINATION:\n s/p AVR w/hypoxia-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH:\n\n INDICATION: 23-year-old male status post aortic valve replacement, pacer lead\n placement, and abscess closure, with hypoxia. Please evaluate for\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: Small right apical pneumothorax has probably decreased slightly in\n size. Questionable left basilar pneumothorax is difficult to evaluate on\n supine radiograph, and lucency at the left base persists. There has been\n interval removal of right internal jugular central venous catheter. There has\n been interval placement of left apical chest tube. Interval removal of right-\n sided PICC line. Other lines and tubes are unchanged in position.\n Cardiomediastinal silhouette is unchanged.\n\n IMPRESSION:\n 1. Status post removal of right-sided PICC line and right internal jugular\n central venous catheter. Status post placement of left chest tube.\n\n 2. Unchanged very small right apical pneumothorax.\n\n 3. Lucency at left base could still represent pneumothorax. Upright\n radiograph, if possible, would be more sensitive for evaluating presence/size\n of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944862, "text": " 7:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation, s/p basilar CT pulled back 4 cm\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess for interval changes.\n\n Comparison is made to prior study from 10 hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n Cardiac size is normal. Continued improvement in left lower lobe and right\n lower lobe atelectasis. Small-to-moderate right pleural effusion is stable.\n Swan-Ganz catheter tip is in the main pulmonary artery. ET tube tip is 6.4 cm\n above the carina. Right-sided chest tubes remain in place. NG tube tip\n outside the film below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 945935, "text": " 1:11 PM\n PORTABLE ABDOMEN Clip # \n Reason: ?daubhoff pulled out\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe ARDS.\n REASON FOR THIS EXAMINATION:\n ?daubhoff pulled out\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 13:50.\n\n INDICATION: Dobbhoff tube position.\n\n FINDINGS: Pigtail catheter projects over the right iliac crest entering from\n the right side. Catheter extending down from above courses in expected\n position of the duodenum but I do not see a metallic Dobbhoff tip. The latter\n may be obscured by overlying pacemaker hardware. Diffuse opacity of the\n abdomen suggests possibility of ascites. There is no free air.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944792, "text": " 3:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?re-expansion of lung\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation, now s/p 2nd CT placement\n REASON FOR THIS EXAMINATION:\n ?re-expansion of lung\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Chest tube placed, check position.\n\n A right chest tube is seen at the base. No pneumothorax is present. There is\n a decrease in the size of the right effusion. The position of the various\n other lines and wires is unchanged.\n\n IMPRESSION: Right tube placed at the base. Reduction in size of effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945925, "text": " 11:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: routine cxr\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS. desats\n REASON FOR THIS EXAMINATION:\n routine cxr\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 11:37\n\n INDICATION: Desaturation.\n\n COMPARISON: .\n\n FINDINGS:\n\n All lines and tubes remain in place with no PTX.\n\n There are no new patchy consolidations. The right pleural fluid is unchanged.\n Cardiomegaly persists.\n\n IMPRESSION: No significant interval change Vs. prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-11 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 944441, "text": " 12:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o pulmonary embolism inc gradient difficult to oxygenate\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n r/o pulmonary embolism inc gradient difficult to oxygenate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old man post-aortic valve replacement with increasing AA\n gradient and difficult to oxygenate, evaluate for pulmonary embolism.\n\n TECHNIQUE: Multidetector contiguous axial images of the chest were obtained\n following the administration of 90 cc of Optiray. Reformatted images in\n coronal and sagittal planes were obtained. Comparison was made to a prior\n noncontrast chest CT study of .\n\n CT CHEST WITH IV CONTRAST: There are no filling defects in the pulmonary\n arterial vasculature. No pulmonary embolism is seen. The caliber of the\n aorta is normal in appearance. There is a prosthetic aortic valve present.\n\n The patient is intubated, with the endotracheal tube tip in satisfactory\n position approximately 5 cm from the carina. There is a right IJ line with\n the tip in the right atrium. There are sternal wires in and mediastinal\n surgical clips present. There is enlargement of the left ventricle. There are\n no pericardial effusions. Soft tissue windows demonstrate subcutaneous\n emphysema in the left anterior chest wall. There is left-sided gynecomastia.\n\n There are enlarged axillary lymph nodes on the left measuring 11 mm in short\n axis diameter (series 2 image 60). Anterior mediastinal soft tissue (2.8 x\n 1.5 cm) could represent residual thymic tissue, relatively unchanged from\n .\n\n There are enlarged mediastinal lymph nodes, right paratracheal measuring 1.4 x\n 2.0 cm. Bilateral hilar lymph node measuring 9 mm on the right and 9 mm on\n the left hilum as well. There is confluent subcarinal lymphadenopathy present\n as well.\n\n Lung windows demonstrate no pneumothorax. There is extensive ground-glass\n opacification throughout both lungs with smooth thickened interlobular septal\n thickening consistent with pulmonary edema. There are extensive\n consolidations at both lung bases. There are smaller consolidations seen in\n the dependent portion of the right upper lobe.\n\n In the right lower lobe, there is a loculated fluid collection with small air\n fluid level. This could represent a small loculated hydropneumothorax (series\n 2, image 141).\n\n Few images through the upper abdomen demonstrate an area of low attenuation in\n (Over)\n\n 12:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o pulmonary embolism inc gradient difficult to oxygenate\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the mid pole of the spleen raising the question of a splenic infarct. An NG\n tube is seen coursing to the esophagus whose tip is not extend below the level\n imaged.\n\n Reformatted images in the coronal and sagittal planes confirm the above\n findings.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions.\n\n IMPRESSION:\n 1. No pulmonary embolism.\n 2. Extensive consolidations at the bases bilaterally as well as in the\n dependent portion of the right upper lobe. Findings could represent pneumonia\n or aspiration.\n 3. Pulmonary edema.\n 4. Small loculated hydropneumothorax at the right lower lung field.\n 5. Possible splenic infarcts.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945659, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS. desats\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:54 A.M., \n\n HISTORY: AVR. Pacer lead placement. ARDS.\n\n IMPRESSION: AP chest compared to through 25:\n\n Mild pulmonary edema has improved since at 1:12 p.m. Borderline\n cardiomegaly unchanged, new since . Small right pleural effusion\n stable. No pneumothorax. Overall, findings are consistent with cardiac\n edema.\n\n Right subclavian introducer, ET tube, in standard placements. Feeding tube\n passes into the stomach and out of view but a nasogastric drainage tube, which\n ends in the lower esophagus, would need to be advanced at least 15 cm to move\n all the side ports into the stomach. No pneumothorax. was\n paged to report these findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943731, "text": " 8:17 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p AVR w/hypotension/hypoxia-r/o PTX\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure *******Pt in OR.\n\n REASON FOR THIS EXAMINATION:\n s/p AVR w/hypotension/hypoxia-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AVR, recent radiograph showing pneumothorax.\n\n CHEST, ONE VIEW: Comparison with examination of same day, 3:21 p.m. Right\n apical pneumothorax is similar/slightly less. Lines and tubes remain in\n place. Otherwise, no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-18 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 945337, "text": " 9:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess feeding tube placemwnt\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n assess feeding tube placemwnt\n ______________________________________________________________________________\n FINAL REPORT\n AP SUPINE PORTABLE CHEST, 9:21 A.M., \n\n INDICATION: Status post AVR. Evaluate feeding tube placement:\n\n Portable AP supine views of the chest and abdomen reveal the tip of the\n feeding tube at the level of the antropyloric region. A pigtail catheter is\n seen in the right mid abdomen.\n\n No significant interval change in the appearance of the chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945236, "text": " 12:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: dobhoff placement and CT Right to water seal\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe ARDS.\n\n REASON FOR THIS EXAMINATION:\n dobhoff placement and CT Right to water seal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dobbhoff tube placement.\n\n COMPARISON: .\n\n CHEST AP: The tip of the Dobbhoff tube is in the stomach. The right Swan-\n Ganz catheter is seen with its tip in the region of the pulmonic valve. Tip of\n the endotracheal tube is about 4 cm above the carina. There is slight\n worsening of mild right pleural effusion. The mild pulmonary edema is\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 945932, "text": " 12:20 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS. desats\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 12:48\n\n INDICATION: Line placement.\n\n COMPARISON: at 11:37.\n\n FINDINGS:\n\n A right CVL is seen with the tip in the SVC and there is no PTX. ETT and NGT\n remain in place. The lungs are stable in appearance with the left lateral\n aspect of the chest cut off from view.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943701, "text": " 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pleural effusion, pulmonary edema, pneumothorax, tamponade\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure *******Pt in OR.\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, pneumothorax, tamponade\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST DATED \n\n COMPARISON: .\n\n INDICATION: Status post AVR.\n\n New Swan-Ganz catheter has been placed, with the tip terminating in the right\n pulmonary artery. Other lines and tubes are unchanged in position except for\n slight withdrawal of nasogastric tube, still terminating in the stomach and\n slight advancement of the endotracheal tube, now terminating about 4 cm above\n the carina. Right PICC line tip is not well demonstrated, but appears to\n extend into the right atrium. Cardiac silhouette is enlarged. Pulmonary\n vascular engorgement persists, but there has been improvement in the degree of\n pulmonary edema with residual asymmetric hazy opacities, right greater than\n left.\n\n A very small right apical pneumothorax has developed accompanied by\n subcutaneous emphysema in the soft tissues of the right neck. Left\n costophrenic angle region appears very lucent, and the possibility of a small\n basilar pneumothorax on the left cannot be excluded.\n\n IMPRESSION:\n 1. New very small right apical pneumothorax.\n\n 2. Questionable left basilar pneumothorax.\n\n 3. Improving pulmonary edema.\n\n Findings communicated to Dr. by telephone on .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 945266, "text": " 3:35 PM\n PORTABLE ABDOMEN Clip # \n Reason: dobhoff advanced ? post pyloric\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n dobhoff advanced ? post pyloric\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male status post aortic valve replacement. Re-assess\n for Dobbhoff placement.\n\n FINDINGS: Comparison is made to prior chest x-ray from same day.\n\n SUPINE ABDOMINAL RADIOGRPAHS.\n\n Gas and feces are identified within the descending colon, however, there is\n otherwise a paucity of gas within the bowel. The Dobbhoff tube is identified\n within the distal stomach but does not appear to be post-pyloric. No evidence\n of pneumatosis or free air. Grossly unchanged appearance to Swan-Ganz\n catheter, multiple overlying wires and pacemaker wires and assumed\n gallbladder catheter. Right- sided chest tubes are also grossly unchanged in\n appearance with no evidence of pneumothorax. Interstitial edema and right-\n sided pleural effusion appear slightly less prominent than radiograph obtained\n from earlier in the day. Median sternotomy and surgical staples are unchanged\n in position. Only most distal tip of endotracheal tube was included on current\n radiographs.\n\n IMPRESSION:\n 1. Tip of Dobbhoff tube likely within gastric antrum.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 944362, "text": " 6:34 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx, check line placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult ventillation\n\n REASON FOR THIS EXAMINATION:\n r/o ptx, check line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 23-year-old man status post pacer lead placement. Recent\n history of endocarditis and respiratory failure.\n\n COMPARISONS: Earlier in the same day.\n\n CHEST, SUPINE: The endotracheal tube lies immediately beyond the thoracic\n inlet, approximately 6 cm above the carina, in an unchanged position. A\n nasogastric tube courses into the stomach. The patient is status post\n sternotomy. A staple line overlies the midline. Multiple pacer leads, and a\n pacer device overlying the mid upper abdomen, are unchanged. A drainage\n catheter has been removed from the right hemithorax. A left internal jugular\n central venous access catheter has been removed. There is a new double-lumen\n catheter terminating in the upper right atrium. There is a persistent left\n effusion. The right costophrenic angle is excluded. Mild pulmonary\n congestion is unchanged.\n\n IMPRESSION:\n 1. Right pleural drain removed.\n 2. Tip of new right internal central jugular venous catheter lying in the\n upper right atrium. If clinically indicated, retraction by 4 cm could be\n helpful for repositioning into the superior vena cava.\n 3. Similar pulmonary venous congestion and effusions.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944642, "text": " 3:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: severe hypoxia\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation\n REASON FOR THIS EXAMINATION:\n severe hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH \n\n COMPARISON: .\n\n INDICATION: Hypoxia.\n\n A moderate-to-large right hydropneumothorax (air > fluid) is present, with\n visceral pleural line projecting approximately 3 cm from the lateral ribs in\n the lower right hemithorax. Endotracheal tube is in standard position. Right\n internal jugular central venous catheter projects below the junction of the\n superior vena cava and right atrium, and pacing leads appear unchanged.\n Cardiac and mediastinal contours are stable. Vascular engorgement and\n perihilar haziness have slightly worsened. Left retrocardiac opacity has\n increased, and there is an apparent layering left pleural effusion. Finally,\n left internal jugular central venous catheter sheath has been placed, with the\n tip likely in the left brachiocephalic vein but not yet making the expected\n turn towards the midline.\n\n The right hydropneumothorax has been discussed by telephone with \n on .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 945011, "text": " 9:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check line placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe ARDS.\n\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST at 21:21\n\n COMPARISON: at 9:22.\n\n INDICATION: Line placement.\n\n Swan-Ganz catheter tip terminates at the junction at the main and right\n pulmonary artery, and a left internal jugular vascular catheter terminates at\n the junction of the left brachiocephalic vein and superior vena cava. No\n pneumothorax is evident on the supine radiograph. Right-sided chest tube and\n Swan-Ganz catheter are unchanged in position. Cardiac and mediastinal\n contours are stable. Pulmonary vascular engorgement is present with perihilar\n haziness and bilateral interstitial opacification consistent with interstitial\n edema. Overall, the degree of interstitial edema has slightly worsened.\n Layering moderate right pleural effusion is without change.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944663, "text": " 6:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation\n REASON FOR THIS EXAMINATION:\n s/p ct placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST RADIOGRAPH\n\n INDICATION: 23-year-old male status post AVR/pacer lead placement/abscess\n closure with difficult ventilation. Status post chest tube placement.\n\n COMPARISON: from 16:20.\n\n FINDINGS: There has been interval placement of right apical chest tube with\n near complete resolution of right pneumothorax. Multiple other lines and tubes\n are unchanged in position. Mediastinal and hilar contours are unchanged. Mild\n pulmonary vascular engorgement and perihilar haziness is unchanged. There are\n probable small layering bilateral pleural effusions.\n\n IMPRESSION:\n\n 1. Status post placement of right-sided chest tube. Interval near resolution\n of right pneumothorax.\n\n 2. Multiple lines and tubes unchanged in position.\n\n 3. Probable small bilateral layering pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944753, "text": " 11:49 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?interveral change in PTX\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation, now s/p CT stripping\n REASON FOR THIS EXAMINATION:\n ?interveral change in PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:57 A.M., \n\n HISTORY: AVR. Check pacer replacements.\n\n IMPRESSION: AP chest compared to through 11:10 a.m. today:\n\n Large right pleural effusion persists despite right apical pleural tube. Right\n subclavian introducer transmits a Swan-Ganz catheter, tip projecting over the\n proximal right pulmonary artery, ET tube in standard placement, nasogastric\n tube passes below the diaphragm, out of view, left internal jugular line tip\n projects over the origin of the left brachiocephalic vein, tip of the right\n jugular line projects over the superior cavoatrial junction, epicardial pacer\n leads are unchanged in their respective positions projecting over the floor\n and the left lateral margin of the cardiac silhouette. No pneumothorax. Right\n lower lobe collapse is unchanged, left lower lobe collapse has become\n partially aerated over the past 24 hours.\n\n Findings were discussed by telephone with the referring physician at the time\n of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-20 00:00:00.000", "description": "T-TUBE CHOLANGIO (POST-OP)", "row_id": 945686, "text": " 10:25 AM\n T-TUBE CHOLANGIO (POST-OP) Clip # \n Reason: please perform Cholesystostomy tube study.\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with history of IVDU, aortic endocarditis, s/p AVR with MOSF.\n cholecystostomy tube placed pre-op. TBili now continues to rise.\n REASON FOR THIS EXAMINATION:\n please perform Cholesystostomy tube study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 23-year-old male with aortic endocarditis status post aortic valve\n replacement with cholecystostomy tube placed. Preop at outside hospital.\n Elevated total bili. Evaluate tube.\n\n Comparison is made to prior abdominal CT dated .\n\n PERCUTANEOUS CHOLECYSTOSTOMY TUBE CHECK\n\n Approximately 60 mL of Optiray contrast was allowed to drain through the\n cholecystostomy tube by gravity. Under continuous fluoroscopic evaluation,\n contrast was noted to fill and opacify the gallbladder lumen which appeared\n grossly normal with no mucosal irregularities or filling defects identified.\n Contrast is noted to fully opacity the cystic duct, common bile duct, and a\n portion of the common hepatic duct and right biliary tree. Contrast is noted\n to pass freely through the common bile duct which was of normal caliber and\n displayed a mild area of narrowing distally near the insertion of the ampulla.\n Unclear if this represents an area of sphincteric spasm or mild stricture.\n Contrast was subsequently identified within the duodenum confirming no\n blockage of biliary tree. Initial scout images display multiple surgical\n staples over the mid chest and a pacemaker device with residual oral contrast\n noted within the rectum and distal sigmoid colon. A post-pyloric tube is also\n identified within appropriate position with its tip in the proximal third\n portion of the duodenum.\n\n IMPRESSION:\n\n 1. Successful cholecystectomy cystostomy tube check with no evidence of\n filling defects or obstruction to biliary drainage.\n\n 2. Questionable region of narrowing within the distal common bile duct may\n represent a region of sphincter spasm.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944832, "text": " 10:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?increasing hemothorax?\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation, with falling HCT\n REASON FOR THIS EXAMINATION:\n ?increasing hemothorax?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess right hemothorax.\n\n Comparison is made with prior study performed 7 hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n Cardiac size is normal. Moderate right pleural effusion is stable. There has\n been interval improvement in the right lower lobe collapse. Left lower lobe\n collapse is unchanged. There are right apical and right basal chest tubes.\n Swan-Ganz catheter tip is in the main pulmonary artery. ET tube is in\n standard position. There is no pneumothorax. Left internal jugular vein\n catheter tip is in the left brachiocephalic vein. NG tube tip is out of view\n below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945500, "text": " 8:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS.\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH.\n\n INDICATION: 23-year-old male, status post AVR/pacer lead placement/abscess\n closure with severe ARDS, for followup.\n\n COMPARISON: .\n\n FINDINGS: Endotracheal tube, Swan-Ganz catheter, and epicardial pacing leads\n are in standard positions, unchanged. Mild perihilar haziness and increased\n interstitial markings are suggestive of mild pulmonary edema. Portions of the\n lung bases are excluded on current film, but there are probable small\n bilateral pleural effusions.\n\n Cardiac size and mediastinal contours are stable. Right apical chest tube is\n unchanged. There has been prior median sternotomy and cardiac surgery.\n Nasogastric tube is high, with the tip located at the GE junction, and side\n port in the distal esophagus. There is no pneumothorax.\n\n IMPRESSION:\n 1. Mild pulmonary edema.\n\n 2. Nasogastric tube is located at the GE junction with side port in the\n distal esophagus. Other lines and tubes unchanged in standard position.\n\n Above findings were called to , NP, 10 a.m. on \n\n" }, { "category": "Radiology", "chartdate": "2102-01-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945285, "text": " 6:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: right base chest tube removed ? pneumo\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS.\n REASON FOR THIS EXAMINATION:\n right base chest tube removed ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old male status post aortic valve replacement and right\n chest tube removal.\n\n Portable AP chest dated at 18:36 is compared to the same examination\n from six hours earlier. The patient remains intubated with the endotracheal\n tube in good position 3.3 cm above the carina. A nasogastric tube courses\n below the diaphragm. A right subclavian catheter sheath and a Swan-Ganz\n catheter terminating in the right main pulmonary artery are in unchanged\n position. Median sternotomy wires and staples are in unchanged position. The\n heart size is stable and mediastinal contours are unchanged. There has been\n interval removal of the chest tube at the right lung base. The chest tube\n terminating in the upper mediastinum is stable in location. There is no\n pneumothorax. The lungs show the right hilar airspace opacity is improved.\n No infiltrates are seen. There remain small bilateral pleural effusions.\n\n IMPRESSION: No evidence of pneumothorax status post right chest tube removal.\n Improved appearance of right perihilar airspace opacity. Otherwise, lines and\n tubes unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-12 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 944636, "text": " 3:43 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: RUQ r/o chol ? obstruction elevated Tbili\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hepatitis C, endocarditis with aortic root aneurysm\n\n REASON FOR THIS EXAMINATION:\n RUQ r/o chol ? obstruction elevated Tbili\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C, endocarditis, right upper quadrant pain, elevated\n total bilirubin.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echogenicity and\n contour. No focal liver lesions or biliary ductal dilatation is identified.\n The portal vein is patent and demonstrates normal hepatopetal flow. The\n common bile duct measures 2 mm, which is normal. There is significant\n increase in echogenicity of the right kidney since the prior examination\n consistent with medical renal disease. The gallbladder is not seen. There is\n a small right pleural effusion.\n\n IMPRESSION:\n 1. No evidence for biliary ductal dilatation. The gallbladder is not seen.\n 2. Significantly increased echogenicity of the imaged right kidney compared\n to the prior exam of . These findings are consistent with medical renal\n disease.\n 3. Small right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 944723, "text": " 10:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P LINE PLACEMENT, ? PTX\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with difficult\n ventillation\n REASON FOR THIS EXAMINATION:\n check ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH\n\n INDICATION: 23-year-old male status post AVR/pacer lead placement/abscess\n and recent hydropneumothorax. Status post line placement.\n\n COMPARISON: Multiple studies from and .\n\n FINDINGS: Right subclavian approach Swan-Ganz catheter has been placed, with\n its tip in the main pulmonary artery. Large right hydropneumothorax has\n rapidly reaccumulated, concerning for possible hemothorax. Right apical chest\n tube is unchanged in position.\n\n Mild pulmonary edema is unchanged. Cardiomediastinal contours are unchanged.\n Nasogastric tube extends below the diaphragm and out of view. Epicardial leads\n are unchanged. Endotracheal tube is in standard position. Right IJ approach\n central venous catheter is unchanged. Left IJ catheter sheath is unchanged.\n Patient is status post median sternotomy.\n\n IMPRESSION:\n 1. Rapid reaccumulation of fluid in large right hydropneumothorax. Hemothorax\n should be considered especially given recent intervention/line placement.\n\n 2. Unchanged mild pulmonary edema. New swan ganz catheter placement. Other\n lines and tubes unchanged.\n\n Above findings were called to Dr. on .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-19 00:00:00.000", "description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)", "row_id": 945536, "text": " 10:50 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please advance dophoff to postpyloric\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p AVR/ARDS\n REASON FOR THIS EXAMINATION:\n please advance dophoff to postpyloric\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man with endocarditis. Advance Dobbhoff tube to\n post-pyloric.\n\n No prior studies are available for comparison.\n\n FINDINGS: A dobhoff tube was removed. Under direct fluoroscopic guidance, a\n - feeding tube was passed into the stomach beyond the pylorus\n and into the second portion of the duodenum. Placement was confirmed via\n injection of a small amount of Conray contrast through the tube. There were\n no immediate post-procedure complications.\n\n IMPRESSION: Successful placement of post-pyloric tube.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 945556, "text": " 12:48 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for infiltrates/ptx/et placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p AVR/Pacer lead placement/Abscess Closure with Severe\n ARDS. desats\n REASON FOR THIS EXAMINATION:\n assess for infiltrates/ptx/et placement\n ______________________________________________________________________________\n FINAL REPORT\n Chest PA and lateral performed to assess infiltrates because of continuous and\n increasing cough. The heart is normal in size. The aorta and mediastinum are\n midline. The lungs are clear. There is no evidence of an active infiltrate.\n\n CONCLUSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 942668, "text": " 2:55 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx, check pigtail placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n r/o ptx, check pigtail placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Vascular line placement.\n\n A single AP view of the chest is obtained semiupright at 15:15 hours and is\n compared with the prior radiograph performed approximately seven hours prior\n and showed insertion of a right-sided pleural pigtail catheter. Right-sided\n subclavian line is unchanged in position with its tip in the distal SVC.\n Pulmonary changes are not significantly different allowing for changes in\n technique. The ET tube is approximately 7.5 cm above the carina and it could\n be advanced with benefit.\n\n IMPRESSION:\n Tubes and lines as described above. Pulmonary changes consistent with\n bilateral pleural effusions and bilateral pulmonary edema is not significantly\n changed.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943084, "text": " 12:59 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: NGT placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement.\n Feeding tube advanced\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 22-year-old man with hepatitis C and endocarditis. Evaluate\n placement of nasogastric tube.\n\n FINDINGS: Comparison is made to the prior study performed three hours\n earlier. The nasogastric tube has been advanced. However, the side port is\n still above the gastroesophageal junction. The distal tip is near the\n gastroesophageal junction and could be advanced at least 10-15 cm for more\n optimal placement. The cardiomegaly is unchanged. There are diffuse airspace\n opacities which are also stable. There is a catheter seen at the right base.\n The endotracheal tube and the right-sided central venous catheter are stable.\n There is a single lead left-sided pacemaker which is also unchanged. The\n right CP angle has been cut off from the study. There is a small left-sided\n pleural effusion which is stable.\n\n IMPRESSION:\n 1. The side port of the nasogastric tube is above the gastroesophageal\n junction and the NG tube can be advanced an additional 10-15 cm for more\n optimal placement.\n 2. Unchanged diffuse airspace opacities.\n 3. Marked cardiomegaly, stable.\n 4. Left-sided pleural effusion. The right-sided pleural effusion has\n resolved.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942474, "text": " 1:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Intubation. Endocarditis. Evaluate for infiltrate.\n\n Examination is somewhat limited due to exclusion of the extreme lung apices\n from the radiograph. Endotracheal tube terminates approximately 7 cm above\n the carina. Right internal jugular vascular catheter and nasogastric tube are\n in standard position. Cardiac silhouette remains enlarged, and there is\n persistent vascular engorgement, perihilar haziness, and septal thickening\n consistent with pulmonary edema. There is improving aeration in the left\n retrocardiac region with residual opacity, likely due to atelectasis and\n effusion. Right-sided pleural effusion is without change.\n\n Finally, previously reported right pneumothorax is not visualized, but\n exclusion of lung apices limits assessment for a small residual pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942030, "text": " 1:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p permanant pacemaker\n\n REASON FOR THIS EXAMINATION:\n acute process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 01:04\n\n INDICATION: Endocarditis.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior film, there is pleural fluid layering out on\n the right and this is associated with some patchy features at the right lung\n base, which do not appear significantly different from prior. The visualized\n left lung shows slightly prominent pulmonary vessels in the upper lobe\n suggesting fluid overload. No definite left consolidation was noted. An NGT\n extends below the diaphragm and pacemaker hardware and wire remain in place.\n There is an ETT which appears quite high at the thoracic inlet and this should\n be advanced by 4-5 cm.\n\n IMPRESSION: Compared to prior, there is increased right pleural fluid and\n other features of CHF. Stable right airspace disease.\n\n ETT is high as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942065, "text": " 2:18 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: line tip and PTX\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement\n\n REASON FOR THIS EXAMINATION:\n line tip and PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with hepatitis C and endocarditis after central\n line placement and concern for pneumothorax.\n\n COMPARISON: Today at 1:04 a.m.\n\n FINDINGS: Endotracheal tube is in appropriate position. Nasogastric tube\n extends below the inferior margin of the radiograph. There is a new right\n subclavian central catheter with tip in the SVC. There is a new small right\n apical pneumothorax. Marked cardiomegaly is stable. There is left\n retrocardiac opacity and obscuration of the left hemidiaphragm, probably a\n combination of atelectasis and small left pleural effusion. The right lung is\n grossly clear.\n\n IMPRESSION: New small right apical pneumothorax.\n\n Findings were discussed with Dr. at 5:30 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943064, "text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement\n s/p intubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 22-year-old man with hepatitis C, endocarditis, status post central\n line placement.\n\n FINDINGS: Comparison is made to prior study from .\n\n There has been interval placement of nasogastric tube whose tip and side port\n are in the mid esophagus. There is a single lead left-sided pacemaker with\n distal lead in the right ventricle. There is a right-sided central venous\n catheter with distal tip in the proximal RA. Endotracheal tube is\n appropriately sited. Cardiac silhouette is enlarged and unchanged. Diffuse\n airspace opacities bilaterally remain but are slightly decreased since the\n previous study. There are small bilateral pleural effusions.\n\n IMPRESSION:\n\n 1. The tip and sideport of nasogastric tube is in the esophagus and should be\n readjusted for more optimal placement. As discussed with Dr. .\n\n 2. The rest of the lines and tubes are unchanged in position.\n\n 2. Airspace opacities bilaterally, which are slightly improved. This is\n likely secondary to edema, however, underlying infection cannot be entirely\n excluded.\n\n 4. Small bilateral pleural effusions, stable.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942271, "text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check effusions\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n check effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old man with hepatitis C, endocarditis, right apical\n pneumothorax.\n\n COMPARISON: .\n\n FRONTAL SEMI-UPRIGHT CHEST: Again seen is an apical and lateral small right-\n sided pneumothorax, unchanged since the prior study. The endotracheal tube is\n at the thoracic inlet, 7.8 cm above the carina. The nasogastric tube tip\n extends to overlie the body of the stomach. A left-sided pacemaker is seen\n with a single lead in unchanged position. A right subclavian central venous\n catheter has been pulled back, now its tip overlies the superior vena cava.\n Moderate-to-severe cardiomegaly is stable. There is persistent retrocardiac\n left lower lobe opacity, unchanged. The right-sided pleural effusion appears\n somewhat improved since the prior study. There remains a small amount of\n pleural fluid bilaterally.\n\n IMPRESSION:\n 1. More appropriate positioning of the right subclavian central venous\n catheter.\n 2. Persistent small apical and lateral right pneumothorax.\n 3. Small bilateral pleural effusions, slightly improved on the right.\n Persistent but likely also improved retrocardiac left lower lobe opacity\n present.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942175, "text": " 9:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 10:04.\n\n INDICATION: ET tube placement.\n\n COMPARISON: .\n\n FINDINGS: Tip of the ETT is 4.9 cm above the carina. Tip of the right CVL is\n in the SVC. The NGT extends below the diaphragm.\n\n There is a stable appearance to the right apical pneumothorax with no evidence\n of progression. There are bilateral effusions, and there is persistence of\n retrocardiac density and for the latter, pneumonia or atelectasis could be\n present.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943203, "text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement.\n Feeding tube advanced\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n INDICATION: 22-year-old male with hepatitis C, endocarditis, status post\n central line placement.\n\n COMPARISON: .\n\n FINDINGS: Nasogastric tube is seen coursing below the diaphragm. Side port\n is seen in the region of the stomach well below the diaphragmatic hiatus.\n Cardiomegaly is unchanged in appearance from previous study. Diffuse patchy\n airspace opacities are also unchanged. A catheter is overlying the right lung\n base. Endotracheal tube is located roughly 7.6 cm above the carina and could\n be advanced about 1 cm for more optimal positioning. Right subclavian central\n venous catheter is unchanged in appearance. There has been interval placement\n of right-sided PICC line, with its tip located in the superior vena cava.\n There is no evidence of pneumothorax. There are probable bilateral pleural\n effusions layering on this supine radiograph.\n\n IMPRESSION:\n 1. Interval placement of right-sided PICC line, with tip in the superior vena\n cava.\n 2. Unchanged appearance of diffuse patchy bilateral airspace opacities.\n 3. Unchanged appearance of marked cardiomegaly.\n 4. Probable bilateral pleural effusions.\n 5. Slightly high positioning of endotracheal tube. Tube could be advanced 1\n cm for more optimal positioning.\n\n" }, { "category": "Radiology", "chartdate": "2102-01-04 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 943520, "text": " 2:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx, assess central line\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL\n placement.\n REASON FOR THIS EXAMINATION:\n r/o ptx, assess central line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: at 9:40.\n\n INDICATION: Line placement.\n\n A right internal jugular vascular sheath has been placed, with the tip\n terminating in the proximal superior vena cava. No pneumothorax is evident on\n this supine radiograph. Other lines and tubes are unchanged in position.\n Pulmonary edema has slightly worsened compared to the previous radiograph.\n There is otherwise no substantial change since the recent radiograph of a few\n hours earlier the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-30 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 942792, "text": " 10:43 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for septic source, assess parenchema\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man endocarditis and resp failure. Gm- rods sputum\n REASON FOR THIS EXAMINATION:\n assess for septic source, assess parenchema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure, gram-negative rods in sputum.\n\n COMPARISON: CT abdomen from .\n\n TECHNIQUE: Unenhanced MDCT of the chest from thoracic inlet to upper abdomen\n was obtained with subsequent 1.25- and 5-mm collimation axial images reviewed.\n\n FINDINGS: Mediastinal and hilar lymphadenopathy is significant ranging up to\n 1.5 cm in subcarinal and right lower paratracheal area. The precise\n evaluation of the prevascular and hilar lymph nodes is difficult in the\n absence of contrast injection. Bilateral left more than right axillary\n lymphadenopathy is significant ranging up to 2 cm in diameter. The heart is\n markedly enlarged with significant left ventriculomegaly. There is no\n pericardial effusion. Aortic valve calcifications are present in a patient\n with known aortic bicuspid valve may represent early calcifications.\n\n The airways are patent to the level of segmental bronchi. There is marked\n decrease in the right pleural effusion with reexpansion of the right lower\n lobe with pleural inserted. Bilateral basal consolidations have\n indistinct margins and represent pneumonia, particularly aspiration, in\n contrary to bibasilar atelectasis demonstrated on the previous film.\n\n The patient is intubated with the ET tube terminating 6 cm above the carina.\n The NG tube tip terminates in the stomach.\n\n The imaged portion of the upper abdomen is unremarkable, exept for a dense\n focus in the left kidney may represent small renal stone. There are no bone\n lesions suspicious for malignancy.\n\n IMPRESSION:\n 1. Severe bibasilar consolidation, most likely pneumonia,\n particularly aspiration.\n 2. Significant mediastinal, hilar, and axillary lymphadenopathy.\n 3. Severe cardiomegaly, unchanged.\n 4. Decreased right pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942945, "text": " 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement\n s/p intubation\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Evaluate for effusion.\n\n Endotracheal tube has been repositioned, now terminating about 6.5 cm above\n the carina. Other lines and tubes are unchanged in position. Cardiac\n silhouette remains enlarged, and there is vascular engorgement and mild\n perihilar haziness attributed to interstitial edema from either CHF or fluid\n overload. There has been improved aeration in the left retrocardiac region,\n and a peripheral right basilar opacity has also improved. Small bilateral\n pleural effusions are present, but there is no pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942594, "text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 8:52 A.M., \n\n INDICATION: Endocarditis. Status post CVL and ETT placement.\n\n FINDINGS: Compared with , the study is limited by patient motion.\n Allowing for this, the CVL, and ETT, and NGT appear grossly unchanged in\n positions.\n\n Even allowing for supine positioning, the right pleural effusion appears\n increased.\n\n There is also increased collapse/consolidation at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 941995, "text": " 3:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for infarct\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with endocarditis, intubated\n REASON FOR THIS EXAMINATION:\n assess for infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old man with endocarditis, intubated. Assess for\n infarction.\n\n COMPARISON: MRI of the brain from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The tiny left frontal subcortical infarct seen on MRI is not\n definitively seen on this study. No intra- or extra-axial hemorrhage is\n identified. There is no mass effect or shift of normally midline structures.\n There is no hydrocephalus. The visualized paranasal sinuses and mastoid air\n cells appear clear. There is a nasogastric tube as well as an endotracheal\n tube in place. Soft tissue structures appear unremarkable.\n\n IMPRESSION: Known small left frontal subcortical infarct seen on MRI not\n definitively visualized on this study. No acute intracranial hemorrhage or\n mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2101-12-24 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 941996, "text": " 3:01 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: acute processrecent ARF, now recovered\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with endocarditis, aortic root aneurysm, CHF\n\n REASON FOR THIS EXAMINATION:\n acute processrecent ARF, now recovered\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old man with endocarditis, congestive heart failure,\n recent acute renal failure, now resolved. We are asked to evaluate for\n abdominal pathology.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed\n after the administration of oral and intravenous contrast. Coronal and\n sagittal reformations were obtained. The initial scan is an oral contrast\n only because the IV fell out as the contrast injection was taking place.\n Therefore the patient was rescanned.\n\n CT OF THE ABDOMEN: Evaluation of the abdominal organs is limited by early\n arterial phase. There is a large right- sided pleural effusion. There is\n bibasilar atelectasis, and a more low attenuation area in the right lower\n lobe. Again seen is severe cardiomegaly. A pacemaker is seen with leads in\n unchanged position. There is a punctate calcification in the right lobe of the\n liver. There is a catheter in the expected location of the gallbladder. The\n adrenal glands are not well seen. The pancreas is difficult to distinguish\n from other retroperitoneal structures, unchanged. The hypodensities previously\n seen in the spleen, not as well visualized but appear essentially stable. The\n kidneys enhance and excrete contrast symmetrically. The previously seen wedge\n shaped hypodensity in the left kidney is also not well visualized on today's\n study. The small 5 mm left kidney cyst is unchanged. The loops of small and\n large bowel appear normal in caliber and contour. The major arterial\n structures appear patent. The study due to timing cannot evaluate the venous\n structures well. A small amount of ascites fluid is seen around the liver.\n\n CT OF THE PELVIS: A Foley catheter is within the bladder lumen. The\n prostate, seminal vesicles, and rectum appear unremarkable. There is a small\n amount of fluid in the pelvis. Borderline inguinal lymph nodes are seen,\n unchanged from the prior study.\n\n OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Limited study with suboptimal intravenous contrast opacification. However,\n no acute abdominal or pelvic pathology is identified. There is a small amount\n of ascites. A drainage catheter is in the collapsed gallbladder.\n (Over)\n\n 3:01 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: acute processrecent ARF, now recovered\n Admitting Diagnosis: ENDOCARDITIS\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. The previously seen hypodensities in the spleen and left kidney do not\n appear worse than on the prior study of .\n\n 3. Large right-sided pleural effusion and bibasilar extensive atelectasis. A\n region of the right lower lobe does not enhance as briskly as the remainder --\n raising the question of infection in that region.\n\n 4. Severe cardiomegaly remains.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943002, "text": " 4:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o ptx, re-intubated, hypoxic\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement\n s/p intubation\n REASON FOR THIS EXAMINATION:\n r/o ptx, re-intubated, hypoxic\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 16:30.\n\n COMPARISON: at 10:12.\n\n INDICATION: Reintubation.\n\n Endotracheal tube terminates approximately 6 cm above the carina. Right\n pleural catheter and right subclavian catheter are unchanged in position.\n Nasogastric tube has been removed. Cardiac silhouette remains enlarged.\n There are worsening bilateral airspace opacities with a perihilar and basilar\n predominance, most consistent with pulmonary edema. Left pleural effusion\n appears slightly smaller, but right effusion is possibly slightly worse.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 942754, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check ET placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement s/p\n intubation\n REASON FOR THIS EXAMINATION:\n check ET placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:50 A.M. \n\n HISTORY: Hepatitis C and endocarditis.\n\n IMPRESSION: AP chest compared to through 4:\n\n Small right pleural effusion has drained appreciably since at 3:11\n p.m. following insertion of a right pigtail drain which projects over the\n medial aspect of the right hemithorax and the right margin of the cardiac\n silhouette, but cannot be localized precisely on the single view. Left lower\n lobe consolidation and right peribronchial infiltration of both the pneumonia\n and both are unchanged since , along with a moderate to severely\n enlarged cardiac silhouette. There is no mediastinal or vascular engorgement\n to suggest elevated central venous pressure. ET tube is in standard\n placement, nasogastric tube ends in the upper stomach, a transsubclavian right\n ventricular pacer lead follows the expected course to the floor of the right\n ventricle. Right subclavian catheter tip projects over the mid SVC. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2101-12-27 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 942276, "text": " 9:29 AM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: RUQ US, s/p gastrostomy tube\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hepatitis C, endocarditis with aortic root aneurysm\n\n REASON FOR THIS EXAMINATION:\n RUQ US, s/p gastrostomy tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C, endocarditis with aortic root aneurysm, status post\n presumed cholecystostomy tube.\n\n COMPARISON: Abdominal ultrasound and CT abdomen and pelvis\n from .\n\n PORTABLE LIMITED ABDOMINAL ULTRASOUND: A percutaneous catheter is seen\n traversing the left lobe of the liver parenchyma and terminating in what\n is presumed to be a gallbladder filled with echogenic material likely\n representing sludge. The walls of the gallbladder appear normal without\n evidence of edema. No pericholecystic fluid is definitively identified. The\n liver is normal in echotexture without focal hepatic masses. There is no\n intra- or extra-hepatic biliary duct dilatation. The common bile duct\n measures 3 mm, which is normal. Portal vein is patent demonstrating normal\n hepatopetal flow. Trace amount of ascites is present. A large right pleural\n effusion is identified.\n\n IMPRESSION:\n 1. Percutaneous catheter appears to terminate within a presumed gallbladder\n filled with sludge. No gallbladder wall edema or pericholecystic fluid is\n identified.\n 2. Small amount of ascites.\n 3. Large right pleural effusion.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2102-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 943477, "text": " 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess efffusions/infiltrates\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL\n placement. Feeding tube advanced\n REASON FOR THIS EXAMINATION:\n assess efffusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 9:40 A.M. :\n\n INDICATION: Feeding tube advanced. Assess effusion/infiltrates.\n\n FINDINGS: Compared with at 2:30 p.m., the feeding tube appears\n essentially unchanged in position within the proximal stomach. The drainage\n catheter at the right lung base is unchanged in position. The right\n subclavian central line has been removed and there is now a right PICC line\n present with the tip at the mid SVC level. ETT is unchanged roughly 7 cm\n above the carina.\n\n There is now increased collapse of the left lower lobe.\n\n The lung fields are otherwise unchanged with scattered patchy opacities\n bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-01-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 943231, "text": " 2:05 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: check picc placement\n Admitting Diagnosis: ENDOCARDITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with hep c, endocarditis, s/p CVL placement.\n Feeding tube advanced\n REASON FOR THIS EXAMINATION:\n check picc placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Central line placement.\n\n A single AP view of the chest was obtained at 1320 hours and is\n compared with the prior radiograph taken just over one hour previously.\n Patient remains intubated with the tip of the ET tube approximately 6 cm above\n the carina. A right-sided subclavian line has its tip in the expected\n location of the distal SVC. The right-sided PICC line is again seen but its\n distal portion is overlapping the subclavian line and is therefore not well\n seen. Multifocal opacities and cardiomegaly/pericardial effusion unchanged.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2163-07-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832691, "text": " 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: y/o woman with a history of coronary artery disease. Evaluate\n for CHF.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from .\n\n FINDINGS: There is stable cardiomegaly. The aorta is calcified and tortuous.\n There is bilateral pulmonary vascular congestion with upper zone\n redistribution. There is interstitial edema bilaterally. There are no pleural\n effusions. Pacemaker leads remain in unchanged position. Osseous and soft\n tissue structures are unchanged from prior study.\n\n IMPRESSION: Worsening CHF superimposed on chronic lung disease.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833030, "text": " 9:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: DECREASE IN SATS, INTUBATION\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low urine\n output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old with decreasing sats just intubated.\n\n This study is compared to a previous examination of a day earlier and again\n shows dense infiltration in the right upper lobe and patchy areas of bilateral\n diffuse pulmonary infiltration, unchanged. There is continual application of\n the endotracheal tube. The tip is 5.7 cm above the carina. The left\n subclavian intravenous pacemaker remains in place. The leads are in the right\n atrium and the right ventricle. The tip of the right subclavian central\n venous line remains at the junction of the superior vena cava and the right\n atrium. The NG tube remains in place.\n\n Since the previous study, there has been complete loss of the left\n hemidiaphragm due to worsening left pleural effusion and left lower lobe\n partial atelectasis. The right lower lobe is better expanded at this time.\n There has been no significant changes in the degree of bilateral pulmonary\n infiltration.\n\n IMPRESSION:\n 1) Multiple lines and tubes remain in place. The left lower lobe shows\n worsening partial atelectasis. The right lower lobe is better expanded.\n 2) No significant changes in the appearance of bilateral pulmonary\n infiltration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2163-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833119, "text": " 9:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: central line placement\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low\n urine output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreasing oxygen saturation. Status-post line placement.\n\n COMPARISON: at 9:00 am.\n\n CHEST, PORTABLE AP RADIOGRAPH: There is no significant change in the\n appearance of the heart and lungs since the previous study. The tube is in\n unchanged positioning along with the right subclavian Swan-Ganz catheter tip\n which extends distally into the right lower lobe pulmonary artery. There is a\n new right internal jugular central venous line tip in the mid-SVC without\n evidence of pneumothorax. The osseous structures are unremarkable. The\n dual lead pacemaker tips are in unchanged position.\n\n IMPRESSION:\n 1. New right internal jugular central venous line tip in the mid-SVC without\n evidence of pneumothorax.\n\n 2. Swan-Ganz catheter tip is still seen extending distally into the right\n lower lobe pulmonary artery, as discussed with the clinical service caring\n for the patient.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833065, "text": " 6:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval new pa line\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low urine\n output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n eval new pa line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to previous study of earlier the same day.\n\n INDICATION: Pulmonary artery catheter placement.\n\n There has been placement of a pulmonary artery catheter which coils in the\n right pulmonary artery with the distal tip directed towards the midline. No\n pneumothorax is identified, and there has otherwise been no significant change\n since the recent study performed earlier the same date. At the time of this\n dictation, a subsequent chest radiograph has been performed and shows\n successful repositioning of the catheter.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833066, "text": " 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval swan replaced\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low\n urine output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n eval swan replaced\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST of at 19:28 compared to 18:45:\n\n CLINICAL INDICATION: Repositioning of catheter.\n\n A Swan-Ganz catheter has been successfully repositioned with the tip\n terminating in the right pulmonary artery. There has otherwise been no\n significant interval change since the previous study performed less than one\n hour earlier.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833257, "text": " 12:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Swan adjustment\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with\n low urine output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n Swan adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreasing oxygen saturations, status post right colectomy with\n bibasilar rales and Swan adjustment.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube, nasogastric tube,\n pacemaker leads, and right internal jugular central venous catheter are remain\n in stable and satisfactory position. The Swan-Ganz catheter has been withdrawn\n in the interval with the tip now curled in the right main pulmonary artery.\n The heart is decreased in size since the prior study. There has been interval\n improvement in the previously identified congestive heart failure pattern.\n There is residual perihilar haziness and upper zone vascular redistribution.\n There has been interval improvement in the multifocal patchy opacities seen\n within the upper lobes bilaterally and left lower lobe, likely representing\n interval improvement in asymmetric pulmonary edema. No definite pleural\n effusions are seen, however. The left costophrenic angle is excluded from the\n study. No pneumothorax is present.\n\n IMPRESSION:\n 1. Interval withdrawal of the Swan-Ganz catheter with the tip now curled\n within the main right pulmonary artery.\n 2. Interval improvement in multifocal opacities and congestive heart failure\n pattern, findings consistent with interval improvement in asymmetric pulmonary\n edema.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833057, "text": " 4:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low urine\n output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , compared to previous study earlier the same\n date.\n\n CLINICAL INDICATION: Decreasing oxygen saturation.\n\n Various lines and tubes are unchanged in position. The cardiac silhouette\n remains enlarged. Bilateral multifocal alveolar opacities are again\n demonstrated, most prominent in the right upper lobe. Note is also made of\n small pleural effusions. Overall, allowing for differences in technique,\n there has probably been no significant change since the recent study of\n earlier the same date.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833099, "text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low urine output\n and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n INDICATION: Bibasilar rales. Evaluate ETT position.\n\n An ETT remains in satisfactory position but the cuff is slightly over\n distended. There has been advancement of a Swan-Ganz catheter which now\n terminates within the right lower lobe pulmonary artery. Other lines and tubes\n are in satisfactory position. Cardiac silhouette is enlarged but stable. There\n is a persistent bilateral multifocal alveolar pattern which is asymmetric,\n involving the right upper lobe to the greatest degree. This shows slight\n interval improvement since the recent study. There are probable small\n bilateral pleural effusions, not significantly changed.\n\n IMPRESSION: 1) Distal location of Swan-Ganz catheter within right lower lobe\n pulmonary artery, as communicated to clinical service caring for the patient.\n Slight over extension of ETT cuff has also been communicated.\n\n 2) Slight improvement in multifocal asymmetric alveolar pattern.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833534, "text": " 8:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with\n low urine output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Bibasilar rales and oxygen desaturation.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from .\n\n FINDINGS: The cardiac, mediastinal and hilar contours are stable in\n appearance. There is increased pulmonary vascular redistribution, perihilar\n haziness, and interstitial opacities.There are new moderate left pleural\n effusions bilaterally. The endotracheal tube is approximately 3 cm above the\n carina. The nasogastric tube tip overlies the left upper quadrant. The osseous\n structures are unremarkable.\n\n The dual lead pacemaker tips are in unchanged position.\n\n IMPRESSION: New moderate CHF and bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-25 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 833110, "text": " 9:03 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P COLECTOMY FEVER R/O ABCESS\n Admitting Diagnosis: COLON CARCINOMA/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with\n REASON FOR THIS EXAMINATION:\n PO and IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS WITH ORAL AND INTRAVENOUS CONTRAST:\n\n TECHNIQUE: CT scan of the abdomen and pelvis was obtained with oral and\n intravenous contrast, and compared with the prior contrast enhanced CT dated\n .\n\n CT ABDOMEN WITH CONTRAST: Since the prior examination, the patient has\n developed large bilateral pleural effusions, as well as airspace disease\n within the right lung base.\n\n The liver is unremarkable in appearance, except for a low attenuation lesion\n within the right lobe measuring approximately 4 mm, too small to characterize.\n The gallbladder is at the upper limits of normal, containing multiple\n dependently appearing gallstones, without pericholecystic fluid, gallbladder\n wall thickening, or intrahepatic biliary ductal dilatation. The spleen,\n pancreas, and adrenals are unremarkable. A large cyst is seen within the\n upper pole of the left kidney, measuring approximately 6 cm.\n\n There is new moderate ascites. The stomach and small bowel are normal in\n caliber.\n\n CT PELVIS WITH CONTRAST: There is moderate new free fluid within the pelvis.\n The ureters are unremarkable, without evidence of dilatation. Calcified\n uterine fibroids are noted. There is diverticulosis of the sigmoid colon,\n without evidence of acute diverticulitis. The urinary bladder contains a\n foley catheter.\n\n Surgical sutures are seen within the right upper quadrant of the abdomen\n within the colon, presumably at the site of right hemicolectomy.\n\n There is new moderate anasarca.\n\n BONE WINDOWS: An old fracture is seen within the right inferior pubic ramus.\n Extensive degenerative changes are seen, particularly within the lower lumbar\n spine.\n\n IMPRESSION: New effusions, airspace disease, ascites and anasarca. No\n evidence of intra-abdominal abscess.\n\n (Over)\n\n 9:03 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: S/P COLECTOMY FEVER R/O ABCESS\n Admitting Diagnosis: COLON CARCINOMA/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Discussed with the surgical service.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-25 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 833111, "text": " 9:04 AM\n CT CHEST W/CONTRAST Clip # \n Reason: S/P COLECTOMY RESP DISTRESS FEVER R/O ABCESS\n Admitting Diagnosis: COLON CARCINOMA/SDA\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Respiratory distress and fever.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n thoracic inlet through the lung bases, following the administration of 25 cc\n of intravenous Optiray.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The lung windows demonstrate a\n consolidation in the posterior right upper lobe. There is also extensive\n ground-glass opacities predominantly in the central perihilar regions and\n upper lobes. This is associated with smooth intralobular septal thickening.\n The central airways are widely patent. The soft tissue windows reveal a\n mildly enlarged heart in a patient with dual right atrial and right\n ventricular pacemaker leads. The pericardium is unremarkable. Atherosclerotic\n changes are noted throughout the aorta. There are small bilateral pleural\n effusions, right greater than left. No significant lymphadenopathy. There is\n extensive subcutaneous edema. The endotracheal tube is noted in satisfactory\n positioning, but the cuff appears slightly hyperinflated. However, the Swan-\n Ganz catheter tip is again seen extending distally into the right lower lobe\n pulmonary artery.\n\n The osseous windows demonstrate a hemangioma within the T8 vertebral body.\n There is otherwise degenerative changes throughout the mineralized vertebral\n bodies.\n\n IMPRESSION:\n 1. Right upper lobe posterior segment consolidation consistent with a\n pneumonia.\n 2. Diffuse perihilar/central distribution of ground-glass opacities with\n interlobular septal thickening consistent with superimposed congestive heart\n failure.\n 3. The pulmonary arterial Swan-Ganz catheter tip is in a distal location in\n the right lower lobe pulmonary artery, as discussed with clinical service.\n 4. Slightly hyperinflated endotracheal tube cuff.\n\n Please see accompanying report from the CT of the abdomen for further\n descriptions of the abdominal findings.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833700, "text": " 6:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: EVALUATE REPEAT DOBHOFF PLACEMENT\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n\n REASON FOR THIS EXAMINATION:\n EVALUATE REPEAT DOBHOFF PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n Compared to previous study of earlier the same date.\n\n CLINICAL INDICATION: Dobhoff tube repositioning.\n\n A Dobhoff tube remains in place with the tip directed cephalad in the region\n of the body of the stomach. The tip location is similar to the previous exam\n although the entirity of the tube is not included on the current study. The\n exam is grossly unchanged.\n\n IMPRESSION: Coiling of Dobhoff tube with tip direct cephalad as detailed\n above.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832752, "text": " 10:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with\n h/o chf s/p R colectomy with low urine output and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post colectomy with low urine output and basilar rales.\n Comparison .\n\n CHEST, AP PORTABLE RADIOGRAPH: There is stable cardiomegaly with pacemaker\n tips in unchanged position over the right atrium and ventricle. There is\n bibasilar linear atelectasis and small bilateral pleural effusions. There is\n no pulmonary vascular congestion. The soft tissue and osseous structures are\n otherwise unremarkable.\n\n IMPRESSION: Bibasilar atelectasis and small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2163-08-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 834030, "text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for effusion, failure.\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n REASON FOR THIS EXAMINATION:\n Please assess for effusion, failure.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: year-old-woman status post collectomy with pneumonia and ARDS. No\n diuresing.\n\n COMPARISON: .\n\n CHEST, AP: The cardiac, mediastinal, and hilar contours are stable in\n appearance. There is decreased cephalization of pulmonary vasculature\n suggestive of slighty approved CHF. Accounting for difference in technique\n there is increase in bilateral effusions and concomitant bibasilar collapse.\n Right IJ CVL and NGT remain in unchanged position.\n\n IMPRESSION: Interval increase in bilaterally pleural effusions with\n concomitant lower lobe collapse compared to prior study. However, pulmonary\n vascular normalization is suggestive of apparent improvement of CHF.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832962, "text": " 12:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulmonary edema please do STAT\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats\n h/o chf s/p R colectomy with low urine output and bibasilar\n rales.\n REASON FOR THIS EXAMINATION:\n r/o pulmonary edema please do STAT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST COMPARED TO PREVIOUS STUDY OF TWO DAYS EARLIER.\n\n CLINICAL INDICATION: Decreasing oxygen saturations.\n\n The heart is enlarged and there is upper zone vascular redistribution.\n There has been interval development of a bilateral pattern of alveolar\n consolidation which is most prominent in the central portions of the lungs,\n slightly worse in the upper lobes than the lower lobes. A background\n interstitial pattern is also present with numerous septal lines. Bilateral\n pleural effusions are present, increased from the recent study.\n\n IMPRESSION: Interval development of bilateral alveolar and interstitial\n opacities, attributed to diffuse pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 832971, "text": " 3:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R SCV CVL\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with decreasing sats just intubated\n h/o chf s/p R colectomy with low urine output\n and bibasilar rales.\n REASON FOR THIS EXAMINATION:\n s/p R SCV CVL\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF COMPARED TO PREVIOUS STUDY OF EARLIER THE SAME\n DAY.\n\n CLINICAL INDICATION: Line placement.\n\n There has been interval placement of a right subclavian vascular catheter\n terminating just beyond the junction of the superior vena cava and right\n atrium. There is no evidence of pneumothorax. A nasogastric tube and\n endotracheal tube have been placed, in satisfactory position. However, the\n cuff of the endotracheal tube appears overdistended. With the exception of\n these new devices, there has been otherwise no significant interval change\n since the recent study of the same date.\n\n IMPRESSION: Vascular catheter terminates in proximal right atrium. Slight\n overdistention of endotracheal tube cuff.\n\n" }, { "category": "Radiology", "chartdate": "2163-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833642, "text": " 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess bilat pleural effusions\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n REASON FOR THIS EXAMINATION:\n reassess bilat pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE:\n\n HISTORY: y/o status post right colectomy. Right upper lobe pneumonia and\n ARDS.\n\n This study is compared to the previous examination of 1 day earlier. There\n has been improvement in the degree of bilateral pleural effusion and\n reexpansion of the compression atelectasis of the lower lobes since the\n previous study. Diffuse bilateral pulmonary infiltration is still present and\n has not significantly changed since the previous study. There is a moderate\n amount of residual bilateral pleural effusion. Cardiomegaly and\n arteriosclerotic changes involving the thoracic aorta are noted. There is\n continued application of the left subclavian pace maker, the right IJ CVP\n line, the ET tube and the NG tube. The position of these lines and tubes have\n not changed since the previous study.\n\n IMPRESSION:\n Some improvement in the degree of bilateral pleural effusion is noted.\n\n Diffuse bilateral pulmonary infiltration persists.\n\n Multiple lines and tubes in place unchanged in position.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833653, "text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff tube\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n\n REASON FOR THIS EXAMINATION:\n eval dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: year old status post right colectomy and right upper lobe\n pneumonia and ARDS.\n\n The reason for exam evaluate Dobhoff tube.\n\n The study is compared to the previous study of the same day earlier and shows\n that since the previous study there is repositioning of the Dobhoff tube.\n The tube is now coiled in the gastric antrum and the tip is lying in the mid\n gastric body.bilateral pulmonary infiltration and bilateral pleural effusions\n are unchanged.the Subclavian vein pacemaker remains in place unchanged in\n position.\n\n IMPRESSION: There has been repositioning of the Dobhoff tube since the\n previous study. The tube is coiled in the gastric antrum and the tip of it is\n in the mid gastric body. No other significant changes are noted since the\n previous study.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833650, "text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval dobhoff placement\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n\n REASON FOR THIS EXAMINATION:\n eval dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old status post right colectomy and now with right upper\n lobe pneumonia and ARDS. Evaluate Doboff placement.\n\n FINDINGS: Since the previous study, there has been placement of an NG tube,\n which is coiled in the mid-esophagus, the tip of which is directing to the\n cervical esophagus and is not included on the film.the ET tube has been\n removed. There is continued application of the right IJ line, the tip of which\n is in the superior vena cava. biLateral pulmonary edema associated with\n bilateral pleural effusions are unchanged. There is continued application of\n the left subclavian pacemaker; the leads remain in the right atrium and the\n right ventricle. Cardiomegaly and arteriosclerotic changes involving the\n thoracic aorta are again noted.\n\n IMPRESSION:\n\n 1. Coiled NG tube in the mid-esophagus, the tip in noted included on the\n film.\n\n 2. Removal of ET tube.\n\n 3. No other significant changes noted.\n\n\n" }, { "category": "Radiology", "chartdate": "2163-08-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 833894, "text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: COLON CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p R colectomy c/b RUL PNA and ARDS, now diuresing.\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: year old woman status post colectomy with pneumonia and ARDS.\n Evaluate for CHF.\n\n COMPARISON: .\n\n CHEST AP: There is stable cardiomegaly. The aorta is calcified and tortuous.\n Upper zone redistribution of pulmonary vessels remains but is improved. There\n is improved inflation of the lungs and decreased pleural effusions. Right IJ\n CVL, NG, and pacemaker leads remain in unchanged position. Osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION:\n\n Improving CHF.\n\n\n" }, { "category": "Echo", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 94626, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 110\nBSA (m2): 1.48 m2\nBP (mm Hg): 108/50\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 12:43\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle. No\natrial septal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis severely depressed. There is no resting left ventricular outflow tract\nobstruction.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. There is no significant mitral stenosis. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: There is moderate pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis severely depressed (ejection fraction 20-30 percent) secondary to severe\nhypokinesis of the anterior septum, anterior free wall, and lateral wall, with\nextensive apical akinesis. Right ventricular chamber size is normal. Right\nventricular systolic function appears depressed. The aortic root is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but not stenotic.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nComapred to the prior study of , there has been major worsening\nof left ventricular contractile function.\n\n\n" }, { "category": "ECG", "chartdate": "2163-07-26 00:00:00.000", "description": "Report", "row_id": 270818, "text": "Atrial fibrillation\nIntermittent ventricular paced rhythm\nLeft axis deviation - probably left anterior fascicular block\nLow voltage\nAnteroseptal myocardial infarct, age indeterminate\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , intermittent ventricular paced beats seen\n\n" }, { "category": "ECG", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 270819, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of atrial fibrillation is new. Beats are conducted. This\nsuggests that the tracing of have been atrial fibrillation with\na DVD pacemaker.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2163-07-23 00:00:00.000", "description": "Report", "row_id": 270820, "text": "Probable atrial sensed and ventricular paced rhythm, rate 95-100. Since the\nprevious tracing of earlier in the day the sinus rate has increased and\nthe QRS width has increased. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2163-07-23 00:00:00.000", "description": "Report", "row_id": 270821, "text": "Sinus rhythm with atrial sensed and ventricular paced rhythm. Compared to the\nprevious tracing of the atrial rate has slowed. Otherwise, no\ndiagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2163-07-22 00:00:00.000", "description": "Report", "row_id": 270822, "text": "Poor quality tracing. Probable sinus tachycardia with ventricular pacing. Since\nthe previous tracing of the rate has increased and the atrial pacing is\nno longer seen. Clinical correlation is suggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479653, "text": "nursing progress note 7p-7a\nS: INTUBATED AND SEDATED\n\nO: NEURO: PT. CONT ON PROPOFOL GTT AT 8 MCG. WILL OPEN EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS ( LANGUAGE BARRIER) + GAG/COUGH\n\nCV: HR 72 V PACED. NO VEA NOTED. BP STABLE. 115-140/60'S. TOL LOPRESSOR DOSES WELL.\n\nRESP: SEE VENT FLOWSHEET FOR SETTINGS. SUCTIONING FOR PINK TINGED SPUTUM. O2 SATS 92-95%. COARSE BREATH SOUNDS.\n\nGU: URINE OUTPUT ~30-40 CC/HR, URINE YELLOW, CLEAR. IV FLUIDS TO KVO.\n\nGI: OGT TUBE DRAINING BILIOUS MATERIAL, ABD SOFT, HYPOACTIVE BOWEL SOUNDS, NO BM OVERNIGHT. LOWER ABD INCISION INTACT, CLEAN STAPLES OPEN TO AIR.\n\nID: CONT ON VANCO, LEVO, FLAGYL. TEMP LOW GRADE 98.7-100.4\n\nA: STABLE NOC, URINE OUTPUT IMPROVING.\n\nP: CONT TO MONITOR U/O, TEMP\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479654, "text": "RESP CARE: Pt remains intubated/ on vent on SIMV/PSV 550//18/.80/10 PEEP/5 PSV. ABGs cosistent with met. alkalosis. Sxd copious amts thick white clear sputum.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-30 00:00:00.000", "description": "Report", "row_id": 1479681, "text": "CONDITION UPDATE\nD: NEURO: LETHARGIC BUT AROUSABLE TO STIMULI. SPEAKING ONLY- DOES NOT FOLLOW COMMANDS GIVEN IN ENGLISH (NO VISITORS YET TODAY). MINIMAL MOVEMENT OF EXTREMITES SEEN BUT AS PER PRIOR NOTES PT IS VERY WEAK.\nCV: AFEBRILE. REMAINS IN AFIB WITH FREQUENT PACED VENT BEATS. SBP 105-160. CONTINUES ON LOPRESSOR AND AMIODARONE PO.\nRESP: PT EXTUBATED AT 0800. WEAK COUGH. BS = SCATTERED WHEEZES ON LEFT, FAIRLY CLEAR IN RUL BUT DIMINISHED IN BASES. CPT DONE. INITIAL PO2 ON OPEN FACE TENT AT 70%= 62. NP AT 5 LITERS ADDED AND FACE TENT INCREASED TO 100%, WITH IMPROVED PO2 TO 84. SATS REMAIN LOW DESPITE INCREASED O2= 92-95%. CPT DONE, NEBS GIVEN, CHANGED TO CLOSED FACE TENT AND NP AT 5 LITERS.\nGI: NPO. ORAL GASTRIC TUBE D/C'D PRIOR TO EXTUBATION AND STOMACH CONTENTS ASPIRATED OUT. FT PLACED AND PLACEMENT CONFIRMED BY CXR. TF RESUMED AT 1630= RESPALOR AT 40CC/HR. ABD SOFT AND SLIGHTLY DISTENDED. FIB INTACT WITH SM AMT STOOL.\nGU: LASIX 10 MG IV GIVEN WITH GOOD DIURESIS.\nA: HEMODYNAMICS AND RESP PARAMETERS MONITORED, OOB TO CHAIR VIA LIFT FOR 2 1/2 HRS.\nR: RESP STATUS REMAINS GUARDED, CONTINUE TO MONITOR SATS AND VIGOUROUS PULMONARY TOILET.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-31 00:00:00.000", "description": "Report", "row_id": 1479682, "text": "7p-7a; Full assessment in flow sheet.\n\nAlert/lethargic - oriented to self (able to open eyes when name call). MAE - weak, upper slightly stronger than lower. PERLA. Speak and understand only (words sound clear). Good gag and cough reflex (nonproductive). Afib (80-110) with PVC. BP 110-140/55-60. Afebrile. warm, dry, general edema +1. Coarse lung sound in upper lobes, dimish at bases. Chest PT and vibration done. Neb treatment given. ABG - metabolic alkalotic with respiratory compensation. Obese abd, +BSX4. loose brown stool. Dobhoff - +placement (CXRAY - and OK to use by Dr. , TF at goal. suture site - d/c/i. Skin intact. AM lab done. Magnesium replace. Spoke with daughter - answer all questions.\n\nPlan; Continue to monitor. Respiratory toileting. transfer to floor?\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-31 00:00:00.000", "description": "Report", "row_id": 1479683, "text": "CONDITION UPDATE\nD: NEURO: MORE ALERT TODAY THAN YESTERDAY. OPENS EYES SPONT, MINIMAL MOVEMENT OF LE SECONDARY TO EDEMA, MOVES ARMS SPONT\nCV: AFEBRILE. REMAINS IN AFIB WITH FREQUENT PACED BEATS. BP STABLE. SEE CAREVUE FOR SPECFICS\nRESP: GOAL OF SAT >90%, PRESENTLY ON NP AT 5 LITERS WITH SATS 92-96%. BS CLEAR IN UPPER LOBES AND DIMINISHED IN BASES. COUGHING BUT NOT RAISING.\nGI: NPO. TOL TF AT GOAL. NO STOOL. ABD SOFT AND NON-DISTENDED\nGU: PT GIVEN ADDITIONAL DOSE OF 20 MG LASIX IN ADDITION TO DOSE OF 10MG WITH EXCELLENT DIURESIS.\nA: VIGOUROUS PULM TOILET, OOB VIA TO CHAIR FOR 4 HRS\nR: IMPROVED RESP STATUS, ? TRANSFER IN AM\n" }, { "category": "Nursing/other", "chartdate": "2163-07-31 00:00:00.000", "description": "Report", "row_id": 1479684, "text": "Respiratory Care Note:\n Patient received 2 albuterol atrovent unit dose aerosol treatments today. BS this afternoon with slight exp wheezing and few scattered rales. Cough moist and non-productive. BS slightly improved after meds. She has been weaned to 5lpm nasal O2 with SaO2>93%. Plan to continue with med nebs per order. Her respiratory status appears to be improving.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-23 00:00:00.000", "description": "Report", "row_id": 1479651, "text": "Nursing Progress Note\n\n yo women transferred from CC6 after acute resp distress with desating into 70's. Pt has h/o CAD, AF, perm pacer, COPD & HTN. Pt underwent recent colonoscopy with positive biopsy for adenocarcinoma. On underwent R colectomy. Transferred to CC6 om . Pt required high levels of O2 for sats in low 90's. At approx 12noon pt acutely desaturated into 70's. Pt intubated and given lasix 40mgIV. Transferred to CCU. Pt is speaking and lives at Rehab. Prior to surgery pt was DNR/DNI.\n\nTele paced rhythm. BP stable. Lasix 40mg IV prior to transferred.\n\nResp: Pt remains intubated. SIMV 60% 550 18 12 peep. Please see flow sheet for abgs. Suctioned for sm amts of pink frothy sputum. Crackles throughout lungs.\n\nNeuro: Pt arousable to voice. Difficult to assess d/t language barrier. Able to MAE. Conts on Epidural Bupivacaine .1% 1mg/ml at 8cc/hr. No c/o pain.\n\nGU/GI: Pt is NPO. OGTube placed by resident. Placement confirmed although no drainage noted. Bowel sound present. Passing gas. Abd incision is C&D and intact. Foley is draining good amts of clear yellow urine. Creat is 1.0\n\nID: T noted to be 103R. Bld, urine and sputum sent for culture. Started on Levo 250 IV Q24.\n\nSocial: Pt has a daughter who is aware of change in condition and in to speak with MD.\n\nA&P: Acute resp failure requiring intubation secondary to pul edema. Cont to monitor resp status. check abgs. Lasix prn. Epidural pain control. check lytes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479655, "text": "CCU NURSING PROGRESS NOTE 0700-1500\nS. REMAINS INTUBATED/SEDATED; DENIES PAIN WHEN AWAKE\n\nO. SEE CAREVUE FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO/MS: MAE, OPENS EYES TO VOICE, STIMULATION, MOVING PURPOSEFULLY W/AWAKENED - ATTEMPTING TO PULL AT LINES, ON PROPOFOL IN INCREASING AMOUNTS 8 MCGS TO 14 MCGS FOR COMFORT; EPIDURAL CATHETER D/C'D BY PAIN SERVICE THIS AM\n\nID: TEMP MAX 99.8 PO, TYLENOL X1, S/P T SPIKE TO 103, CX'S PND; ON VANCO/LEVO, FLAGYL D/C'D FOR PRESUMED PNEUMONIA, WBC 7\n\nCV: HR 60-70 V-PACED, NO VEA, BP 90'S - 150'S/50'S, BP ^ WHEN AWAKE, LOWER W/INCREASED SEDATION, TOLERATING LOPRESSOR 2.5 IV Q 6HR; REPLACING LYTES AS NEEDED\n\nRESP: REMAINS INTUBATED - PRESENTLY ON 80% AC 400X22, 12 PEEP UP FROM 10, 5 PS LAST ABG 7.41/43/82/28/1; SUX FOR THICK PINK-TINGED SPUTUM, LUNGS COARSE\n\nGI: OGT TO LCS - SM AMTS BILEOUS DRAINAGE, ABDOMEN SOFT, + BS ALL 4 QUADRANTS, NO FLATUS OR STOOL, ABDOMINAL INCISION CLEAN AND DRY, NO DRAINAGE, OPEN TO AIR\n\nGU: FOLEY DRAINING CLEAR AMBER URINE - 30-50CC/HR, FLUID STATUS EVEN FOR DAY, NEG 1 L LOS\n\nENDOCRINE: BS 90-150, COVERING SM AMT INSULIN, PRN\n\nSOCIAL: DAUGHTER, GRANDSON IN TO VISIT TODAY, SPOKE W/SICU RESIDENT CHIN AT LENGTH REGARDING CONDITION, PLAN OF CARE\n\nA: REMAINS VENT DEPENDENT ON HIGH DOSE O2; PRESUMED PNEUMONIA/CHF - UNABLE TO DECREASE O2 THUS FAR DESPITE INCREASED PEEP TO 12\n\nP: MONITOR ABG'S, INCREASE PEEP IF BP TOLERATES, LOWER FIO2 AS ABLE, MONITOR FLUID STATUS, CONT ANTIBX, REPLACE LYTES AS NEEDED, PROPOFOL/MSO4 FOR COMFORT, CONT SUPPORTIVE CARE FOR PT/FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479656, "text": "Resp. Care:\n Pt. remains intubated and on vent.support. Still requiring 80% Fi02 despite going up to twelve of peep. Recruitment maneuver done, but pt. with alot of spont. breathing throughout maneuver. Please see flow sheet for more information. Pt. tranferring over to sicu now. To follow.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-23 00:00:00.000", "description": "Report", "row_id": 1479652, "text": " 2130\n\nNeuro: pt aggitated, PERRL, moves all extremities does not speak due to ET tube. pt.fidgeting in bed and trying to pull at lines and ET tube at times. Does not follow comands though.\n\nCV: HR 80-90 v-paced. BP dropped at 1900 to 60-70/ 30-40 2 iv fulid boulses given with good results. Epidural off MD. Once pt woke up BP rose to 150-160/60-70 versed and morpine PRN doses already given. Propofol started low dose to maintain adequated sedation and adequate BP.\n\nResp: Pt intubated multiple blood gasses obtained and ventilatory changes made MD orders. PT seems to desaturate when awake to 87%. Thick sputum present and is pink.\n\nGI: positive BS all 4 quadrants, abdominal incision clean dry and intact staples midline and intact. cleansed with soap and water. slightly pink. No flatus or stool present.\n\nGU: Urine output decreased. 20-50/ hour. MD aware and will monitor closely. urine clear and yellow.\n\nID: febrlile to 103.0 blood cultures times two drawn along with fungal cultures. urine culture and sputum sent. Will monitor culture results. Started on Levoquin, flagyl and Vancomycin for coverage. Monitor fevers closely and await culture results.\n\nPlan: Will continue to monitor for s/s of sepsis closely. Continuous telemetry, temp Q2-3 hrs and, closely monitor BP. If urine output continues to be low will notify MD again. Wean from ventilator as patient tolerates. ABG's as ordered by MD.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2163-08-05 00:00:00.000", "description": "Report", "row_id": 1479695, "text": "CONDITION UPDATE\nASSESSEMENT:\nPT AROUSES TO VOICE, UNABLE TO COMMUNICATE DUE TO LANGUAGE BARRIER. TRANSLATER IN TO ASSIST WITH COMMUNICATION. PT NOT ANSWERING INTERPRETERS QUESTIONS OR FOLLOWING COMMANDS, APPEARS TO BE CONFUSED (SAME AS DAY SHIFT). LS DIMINISHED BUT MOSTLY CLEAR, ON 80% VENT MASK. PM DOSE OF LASIX HELD AS ORDERED BY DR. (ICU RESIDENT), PT ALREADY ~ 2L NEGATIVE. ALL VITALS STABLE, SEE FLOWSEET. REMAINS AFEBRILE. RESPALOR @ GOAL RATE, PT FROM FIB.\nPLAN:\nCONTINUE WITH PULMONARY HYGEINE. ? PHYSICAL THERAPY CONSULT PLACED.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-08-06 00:00:00.000", "description": "Report", "row_id": 1479696, "text": "7p-7a; Full assessment in flow sheet.\n\nArouse to voice. Speak only Russina. Sleep on/off all night. MAE - stronger in upper than lower. No grimace for pain. VSS,afebrile. warm, dry, no edema. Clear lung sound in upper lobes. Dimish at bases. SaO2 >99%. No episode of desat. SaO2 >88% when face mask remove. Good cough. Chest PT and vibration done X3. Encourage to deep breath and cough when awake. soft abd. +BSx4. loose brown stool, negative guiac. foley patent - clear yellow urine. Skin intact. abd suture - d/c/i.\nAM lab done.\n\nPlan: Continue to monitor. Respiratory toileting. Tranfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-06 00:00:00.000", "description": "Report", "row_id": 1479697, "text": "Neuro: Pt alert most of day. MAE, unable to assess orientation due to language barrier. Family to see pt this afternoon. Note pt to be confused but easily reoriented. Denies pain to family.\nCV: afebrile,HR 80 AV Paced with no ectopy, SBP 100-130's. CVP 1-3. extremities warm with +PP.\nRESP: lungs clear to dim at bases. O2 weaned to 4l via N/C. Tolerating neb tx well.\nGI: tol tube feed at goal. FIB intact draining mod amount of loose brown negative guaiac stool. Spec sent for C-diff.\nGU: foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars slightly elevated. Requiring minimal coverage per RISS.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-08-07 00:00:00.000", "description": "Report", "row_id": 1479698, "text": "7p-7a; Full assessment in flowsheet.\n\nA+OX1 (respond to name). Speak only . ? Confuse. Normal affect. MAE. PERLA. VSS, afebrile. warm, dry, no edema. Clear lung sound in upper lobes. dimish at bases. 4L NC. Encourage to deep breath and cough while awake. Chest PT and vibration X3 done. Neb treatment give q6 hrs. soft abd. +BSX4. loose brown stool. foley patent. clear/yellow urine. Skin intact. AM lab done. Potassium replace. Slept on/off most of the night.\n\nPlan; Continue to monitor. respiratory toileting.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-29 00:00:00.000", "description": "Report", "row_id": 1479676, "text": "7a-7p\nneuro: lethargic, arouses to voice, interpreter in & pt following a few simple commands, pt very weak, slight movement of extremities noted\n\ncv: hr continues in a-fib(rate 88-103), some paced bts, no ectopy, sbp stable(144-160), iv lopressor changed to po, continues on po amiodarone\n\nresp: on 40% cpap 5/5 this am, RSBI 40, extubation held until tomorrow due to poor am CXR so ips increased to 10, bs+ all lobes & course, sux sm/mod amts loose white thick sputum, sat 94-96, rr 14-24, no resp distress noted\n\ngi: TF on hold this am due to ? of extubation, TF resumed @ 1200 @ 50 cc/hr, goal TF 65 cc/hr, fib intact & draining sm amt loose brown stool, iv protonix dc'd & changed to po prevacid\n\ngu: foley patent, clear yellow urine, good uo, started on iv lasix\n\nother: abd suture line ota & c&d, continues on iv vanco & zosyn, no c/o pain, bs 135 & tx with rssi\n\nplan: continue to wean on cpap, ? of extubation in am, hold TF @ 0400 pending am extubation, repeat K+,MG+, ICA+ @ 1500, repleat as needed\n" }, { "category": "Nursing/other", "chartdate": "2163-07-29 00:00:00.000", "description": "Report", "row_id": 1479677, "text": "Respiratory Care\nPt remains oraly intubated PSV 10/5. BS coarse MDI's as ordered. Suctioned for moderate amts. thick white sputum. Last ABG @ 0300\n7.40-45-92. Plan: Continue to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-30 00:00:00.000", "description": "Report", "row_id": 1479678, "text": "7p-7a; Full assessment in flow sheet.\n\nAlert and oriented X1. Nod head appropriately to sons questions (no pain, understand extubation, understand surgery, feeling better). Follow directions - weak movement of ext (hands and feet), grimace with larger movement (bend knee, raise arms, etc) - Passive ROM X2 done - very stiff. Good gag and cough reflex. Strong productive cough. Pain X2 with turn and position and strong cough. speaking only. Good tracking. Afib (stable 80 when sleeping, awake 80-120). Afebrile. warm, dry, general edema +1. Coarse lung sound. CPAP tolerated. obese abd. +BSX4. loose brown stool - rectal bag. foley patent - clear yellow urine. skin intact.\n\nPlan; Continue to monitor. Extubation in am?\n" }, { "category": "Nursing/other", "chartdate": "2163-07-30 00:00:00.000", "description": "Report", "row_id": 1479679, "text": "Respiratory Care Note:\n\nPt remain orally intubated on PSV the whole shift. We were able to slowly wean IPS from 10 to 5 cmH20. RSBI is good. She continue to experience occ episode of hypoventilation and settled herself. Plan: ? elective extubation.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-30 00:00:00.000", "description": "Report", "row_id": 1479680, "text": "Respiratory Care\nPt extubated @ 0730 placed on .7 face tent. BS on Lt side-clear, diffuse wheezes on Rt. MDI's as ordered. ABG post extubation:7.45-43-62-31. Currently .7 FT and 5L n/c for sats of 100%\nWill continue to follow pt.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-27 00:00:00.000", "description": "Report", "row_id": 1479668, "text": "data/action: afrebile. hr 90-104 af w/ paced beats-cont. on aminodarone gtt. pa waveform dampened-w/ flushing wave good for 3 secs. ?co accuracy 1.8-2.1. cvp 14. huo 24-40cc. svo2 60-66.\n weaning levo gtt for map>70.\nt. feeding residuals 15-50cc. bs present. no bm.\npt sedated on ppf-responds to painful stimuli.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-27 00:00:00.000", "description": "Report", "row_id": 1479669, "text": "STATUS\nD: ON PROPOFOL/AMIODARONE/LEVO GTT'S..NEURO: OPENS EYES TO PAINFUL STIMULI..MOVES ALL EXTREM'S\nA: PROPOFOL & LEVO WEANED OFF..MED WITH DILAUDID FOR DISCOMFORT NOTED BY HYPERTENSION & GRIMACE SCALE..ESOPH PRESSURE CHECKED..MULTIPLE VENT CHANGES & ABG'S(SEE FLOW SHEET)SUCTIONED FOR SM AMT THICK WHITE..GIVEN LASIX 10MGM X1 WITH GOOD EFFECT..SWAN & CORDIS DC'D..ABD INCISION C&D OPEN TO AIR..TOL TF'S @ 10CC/H WITH MIN RESIDUALS..NO STOOL..FIB INTACT\nR: IMPROVING PULMONARY/HEMODYNAMIC STATUS\nP: WEAN VENT AS TOL..MED WITH DILAUDID FOR DISCOMFORT..? MORE LASIX IF URINES DECREASE\n" }, { "category": "Nursing/other", "chartdate": "2163-07-27 00:00:00.000", "description": "Report", "row_id": 1479670, "text": "Respiratory Care Note\nPt. had eso. balloon measurements today pt. requires 15cm of peep to maintain ptpexp=0. Pt weaned to psv 15cm peep- 8 cm p/s abg's 739/38/142/24/-.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-28 00:00:00.000", "description": "Report", "row_id": 1479671, "text": "resp Care Note\n\ntp has been relatively comfortable t/o noc on PSV with 15 PeeP. She has an esophageal balloon in place which is due for measurements this afternoon. She was sx multiple times for thick whit sputum.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-28 00:00:00.000", "description": "Report", "row_id": 1479672, "text": "data/action: vss, cvp 6-11. lasix 10mg iv x1 w/ good response (-650 for 24hr). pt attempting to open eyes to verbal stimuli.\ntol. t. fdg w/ resid. . no stool. bs present.\nabg's good on cpap15/8ips.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-28 00:00:00.000", "description": "Report", "row_id": 1479673, "text": "STATUS\nD: OPENS EYES TO STIMULI..MOVES ALL EXTREM'S ON BED..AMIO GTT AT .5MGM REMAINS IN A-FIB WITH PACED BEATS\nA: AMIO GTT DC'D & STARTED ON PO AMIO..TF'S BEING INCREASED BY 10CC Q6H & TOL WELL..ESOPH BALLOON PRESSURE DONE & PT PLACED ON WEANING TRIAL PEEP 5 IPS 5..NOT TOL WELL WITH HR UP 120'S BP 170/'S..PLACED ON PEEP 10 IPS 5..STV >350..ADQUATE ABG'S..SUCTIONED FOR MOD AMT THICK WHITE..LASIX 10MGM GIVEN WITH GOOD RESPONSE..K+ REPLETED..BLADDER PRESSURE 7..MIN LIQ GREEN/BROWN STOOL..FIB INTACT\nR: IMPROVING PULMONARY STATUS\nP: WEAN VENT AS TOL..? PT CONSULT WHEN PEEP TO 5CM..MONITOR LABS CLOSELY\n" }, { "category": "Nursing/other", "chartdate": "2163-07-28 00:00:00.000", "description": "Report", "row_id": 1479674, "text": "Respiratory Care Notes\nPt. weaned to 5/10 psv. Last abg743/37/90/25/0/97. Plan to wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-29 00:00:00.000", "description": "Report", "row_id": 1479675, "text": "7p-7a; Full assessment in flow sheet.\n\nArouse to eyes. Track with eye. Speak and understand only - hard to evaluate. Spoke with daughter - will create an English/ words list. MAE - withdrawal to pain, weakly. PERLA - 3mm brisk. Good gag and cough reflex. Afib - 82-110. BP 93-130/53-60. Afebrile. warm, dry, pink, general edema +1. Coarse lung sound. Tolerating CPAP 10/5. Suction for small white thick sputum. Obese abd. +BSX4. TF tolerating - slow inc to goal of 65. Minimal residual. suture site - some area pink. foley patent - clear yellow urine. Bowel movement - loose brown stool, negative guiac. Skin intact. AM lab.\n\nPlan; Continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-02 00:00:00.000", "description": "Report", "row_id": 1479688, "text": "Condition Update A:\nPlease refer to careview and remarks for details.\n\nPt alert and appears oriented to name. MAE. Per two translators pt cont with periods of confusion. First translator arrived with speach/swallow therapist for an eval of swallow function. During the eval per therapist, the pt unable to focus on task at hand and would cont to talk with food and drink in her mouth, although instructed otherwise. Please refer to therapists note. Second translator arrived for daily visit and stated some of pt's conversation appropriate, at other times diverts from topic. States she lives at \"# \". Mentioned her daughter buys for her to plant in pots.\n\nLS CTA BUL and dim BLL. Pox on 5L 90-96%. Maintaining 97% on 3L NC. Diuressing well. -1220cc as of 1700. CVP wave form wanders, 0-11. In Afib with paced beats for most of shift. At 1700 AV paced.\n\nPLAN:\n Monitor hemodynamics, resp status, fluid balance.\n Monitor tol to 3L NC, Pox.\n Follow up speach/swallow eval in a couple of days.\n Cont ICU care and monitoring. Call H.O. with changes.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-02 00:00:00.000", "description": "Report", "row_id": 1479689, "text": "Resp. Care Note\nPt followed today for Albuterol/ Atrovent nebs q6, see flowsheet for Rx times. BS without wheezes but decreased and bronchial sounding to the bases. O2 via 3L nasal prongs with sats 95%, oxygen weaned today from 6L. Improving resp. status, Cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-03 00:00:00.000", "description": "Report", "row_id": 1479690, "text": "Pt condition update\nIncreasing O2 demand evidenced by increase use of O@ started at NP4l and had to add 40% Face Shield to maintain O2sats in low 90's. Bil crackles 3/4 up both right and left lung fields. Temp decreased to 96 after pt bathed warm blankets applied.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-08-03 00:00:00.000", "description": "Report", "row_id": 1479691, "text": "Resp. Care Note\nPt followed this shift for Albuterol/ atrovent nebs x2. Pt with episode of decreased sats in AM to high 80's requiring ^^O2. Placed on non-rebreather for a while, given diamox with good response and sats improved. Pt then placed on 100% settings of aerosol mask and is maintaining sats of 93-95%. Pt NTS x1 in afternoon for sputum specimen. BS with occas exp wheezes. Cont to follow Q6prn.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-03 00:00:00.000", "description": "Report", "row_id": 1479692, "text": "NPN ( SEE CAREVUE FOR SPECIFICS)\nPT ALERT, DOZING INTERMITTENTLY. ASSESSED PAIN WITH TRANSLATOR, PT DENIES. SEEMS TO BE MORE CONFUSED TODAY. MAE. SATS DROPPED THIS AM TO 88%, NON REBREATHER PLACED FOR A FEW HOURS WITH GOOD EFFECT, SATS INCREASED TO 98%. CHEST PT DONE FREQUENTLY, PT COUGHING AND RAISING SPUTUM. CHEST X-RAY DONE. NOW COMFORTABLE ON AEROSOL MASK AT 100%. OOB TO CHAIR WITHOUT PROBLEMS. LASIX 20MG GIVEN WITH GOOD DIURESIS, GOAL OF 2L BY MIDNIGHT SHOULD BE ACHIEVED. AFEBRILE.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-04 00:00:00.000", "description": "Report", "row_id": 1479693, "text": "CONDITION UPDATE\nSEE CAREVUE FOR SPECIFIC INFO. MAJOR ISSUE REMAINS IS DESAT (88%) EPISODES OFF O2. IV ABX CONTINUE AND RESP TREATMENTS\n" }, { "category": "Nursing/other", "chartdate": "2163-08-04 00:00:00.000", "description": "Report", "row_id": 1479694, "text": "focus update note\nAfebrile VSS Av paced at rate 80, crackles right lung- lasix 20mg , wet cough, aresol mask 80% 15 liters, increasing lethargy ICU team aware ABG sent at 1830 awaiting results. pt opening eyes only with stimulation- repositing and sternal rub, not following commands- not answering questions. lytes repleated, OOB to chair X 4 hrs\n" }, { "category": "Nursing/other", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 1479662, "text": "Respiratory Care\nPt remains on mechanical ventilation oett. Transpulmonary pressures obtained via Esophageal balloon. Vent settings dictated by those results are:PCV .6 f 26 peep24 spontaneous Vt 400 Sats 100%.Transported to CT this afternoon for chest and abdominal CT. Uneventful travel remained mechanicaly ventilated.\nlast ABG 7.37-35-188-21. Plan follow EPV protocol.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-26 00:00:00.000", "description": "Report", "row_id": 1479663, "text": "Resp Care Note:\n\nPt cont sedated/paralyzed intub with OETT on mech vent asper Carevue. Lung sounds ess clear bilat suct sm th white sput. ABGs stable oxygenation has shown steady improvement able to wean FIO2 to .4 overnoc. No other vent changes required overnoc. Cont present vent regime.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-26 00:00:00.000", "description": "Report", "row_id": 1479664, "text": "POD#5 rt colectomy,\nSee flow sheet for specific data\nNeuro: pt continues to be sedated on propofol and cistat(off @ 0500). Responds to painful stimuli, prop titrated maintain resp stability.\n\nResp:Fio2 was weaned down from 60% to 40% maintaining O2sats of 100%. Pt has esophogeal balloon for study. RUL pneumonia on CT scan\n\nCV:No further episodes of a fib since cardioversion . Pt continues on amiodarone gtt until 0800 than will begin NGT amiodarone beta blockers (lopressor Dc'd per d.o). Steady AV paced @ 80/min. BP continues to respond to fluid. Milronone d/c'd. Swan #s questionable as calc FICK CO >4 when COO <3.0. COO recalibrated but #s still off.\n\nRenal:U/O compromised < 20 ml/hr.\n\nPlan:Fluid, Levo to maintain CO.\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-26 00:00:00.000", "description": "Report", "row_id": 1479665, "text": "PLEASE REFER TO CAREVUE FOR SPECIFICS AND COMPLETE ASSESSMENT.\n\nNEURO: PT REMAINS SEDATED ON PROPOFOL, WITHDRAWS SLIGHTLY TO PAINFUL STIMULI W/ ALL EXTREMETIES.\n\nCV: HR SET AT 80, AV-PACED. MAP GOAL >70. PT WENT INTO A-FIB AT ~11:00 W/ RATE 90-115, DR. INFORMED. SBP TO 70-80'S, RECEIVED BOLUS LR 500CC X1 W/ GOOD RESPONSE OF INC SBP AND LEVO GTT TITRATED ACCORDINGLY. GIVEN AMIO BOLUS DOSE AND AMIO GTT RESTARTED AT 1MG/MIN X 6HRS AND THEN TO 0.5MG/MIN X 18HRS. PAS 30-50'S, CO 1.9-4.7, CI 1.16-2.87, PCWP AT 15CM.\n\nRESP PLEASE SEE RESP NOTE FOR COMPLETE DETAILS. LUNG SOUNDS COARSE. VENT SETTTINGS CURRNTLY PCV W/ 40%O2, TV 355-406, PEEP 20, RATE 30. SXN PRN FOR SMALL AMT THICK YELLLOW SPUTUM. LAST ABG UNREMARKABLE. PT TO HAVE BRONCH.\n\nGI: ABD SOFTLY DISTENDED, BOWEL SOUNDS, TOLERATIG TF IMPACT W/ FIBER AT 10CC/HR VIA OGT W/OUT ADVANCEMENT PER DR. . RESIDUAL CHECKS Q4HRS. INC OTA W/ CLIPS C/D/I.\n\nGU: U/O 15-26CC/HR, CLEAR AMBER URINE. BLADDER PRESSURE 15.\n\nID: TMAX 36.9 CELCIUS.\n\nPLAN: MONITOR VS, LABS RESP STATUS. MONITOR TF RESIDUALS AND HOLD FOR RESIDUAL>100CC. ? BRONCH TODAY VS TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-26 00:00:00.000", "description": "Report", "row_id": 1479666, "text": "RESPIRATORY CARE NOTE\nPT. REMAINS SED. ON PCV VENTILATION. PT. WAS WEANED ON SUPPORT AFTER ESO. BALLON MEASUREMENTS REVEALED PtPexp was 5+ weaned peep to 14 for PtPexp of 1+. PT. HAD EPISODE OF A-FIB. INCREASED PEEP TO 20. SEE CAREVUE FOR SETTINGS. GOOD GASES 743/35/157/24/0/98. CAN WEAN RATE.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-27 00:00:00.000", "description": "Report", "row_id": 1479667, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds ess clear after suct for mod th tan sput. ABGs trending resp alkalosis decreased rate to 26 will repeat gas. Otherwise pt in NARD on current vent settings. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-01 00:00:00.000", "description": "Report", "row_id": 1479685, "text": "7p-7a; Full assessment in flow sheet.\n\nAlert. Oriented to self. Speak clear . Appropriate per family. MAE - stronger in upper than lower ext (very weak - mostly feet movement). Good gag and cough reflex. Afib with pacing. VSS, afebrile. warm, dry, general edema +1. Coarse in upper lobes, dimish at bases. Nasal canula 5L - SaO2 >92%. obese abd. +BSx4. Chest PT and vibration X2 done. Encourage to deep breath and cough. loose brown stool. negative guiac. foley patent - clear yellow urine. Dobhoff - TF at goal, +placement. skin intact except blister area in R. upper thich and R. lower leg. AM lab done.\n\nPlan; Continue to monitor. Respiratory toileting. Tranfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-01 00:00:00.000", "description": "Report", "row_id": 1479686, "text": "Condition Update A:\nPlease refer to careview and remarks.\n\nNEURO: Pt alert and via interpretor oriented to person and month and year. Per interpretor speach clear, pt very talkative. No indications of pain.\n\nCV: Afeb. Cont in Afib with paced beats. A-line positional, monitoring NIBP as well. CVP 6-9. Cont with generalized 2+ pit edema.\n\nRESP: BLL dim, BUL clear to wheezing. Lasix 20mg IVP admin x2 for pulmonary edema. Pox 89-94%. CPT x2 done.\n\nGU: Diuressing very well from IV lasix. Fluid balance - as of 1900.\n\nSKIN: W/D/I.\n\nPLAN:\n Monitor hemodynamics, keep Pox >=90.\n Monitor resp status, pulmonary tiolet, pulmonary edema, metabolic alkalosis.\n Obtain evening labs per oders.\n Cont with ICU care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2163-08-02 00:00:00.000", "description": "Report", "row_id": 1479687, "text": "condition update\nD: pt is alert and oriented per grandson. speaks only . moves all extremities. denies any pain to family.\ncardiac: pt continues in vpace to afib rate of 80-100. she is on lopressor and amiodarone.\nresp: pt with upper airway wheezes. coughing without raising. diminished in the bases. pt desatted to 87on 6l of nc with activity of bed bath. placed on 50% face mask and up to 95%. albuterol and atrovent nebs given by resp. Dr. aware and cxr for the am. lasix on hold and diamox started. abgs are unchanged. see flowsheet. pt continues to have metabollic alkalosis and po2 in the 60's. Dr. is aware.\ngi: pt continues on tf at 40cc/hr tolerating well. fecal bag is intact and draining liquid brown stool.\ngu: urine output is good on diamox. i&o is 3liters negative.\nskin: abd incision is clean and dry and open to air.\na: continue with pulmonary toilet.nebs as needed. check regarding lasix this am during rounds. tylenol for pain\nr: pt's resp status is still marginal and she becomes wheezy with activity. abd incision is clean and dry. diuresing well with diamox.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479657, "text": "PT ADMITTED FROM CCU AT ~15:30, SEE CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT IS SEDATED ON PROPOFOL CURRENTLY AT 30MCG/KG/MIN-INC DUE TO PT BREATHING OVER VENT. PT OPENING EYES WHEN CALLING OUT HER NAME, ABLE TO NOD SHE DOESN'T HAVE PAIN ASKED W/ TRANSLATED WORD. MAE SPONT/PURP. UNABLE TO COMMUNICATE W/ PATIENT DUE TO LANGUAGE BARRIER.\n\nCV: PT IS , HR 70-80'S, SBP 125-140. +BLOOD CX GRAM + COCCI IN PAIRS AND CHAINS. SWAN TO PLACED AND ECHO TO BE OBTAINED PER DR. .\n\nRESP: PT O2 SAT TO 88%, ABG DRAWN WHICH REVEALED PO2 OF 59, VENT SETTINGS CHANGED FROM SIMV+PS TO AC, PEEP INC FROM , AND O2 INC FROM 80% TO 100%, REPEAT ABG REVEALED INC PO2 TO 94. SEE CAREVUE AND RESP NOTE FOR COMPLETE DETAILS. CXR DONE AND APPEARS WORSE PER DR. , ?ARDS.\n\nGI: ABD SOFT, +BOWEL SOUNDS, NPO. INC OTA W/ CLIPS C/D/I.\n\nGU: ADEQ U/O VIA FOLEY CLEAR YELLOW URINE.\n\nPLAN: MONITOR VS, LABS, RESP STATUS. SWAN TO BE PLACED, ECHO TO BE DONE.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-24 00:00:00.000", "description": "Report", "row_id": 1479658, "text": "Resp care\nPt transfered from CCU, placed on full vent support(see flowsheet). ABG's show acceptable ventilation, poor oxygenation. OET patent/secure in good position. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 1479659, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear. Pt requires high oxygen level to maintain adequete oxygenation. Presently ABGs acceptable on .8FIO2. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 1479660, "text": "Hemodynamic Instability s/p POD#4 rt Colectomy, possible ARDS, Sepsis and cardiogenic shock,\nPt became hypotensive SBP 60s, atrial fib at 130 with drop in PA#s and CO/CI after recieving lasix 10 mg IVP. CVP off vent was 10.Pt treated with fluid NS wide open per D.O. lopressor given per d.o. in attempt to decrease HR to maintain better CO. Hct of 28 treated with 1 unit PRBCs. Pt recieved 4 l NS per d.o to maintain BP over night. Pt cotinued to have poor CO overnoc and was started on Dobutamine. Ca, Ionized Ca, Mg Phos were all low and treated with Calcium Gluconate, Mg sulfate and phosphate respectively. Pt started on BNP study by cardiology resident.\n" }, { "category": "Nursing/other", "chartdate": "2163-07-25 00:00:00.000", "description": "Report", "row_id": 1479661, "text": "PLEASE SEE CAREVUE FOR SPECIFICS AND COMPLETE ASSESSMENT.\n\nNEURO: PT SEDATED ON PROPOFOL, WITHDRAWS TO PAINFUL STIMULI, OPENS EYES TO VOICE OCC. PRESENTLY SEDATED AND PARALYZED ON CISAT FOR POOR SATS.\n\nCV: THIS AM HR 90-100'S, IN AFIB, STARTED ON AMIO GTT (CURRENTLY AT .5MG/MIN) AND CARDIOVERTED, RYTHM CHANGED TO AV-PACED AT 60. EP CONSULTED AND PACER RATE INC TO 80 BY EP. PT DROPPING SBP TO 70-80'S, RECEIVED MULTIPLE FLUID BOLUSES W/ GOOD RESPONSE, ALSO STARTED ON LEVO GTT. MILRINONE GTT STARTED FOR LOW CO AND CI, WEDGE 23. CVP 16-24. TRANSFUSED 2 U PRBC'S, REPEAT HCT 38.5 ECHO DONE, EF 25% DOWN FROM 60% X1 YRS AGO. PER DR. , KEEP MAP>70. CT ABD/CHEST DONE REVEALED RUL PNA, ANASARCOSIS, NO ABCESS.\n\nRESP: SEE RESP NOTE FOR COMPLETE DETAILS. VENT SETTINGS CURRENTLY PCV W/ 60% O2, TV 300-400, RATE 26, PEEP 24.\n\nGI: ABD DISTENDED, HYPO BOWEL SOUNDS, REMAINS NPO. OGT DRAINING GREENISH FLUID MIXED W/ BARRICAT.\n\nGU: U/O MARGINAL, CLEAR AMBER URINE. BLADDER PRESSURE 5.\n\nID: TMAX 36.9 CELCIUS.\n\nPLAN: MINOTOR VS, LABS, RESP STATUS. ATTEMPT TO WEAN MILRINONE TO OFF. F/U CARDIOLOGY CONSULT. **DNR** CONT CURRENT MGMT\n\n" }, { "category": "Nursing/other", "chartdate": "2163-07-23 00:00:00.000", "description": "Report", "row_id": 1479650, "text": "Resp. Care Note\nPt intubated on floors for hypoxemia and resp., failure. Transported to CCU and placed on vent with settings as per resp flowsheet. ABG drawn from L radial artery was 7.28/53/55/26/-2. Minute ventilation increased based on ABG and sats have improved to 97%. A-line placed and repeat ABG pending. BS coarse and wet sounding bilat., sxn for thin blod tinged secretions. Cont vent support, follow ABG's and adjust vent as needed.\n" } ]

[ { "category": "Radiology", "chartdate": "2176-07-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970193, "text": " 2:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen requirements\n\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cholangitis with increasing oxygen requirements, evaluate for\n infiltrate.\n\n COMPARISON: .\n\n CHEST, SINGLE VIEW: A subclavian catheter is again seen with its tip in the\n lower SVC. There has been internal insertion of an NG tube with its tip\n projecting below the diaphragm. There is a layering pleural effusion on the\n left. There is retrocardiac opacification bilaterally. Vascular congestion\n suggests volume overload. Opacification of the soft tissue suggests anasarca.\n Apparent rightward tracheal deviation is likely due to rotation. There is no\n pneumothorax. There is no lytic osseous lesion seen.\n\n IMPRESSION:\n 1. Moderate layering left pleural effusion.\n 2. Bilateral retrocardiac opacification, likely atelectasis, but aspiration\n pneumonia is not excluded.\n 3. Vascular congestion and soft tissue skin thickening suggest volume\n overload with anasarca and probable ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970023, "text": " 2:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with cbd obstruction\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Chest and AP portable view of the chest to evaluate pneumonitis. The trachea\n and mediastinum as well as the cardiac silhouette are slightly deviated\n towards right. There is pleural fluid encasing the left lung base and there\n is decreased volume in the left lower lobe with prominent vascular markings\n bilaterally which is related to poor inspiratory effort or subpulmonic fluid.\n The lung bases at the diaphragm are under exposed and pneumonitis can better\n be evaluated on a followup over-exposed film.\n\n CONCLUSION: Pulmonic fluid on the left with a small amount of fluid in the\n costophrenic angle. Subpulmonic fluid on the right cannot be excluded.\n Suggest followup exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970249, "text": " 3:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen requirements\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased oxygen requirement.\n\n Portable AP chest radiograph compared to obtained at 2 p.m.\n\n The NG tube tip terminates in proximal stomach with the side-hole most likely\n at the level of the gastroesophageal junction. Advancement for at least \n cm would be recommended.\n\n The cardiomediastinal silhouette is mildly enlarged, but stable. There is\n decrease in left pleural effusion, part of which might be subpulmonic. New\n linear opacities in the right lower lobe might be due to new developed\n atelectasis.\n\n IMPRESSION:\n\n 1. Too proximal position of the NG tube, advancement for 15 cm would be\n recommended.\n\n 2. Increased significant amount of left pleural effusion, part of which might\n be subpulmonic.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-24 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 970081, "text": " 12:20 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Please evaluated CBD specifically for evidence of cholangiti\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with sepsis, ?cholangitis s/p CCY, also s/p perf gastric ulcer\n with OR repair c/b wound dehiscence and partial SBO.\n REASON FOR THIS EXAMINATION:\n Please evaluated CBD specifically for evidence of cholangitis, as well as\n evaluation of possible abscess or other intraabdominal source of infection.\n Please also evaluate lungs for evidence of ARDS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis; status post perforated gastric ulcer repair approximately\n two weeks ago, wound dehiscence and partial small bowel obstruction; patient\n also has a known diagnosis of CLL.\n\n COMPARISONS: None.\n\n TECHNIQUE: Multiple contiguous axial images from the lung bases through the\n ischial tuberosities were obtained with intravenous and oral contrast.\n Abdominal images were acquired in the unenhanced, arterial, portal venous and\n delay phases. Multiplanar reformations were essential to interpretation.\n\n LOWER CHEST: A central venous catheter tip is visualized in the distal\n superior vena cava. There are bilateral pleural effusions with adjacent\n atelectasis, moderate on the left and small on the right. A lingular\n granuloma is present. Evaluation of the lung parenchyma is somewhat limited\n by patient motion. A nasogastric tube is seen in the esophagus and terminates\n in the stomach. There is contrast visualized in the esophagus to the level of\n the carina, compatible with reflux. There are enlarged bilateral axillary\n lymph nodes, which measure up to 17 mm in short axis. Right hilar adenopathy\n is also suggested.\n\n ABDOMEN: The liver measures 25 cm in craniocaudad dimension. It is\n homogeneously enhancing, without ductal dilatation. There is a single\n calcification in the gallbladder, with multiple foci of air, presumed to lie\n within additional gallstones. The spleen is enlarged, measuring 17 cm in\n greatest dimension. The adrenal glands and kidneys are unremarkable. The\n pancreas appears unremarkable. There is a large amount of low density ascites\n with associated peritoneal enhancement. There are innumerable enlarged\n intraperitoneal and retroperitoneal lymph nodes in the mesentery, periaortic,\n celiac and aortocaval regions, with short axis measurements up to 21 mm. There\n are scattered locules of extra-peritoneal air. The patient is known to be\n status post laparotomy. An anterior abdominal wound is present in the\n midline.\n\n PELVIS: A Foley catheter is present. Air in the urinary bladder is believed\n to be iatrogenic. The rectum and colon are decompressed. Multiple dilated\n small bowel loops are present, with a possible transition point in the left\n (Over)\n\n 12:20 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Please evaluated CBD specifically for evidence of cholangiti\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lower quadrant. The terminal ileum appears to be decompressed. Innumerable\n enlarged lymph nodes are present in the pelvis and in both inguinal regions.\n Loculated ascites is also identified, with the largest pelvic collection\n measuring 11 x 8 cm. Diffuse anasarca is noted.\n\n OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions are identified.\n\n IMPRESSIONS:\n\n 1. Distal small bowel obstruction.\n\n 2. Large amount of ascites, some of which is loculated, and minimal free\n intraperitoneal air. These findings may be related to previous laparotomy.\n\n 3. Cholelithiasis.\n\n 4. Innumerable enlarged lymph nodes in the chest, abdomen and pelvis,\n compatible with known diagnosis of CLL.\n\n 5. Diffuse anasarca.\n\n These findings were conveyed to Dr. by at 11 am on\n .\n\n" }, { "category": "Radiology", "chartdate": "2176-07-25 00:00:00.000", "description": "GALLBLADDER SCAN", "row_id": 970308, "text": "GALLBLADDER SCAN Clip # \n Reason: PT ADMITTED TO HOSP. TRANSFERRED TO W/? CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 4.3 mCi Tc-m DISIDA ();\n HISTORY: Hyperbilirubinemia\n\n REPORT: Serial images over the abdomen show diffuse uptake of tracer into the\n hepatic parenchyma without visualization of the intrahepatic bile ducts or\n gallbladder and. A delayed scan at 22 hours shows tracer activity within the\n small bowel.\n\n The above findings are consistent with severe liver dysfunction without evidence\n of common bile duct obstruction.\n\n IMPRESSION: The above findings are consistent with severe liver dysfunction\n without evidence of common bile duct obstruction. Please note the gallbladder\n and cystic duct cannot be adequately assessed in the setting of liver\n dysfunction.\n\n\n , M.D.\n , M.D. Approved: TUE 10:34 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2176-07-24 00:00:00.000", "description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT", "row_id": 970136, "text": " 9:35 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please assess RUQ, GB wall (air?)\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with elevated bili, stones on CT, air in gallbladder lumen on\n ct\n REASON FOR THIS EXAMINATION:\n please assess RUQ, GB wall (air?)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for questionable gallbladder wall air.\n\n Comparison is made to recent CT examination from the same date.\n\n LIMITED ABDOMINAL ULTRASOUND\n\n The liver displays normal parenchymal architecture without evidence of focal\n mass. No intrahepatic biliary dilatation is identified and the common bile\n duct is normal measuring approximately 5 mm. Evaluation of the gallbladder is\n grossly limited due to a large amount of shadowing from previously identified\n numerous gallstones noted on CT, some of which contain air within them. A\n thin gallbladder wall is noted anteriorly. There is partial\n visualization of a small right pleural effusion. Portal vein is patent with\n normal hepatopetal flow.\n\n IMPRESSION:\n Limited evaluation of gallbladder due to multiple air containing stones as\n viewed on CT causing diffuse posterior shadowing. No definite evidence of air\n within the wall itself.\n\n These findings were discussed with the covering ICU resident shortly after\n exam acquisition.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970509, "text": " 5:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: diffuse rales, febrile\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia\n REASON FOR THIS EXAMINATION:\n diffuse rales, febrile\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old man with possible cholangitis with increasing oxygen\n requirements and tachycardia. Diffuse rales, fever.\n\n Comparison is made to , at 20:09.\n\n PORTABLE UPRIGHT CHEST: Right subclavian central line again terminates at\n cavoatrial junction. The NG tube has been slightly advanced with the\n tip and sidehole in the stomach. Again seen is diffuse hazy opacity involving\n the left mid and lower lung zone with a persistent left retrocardiac opacity.\n There is stable atelectasis in the right upper lobe. The cardiac silhouette is\n approximately stable in size given differences in technique. No pneumothorax.\n\n IMPRESSION:\n 2. Stable left retrocardiac opacity may represent effusion or pneumonic\n consolidation.\n\n 3. Stable atelectasis in the right upper lobe.\n\n 4. NG tube in satifactory position.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 970837, "text": " 8:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: verify CT placement and ETT\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia s/p intubation\n REASON FOR THIS EXAMINATION:\n verify CT placement and ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible cholangitis, increasing O2 requirement, tachycardia, status\n post intubation; verify chest tube placement.\n\n chest, 1 vw\n\n An ET tube is present, slightly high, approximately 7.2 cm above the carina.\n An NG tube is present -- the tip overlies the gastric fundus, but the\n sideport overlies the lower esophagus, proximal to the EG junction. A left\n subclavian Swan-Ganz catheter is present, tip over main pulmonary artery, new\n compared with earlier the same day. The right subclavian line appears to have\n been removed in the interim. The left subclavian line is unchanged, with tip\n over mid SVC.\n\n Compared to earlier the same day, a left chest tube is now present, with the\n distal portion abutting the upper portion of the mediastinum. There has been\n considerable interval improvement in the left pleural effusion. No\n pneumothorax detected on this supine film.\n\n Again seen are patchy alveolar and interstitial infiltrates predominantly in\n the mid and upper zones, quite confluent in the left mid zone laterally.\n Allowing for technical differences, there may have been slight interval\n worsening in the right lung. The paratracheal soft tissues are prominent,\n with distortion of the course of the trachea, unchanged compared with earlier\n the same day.\n\n IMPRESSION:\n\n 1. Interval placement of left chest tube with resolution of left effusion.\n\n 2. Other lines and tubes as described. No pneumothorax detected.\n\n 3. Bilateral interstitial and alveolar infiltrates, possibly slightly worse\n on the right, but overall grossly unchanged. Prominence of the paratracheal\n soft tissues, as described.\n\n Please note that the side port of the NG tube lies proximal to the EG\n junction.\n (Over)\n\n 8:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: verify CT placement and ETT\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2176-07-28 00:00:00.000", "description": "BAS/UGI AIR/SBFT", "row_id": 970655, "text": " 10:37 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: Please evaluate for leak at patch/anastomosis\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Contrast: CONRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with patch, h/o dehiscence of anastomosis\n REASON FOR THIS EXAMINATION:\n Please evaluate for leak at patch/anastomosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old male with recent patch repair of gastric\n perforation at at an outside hospital referred for assessment of leak.\n\n COMPARISON: CT abdomen and pelvis , chest radiograph .\n\n PROCEDURE AND FINDINGS: The patient was placed in a semi-upright position on\n the fluoroscopic table. Spot fluoroscopic images were obtained in AP, LPO,\n RPO, and right lateral positions during injection of a total of approximately\n 200 mL of water-soluble Conray contrast via the previously placed nasogastric\n tube. The patient could not tolerate imaging in a prone position due to his\n recent operation.\n\n There is free rapid passage of contrast through the stomach into the duodenum.\n There is no evidence of extraluminal leak. The mucosal folds of the gastric\n body are thickened and the stomach does not distend well despite injection of\n approximately 100 mL of air via the NG tube. The patient tolerated the\n procedure without immediate complications.\n\n IMPRESSION:\n 1. No evidence of extraluminal extravasation of contrast on this study\n limited by patient intolerance of prone positioning.\n\n 2. Free passage of contrast through the stomach into the duodenum.\n\n 3. Thickened folds of the gastric body and limited gastric distensibility.\n\n\n These findings were discussed with Dr. at the time of completion of the\n study at 12:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970760, "text": " 11:11 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Left SC CVL placed (old one on Right)\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia s/p intubation\n REASON FOR THIS EXAMINATION:\n Left SC CVL placed (old one on Right)\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY DATED AT 11:40 A.M.\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Line placement.\n\n Endotracheal tube remains proximal in location, now terminating about 9.5 cm\n above the carina. New left subclavian vascular catheter terminates in the\n superior vena cava and pre-existing right subclavian catheter continues to\n terminate in the superior vena cava as well. New nasogastric tube is coiled\n within the stomach. Vascular engorgement and widening of the vascular pedicle\n show interval improvement suggesting improving volume status of the patient.\n Residual mediastinal and hilar lymphadenopathy are noted as reported on the\n recent exam. There is slightly improving pulmonary edema. Moderate left\n pleural effusion is probably unchanged allowing for positional differences.\n\n Position of endotracheal tube has been communicated by telephone with Dr.\n on by telephone.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 970779, "text": " 1:00 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: Patient with generalized seizure, (please obtain at time of\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p SBO post patch. Abdominal distension, elevated WBC.\n also seizure activity\n REASON FOR THIS EXAMINATION:\n Patient with generalized seizure, (please obtain at time of abd ct, chest ct)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male status post small-bowel obstruction, presenting\n with generalized seizure.\n\n COMPARISONS: None.\n\n TECHNIQUE: CT of the head without and with IV contrast was performed.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, shift of normally\n midline structures, mass effect or hydrocephalus. The -white matter\n differentiation is preserved. No vascular territorial infarct is identified.\n No enhancing abnormalities are noted. Calcifications are noted over the right\n orbit, presumably within the eyelid. Nasogastric and endotracheal tubes are\n noted in place. There is opacification of the left maxillary sinus with an\n air fluid seen in the right. Moderate mucosal thickening is seen within the\n ethmoid and sphenoid sinus. Several mastoid air cells are opacified\n bilaterally. Fluid is also noted within the - and oropharynx. No osseous\n erosions are identified.\n\n IMPRESSION:\n\n 1. No intracranial hemorrhage, mass effect, or abnormal enhancement.\n 2. Mucosal thickening in multiple paranasal sinuses with features as\n described above.\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 970780, "text": " 1:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with new confusion/resp distress, known free intraperitoneal\n air\n REASON FOR THIS EXAMINATION:\n assess interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old man with new confusion and respiratory distress,\n known intraperitoneal free air.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and pelvis are\n obtained with the administration of intravenous contrast . Multiplanar\n reformation images are reconstructed.\n\n COMPARISON: Abdominal CT dated .\n\n FINDINGS:\n\n CHEST: There is massive mediastinal and hilar and axillary lymphadenopathy in\n this patient with known leukemia. There is bilateral moderate pleural\n effusion with atelectasis. There is bilateral diffuse airspace consolidation\n with air bronchogram, suggestive of ARDS in this patient with intubation.\n\n ABDOMEN: There is free fluid and diffuse edema in the peritoneal fat. There\n is no definitive intraperitoneal air identified on this CT scan, and most of\n the area appears to be within the bowel loops. Again note is made of\n loculated fluid collection at the left flank and anterior to the rectum, which\n can represent abscess. It is unceratain if these two collections\n are communicating each other. There is diffuse and marked wall thickening of\n the colon throughout, representing pancolitis, increased since prior study.\n There is significant mesenteric and retroperitoneal lymphadenopathy, due to\n CLL. The loops of small bowel are less dilated compared to the prior study.\n Gallstones are again noted, without evidence of gallbladder dilatation. There\n is no focal liver lesion or intra- or extra-hepatic ductal dilatation. There\n is splenomegaly. The pancreas appears unremarkable; however, the evaluation\n is limited. Adrenal glands and kidneys are unremarkable without evidence of\n hydronephrosis.\n\n PELVIS: Loculated fluid collections versus abscesses as described above are\n seen. There is marked wall thickening of the sigmoid colon as well. There is\n diffuse edema in the intraperitoneal fat.\n\n There is no suspicious lytic or blastic lesion in skeletal structures.\n\n IMPRESSION:\n (Over)\n\n 1:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess interval change\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Bilateral airspace consolidation with moderate pleural effusion and\n atelectasis, suggestive of ARDS.\n 2. Massive mediastinal, hilar, axillary, mesenteric, and retroperitoneal\n lymphadenopathy due to chronic leukemia.\n 3. Two loculated fluid collections versus abscesses, one at the left flank\n and one anterior to the rectum, which may be communicating.\n 4. Marked wall thickening throughout the colon, suggestive of pancolitis.\n Edema in the peritoneal fat and small amount of ascites.\n 5. Gallstones.\n\n The finding was discussed with Dr. by Dr. , the\n radiology attending.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-26 00:00:00.000", "description": "MRCP (MR ABD W&W/OC)", "row_id": 970450, "text": " 10:42 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval for stone\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with rising bili, unable to have ERCP\n REASON FOR THIS EXAMINATION:\n please eval for stone\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 44-year-old male with rising bilirubin, unable to have\n ERCP, evaluate for stone disease.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5-T\n magnet including dynamic 3D imaging obtained prior to, during, and after the\n uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\n\n FINDINGS: Direct comparison is made to a recent CT scan dated .\n\n The common bile duct appears unremarkable. The duct measures approximately 5\n mm in diameter. There is no evidence for choledocholithiasis. The\n intrahepatic ducts also appear unremarkable. Consistent with the patient's\n known clinical history of CLL, multiple enlarged lymph nodes are identified\n throughout the peritoneal cavity. One of these lymph nodes is noted to abut\n the mid portion of the common bile duct. However, the bile duct does not\n appear to be narrowed in this region.\n\n The spleen appears markedly enlarged. The pancreas is not well visualized\n secondary to intra-abdominal fluid and lymphadenopathy. However, the pancreas\n appears grossly unremarkable. The kidneys and adrenal glands appear grossly\n normal. Gallstones are again noted.\n\n Moderate ascites is seen throughout the peritoneal cavity. Additionally,\n dilated loops of small bowel are again seen as on recent CT noted above.\n\n Evaluation of the stomach reveals areas of gastric wall thickening with\n hyperenhancement seen on the contrast-enhanced images. These findings are\n likely representative of post-operative changes, given the patient's recent\n gastric ulcer patch repair. The hyperenhancement may be related to post-\n operative changes or continued ulcer disease.\n\n Bilateral pleural effusions and basilar atelectasis is again noted as on\n recent CT.\n\n No bony abnormality is identified.\n\n Anasarca is noted diffusely.\n\n Multiplanar T1- and T2-weighted images and subtraction images were generated\n on an independent workstation.\n\n (Over)\n\n 10:42 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please eval for stone\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Intra- and extra-hepatic bile ducts appear unremarkable. There is no\n evidence of choledocholithiasis.\n\n 2. Gastric wall thickening and hyperenhancement likely representing post-\n operative changes and possible ongoing ulcer disease.\n\n 3. Pleural effusion and moderate ascites.\n SWANa\n\n" }, { "category": "Radiology", "chartdate": "2176-07-28 00:00:00.000", "description": "R UNILAT LOWER EXT VEINS RIGHT", "row_id": 970689, "text": " 8:12 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: ? DVT\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man w/CLL s/p perforated anterior gastric ulcer s/ patch\n c/b SBO s/p LOA now w/ increased swelling RUE\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Unilateral upper extremity venous ultrasound of the right arm.\n\n INDICATION: 44-year-old male with a history of CLL with increased right upper\n extremity swelling. Assess for DVT.\n\n COMPARISONS: None.\n\n FINDINGS: Doppler and grayscale images of the right axillary, and brachial\n veins demonstrates normal compressibility and waveforms. Intraluminal\n thrombus is not identified. However, an echogenic focus within the mid\n portion of the basilic vein is consistent with nonocclusive intraluminal\n thrombus. Good Doppler waveforms are obtained, both proximally and distally\n to this area. The right subclavian vein demonstrates normal wall to wall flow\n and good Doppler waveforms. However, the right internal jugular vein is not\n well visualized. This appears to be secondary to extensive prominent\n lymphadenopathy throughout the neck. The right common carotid artery is\n identified. The left internal jugular vein demonstrates normal\n compressibility and Doppler waveforms. The left subclavian vein also\n demonstrates normal waveform.\n\n IMPRESSION:\n\n 1. Nonocclusive thrombus present within the right basilic vein.\n 2. Right internal jugular vein not directly identified. Followup study may be\n performed is there is clinical concern for venous occlusion.\n 3. Cervical lymphadenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970874, "text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute oxygen desaturation.\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia s/p intubation\n REASON FOR THIS EXAMINATION:\n acute oxygen desaturation.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:05 A.M., .\n\n HISTORY: Cholangitis, increasing oxygen requirements.\n\n IMPRESSION: AP chest compared to through 23:\n\n Left pleural effusion has cleared since insertion of a left apical pleural\n drain on , but a moderate left pneumothorax may have resulted,\n unchanged since at 10:15 p.m. Severe bilateral pulmonary\n consolidation has improved only minimally in the right upper lobe, probably an\n artifact of changes in ventilation rather than real improvement in what is\n probably multifocal pneumonia or pulmonary hemorrhage. Heart size is normal\n and pleural effusion, if any, is on the right, small-to-moderate and increased\n since earlier on . ET tube is in standard placement, although the cuff\n mildly distends the trachea and is marginated by pooled secretions superiorly.\n Left jugular line ends in the right pulmonary artery. Nasogastric tube ending\n in the upper stomach would need to be advanced at least 5 cm to move all side\n ports beyond the gastroesophageal junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970699, "text": " 1:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placement\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen requirements\n and tachycardia s/p intubation\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Possible cholangitis with increasing oxygen requirements and\n tachycardia.\n\n COMPARISON: \n\n SEMI-UPRIGHT AP CHEST: The endotracheal tube is 9.6 cm from the carina. A\n right internal jugular central venous catheter tip overlies the cavoatrial\n junction. The mainstem bronchi are splayed, consistent with subcarinal\n lymphadenopathy, and there is evidence of hilar lymphadenopathy as well,\n better appreciated on the CT abdomen study of . Interstitial and\n alveolar opacities in both lungs appear worsened compared to but\n probably unchanged from , most consistent with pulmonary edema. Cystic\n changes of the right upper lobe may be related to underlying emphysema. A\n moderate left effusion persists. No evidence of pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube is superiorly positioned, and advancement is recommended\n for standard positioning.\n 2. Pulmonary edema is unchanged from but worsened from .\n 3. Mediastinal and hilar lymphadenopathy, of unclear etiology. This could be\n further evaluated by dedicated chest CT when the patient's condition\n improves.\n Findings and recommendations discussed with Dr. on the morning of .\n\n" }, { "category": "Radiology", "chartdate": "2176-07-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970388, "text": " 7:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o pulm edema\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased oxygen requirements.\n\n Portable AP chest radiograph compared to obtained at 4:17 a.m.\n\n The NG tube tip terminates in the stomach, but the side hole might be at the\n level of the gastroesophageal junction. The right subclavian line is\n unremarkable. The right lower lobe atelectasis has slightly increased in size\n and there is there is also worsening atelectasis of the anterior segment of\n the right upper lobe. No change in left retrocardiac atelectasis and left\n pleural effusion, which is moderate in size demonstrated.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970679, "text": " 4:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pleural effusions\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with possible cholangitis with increasing oxygen\n requirements and tachycardia\n REASON FOR THIS EXAMINATION:\n eval pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cholangitis, increasing oxygen requirement, diffuse\n interstitial alveolar opacities present in both the right and left lung.\n\n A left pleural effusion is probably present. Mediastinal widening is present.\n The heart is probably at the upper limits of normal.\n\n The appearances are consistent with failure, pneumonia, or a combination of\n both.\n\n Compared to the prior chest x-ray of , appearances have worsened.\n\n IMPRESSION: Diffuse alveolar interstitial opacities and left effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-07-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 970763, "text": " 11:36 AM\n PORTABLE ABDOMEN Clip # \n Reason: Abdominal distension\n Admitting Diagnosis: COMMON BILE DUCT STONE;GASTRIC PERFORATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n Abdominal distension\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 43-year-old man with abdominal distention.\n\n Comparison is made to upper GI study dated and CT examination\n dated .\n\n SINGLE SUPINE ABDOMINAL PORTABLE RADIOGRAPH:\n\n FINDINGS: There is no evidence of pneumoperitoneum or pneumatosis. There are\n multiple dilated loops of small bowel measuring up to 5 cm within the left\n upper quadrant. A nasogastric tube is noted to be coiled within the stomach\n and a linear radiopaque post-surgical focus noted over the mid abdomen.\n Evaluation of distal bowel was limited by lack of complete inclusion of the\n pelvis on this portable film. Oral contrast from recent CT examination/upper\n GI is noted within dilated loops of small bowel within the right lower\n quadrant. Mild wall thickening/irregularity is noted within the bowel wall\n in the RLQ.\n\n IMPRESSION:\n Dilated loops of small bowel consistent with small-bowel obstruction as noted\n on recent CT examination.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-07-30 00:00:00.000", "description": "Report", "row_id": 1627325, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FOR SPECIFICS.\nAT APPROX. 10:00, DR. HAD DISCUSSION WITH FAMILY REGARDING PROGNOSIS, AND IT WAS DECIDED AT THIS TIME THAT WE WOULD CONTINUE THERAPIES AS THEY ARE, BUT WILL NOT ESCALATE CARE AND THAT CPR WOULD NOT BE MEDICALLY INDICATED AT THIS TIME SECONDARY TO GRIM PROGNOSIS. FAMILY AT BEDSIDE THROUGOUT THE MORNING, ALL THERAPIES CONTINUED AS OREDERED, EMOTIONAL SUPPORT WAS OFFERED. PRIEST PERFORMED LAST RITES PER FAMILY REQUEST. AT 1330, DR. MET WITH FAMILY AGAIN AND IT WAS DECIDED AT THIS TIME THAT PRESSORS WOULD BE D/C'D, AND VENT. WOULD BE WEANED DOWN AND PT WOULD BE COMFORT MEASURES ONLY. PRESSORS SHUTOFF AND VENT. WEANED AT 1330 AND PT WAS ASYSTOLIC AT 1335.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-29 00:00:00.000", "description": "Report", "row_id": 1627322, "text": "nursing progress note\nSee Carevue for specifics\n\nPt unstable at start of shift. ST in 140s, tachypnic in 30s, hyptotensive, desatting, acidosis, firm/distended abdomen and febrile to 103.7.\n\nNeo gtt increased to max dose, levophed gtt started, tylenol 650 given PR. CVL was resited to L subclavian, placement verified on chest xray. Nasal ETT was changed to oral intubation. OGT was placed and put to LCS.\n\nPt had seizure at approx 1100, which started focally and progressed to general. Duration was approx 3 minutes. MD Young was in attendence and assessed pt. Ativan bolus was given and an ativan gtt was started with + result.\n\nNeo gtt was weaned and vasopressin gtt started. Hemodynamic status continued to remain very labile and ABGs showed worsening acidosis. See RT note for specifics. Fentanyl gtt was started to slow breathing rate, MD Young.\n\nHead, neck and abdominal CT with contrast showed lung collapse and large colitis.\n\nLung recruitment maneuvers and bronchoscopy performed at bedside at approx 15:00. ABGs showed continued acidosis and hemodynamic status remained unstable. Patient seized again at approx 1400 and again at 1500, both times witnessed by MD Young. Ativan boluses given and gtt increased with positive result.\n\nAt approx 1530 pt was sent emergently to the OR for ?total collectomy s/t cdiff megacolon.\n\nFamily is in waiting room and has been kept up to date throughout the day.\n\nPLAN: Monitor hemodynamic status overnoc, titrating pressors as needed. Assess for seizure activity and tx as indicated. Monitor respiratory status overnoc. Keep 4 units prbc in blood bank for transfusion as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-30 00:00:00.000", "description": "Report", "row_id": 1627323, "text": "NURSING UPDATE\nPT RECEIVED FROM OR @ , INTUBATED AND SWAN'D. RECIEVED MULTIPLE BLOOD PRODUCT AND FLUID RESUS INTRA-OP, ANASTHESIA ALSO REPORTS PT SEIZED .\n\nCV: BP SUPPORTED ON LEVOPHED, VASOPRESSIN AND EPINEPHRINE GTTS FROM OR. ALL GTTS AT MAX DOSES+, IN ADDITION PT HAS REQUIRED CONSTANT FLUID BOLUS TO MAINTAIN MAP>60. BP RESPONDS FAVORABLY TO FLUID BOLUS, EPI GTTS WEANED VERY CAUTIOUSLY. TRANSFUSED WITH 1U FFP AND 1U PRBC'S AFTER ARRIVAL FROM OR, HCT NOW STABLE AND COAGS WNL. PLTS 76, TRANSFUSED WITH 1U PLATELETS WITH POOR EFFECT, PLST TX PLTS 78. HR SINUS TACHY 120-130'S, NO ECTOPY. CVP TANKED @ 22-24, PAS IN 40'S.\n\nRESP: ACIDOTIC 7.01-7.07, MULTIPLE VENT CHANGES, S/B CRITICAL ATTENDING ALSO. SATS 89-93% BREATH SOUNDS CLEAR->COARSE. LT PLEURAL CHEST TUBE DRAINING SEROUS. SEE RRT NOTE ALSO.\n\nGI: OGT->LOW SUCTION DRAINING PINK->BILE, ABDOMEN OPEN WITH TRANSPARENT DRESSING, OOZING LG AMOUNT OF SEROSANG FLUID. BOWEL SOUNDS ABSENT. BLADDER PRESSURE 12 IN PM.\n\nGU: HUO>30CC CLEAR ICTERIC URINE. BUN CREAT WITHIN ACCEPTABLE PARAMETERS FOR THIS PT.\n\nNEURO: PARALYZED ON CISATRACURIUM, SEDATED ON ATIVAN AND FENTANYL GTTS. NO SEIZURES OBSERVED IN POST-OP PERIOD. PUPILS 5MM BILATERALLY(SAME AS PRE-OP), VERY SLUGGISH IN REACTION.\n\nID: TMAX 101.7 TO THIS TIME. PT WAS PAN CX PREOPERATIVELY. ABX GIVEN AS ORDERED.\n\nSOCIAL: BROTHERS HAVE BEEN PRESENT IN HOSPITAL THROUGH NOC, IN TO VISIT PERIODICALLY. SIGNIFICANT OTHER '' HAS RELINQUISHED POWER OF HEALTH CARE PROXY TO BROTHER 'SAL'.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-30 00:00:00.000", "description": "Report", "row_id": 1627324, "text": "resp care\nPt arrived from or and was placed on 550 x 22 100% 10peep. Abd revealed a resp acidosis. Multipe changes made in an attempt to correct. Pt eventually changed to pcv with slight improvement in sats. Complience continued to deteriorate and pt was changed back to volume ventilation. Co2 started to improve but oxygenation deteriorated. Attempted to inc peep but complience worsened.Water bags tried with no improvement. Spoke to icu attending about Nitric. Will attempt. Currently pt is on a/c 600x33 100% 15 peep. Peak/plat 49/40. Sats 79%. Will cont to follow and make adjustments as needed.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-25 00:00:00.000", "description": "Report", "row_id": 1627313, "text": "CONDITION UPDATE\nRECEIVED FROM 4 AT 2130. ALERT, ORIENTED X 3, MAE. C/O PAIN TO ABDOMEN AND BLE D/T EDEMA. ON MORPHINE PCA UPON ARRIVAL WITH BASAL RATE 2MG/HR. CHANGED TO 1/5/6/15, GOOD PAIN CONTROL AT REST ALTHOUGH HAS SEVERE PAIN WITH MOVEMENT. T101.2 UPON ARRIVAL, BLOOD CULTURES SENT. ST HR 120-130'S CONSISNTANTLY, DR AWARE. PER REPORT THIS HAS BEEN BASELINE SINCE ADMISSION FROM OSH ON . BP STABLE 100-120'S/60'S. +PP, SIGNIFICANT BLE AND SCROTAL EDEMA. LUNGS COARSE THROUGHOUT, PER DR HAS BEEN FLUID OVERLOADED ON CXR. INSP/EXP WHEEZES UPON ARRIVAL WITH INCREASED O2 DEMAND. DR AWARE, PLACED ON FACE MASK AND GIVEN NEB TX. ALBUTEROL CHANGED TO XOEPENEX D/T TACHYCARDIA. LUNGS REAMAIN COARSE AND DIMINISHED AT BASES. DENIES SOB. CXR DONE ON AM ROUNDS, RESULTS PENDING. FOLEY WITH CLEAR URINE, ICENTIRIC, U/O ~30CC/HR. 2L POSITIVE AT MIDNIGHT, DR AWARE. MD PRIMARY TEAM DOES NOT WANT TO DIURESE PATIENT AT THIS TIME. REMAINS ON IVF @100, DECREASED TO 70 BUT TEAM DOES WISH TO CONT TO RUN IVF. CVP 10-11 OVERNIGHT BUT INCREASED TO 15-16 AT 0500, DR AWARE. ALBUMIN 25% ORDERED, OK TO GIVE WITH ELEVATED CVP PER DR . ABD DISTENEDED WITH HYPOACTIVE BS NOTED THIS AM. NGT WITH MOD AMT BILOUS OUTPUT, NO NAUSEA. MIDLINE ABD WOUND WITH RETENTION SUTURES, SEROSANG DRAINAGE WITH SOME GREEN DRAINAGE NOTED ON WOUND BASE. DR INTO ASSESS WOUND. COVERED IN DSD. DUODERM TO COCCYX, INTACT. NO FURTHER BREAKDOWN. LFT'S ELEVATED UPON ARRIVAL, DR AWARE. PLAN TO CONT BOWEL REST, ?OR IF OBSTRUCTION DOES NOT RESOLVE, F/U WITH REAM RE: PLAN FOR MULTIPLE GALLSTONES ?ERCP, MONITOR FLUID STATUS, RESP STATUS, HEMODYNAMICS, PAIN MANAGMENT.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-25 00:00:00.000", "description": "Report", "row_id": 1627314, "text": "7am-7pm Nursing Note\nSee CareVue for objective data and trends:\n Pt sleeping in naps but easily awakens to verbal stimuli. Pt oriented X 3, following commands appropriately.\nRESP: LS with occasional inspiratory wheezing heard and coarse crackles at bases. Pt getting scheduled nebulizers which helps decrease wheezing. Currently on 5 liters via NC and pox 93-98%.\nCV: Pt remains in sinus tachycardia at 110-130, getting PRN IV lopressor. Pt BP maintaining 110-120s/60s. CVP ranging .\nGI: Abdomen firm with faint, hypoactive bowel sounds. Pt remains NPO and has NGT in place to LCWS, putting out bilious fluid. Pt reports positive flatus. Pt went down for HIDA scan to evaluate common bile duct as pt's bilirubin remains elevated and pt continues to have jaundiced color in skin and sclera.\nSKIN: remains jaundiced, abdominal dressing clean,dry and intact. Duoderm changed to stage 2 on coccyx area today.\nGU: Urine output 30/60 cc/hr.\nPAIN: Pt using Morphine PCA at 1.5-6-15 to cover pain. Pt stating pain is at rest but escalates to with activity.\nID: Pt has been afebrile today, continues on IV Vancomycin, Meropenum and Flagyl for antibiotic coverage.\nPLAN: Monitor temp, HR and labwork closely. Assess GI status and pain level. Pt likely to go back to nuclear medicine tomorrow for additional pictures for further evaluation of common bile duct.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-07-24 00:00:00.000", "description": "Report", "row_id": 1627312, "text": "MICU/SICU Nursing Progress Note (0700-1900)\n\nPlease see FHPA and flowsheet for all objective data.\nPt. has been stable with bowel rest, decompression and IVF due to small bowel obstruction and is awaiting transfer to SICU West.\n\nCNS: Pt. is much more comfortable, alert and oriented today. He has\n been sleeping off and on, visiting with family and girlfriend.\n\nPAIN: Pain under better control today on Morphine PCA with basal rate of 2mg/hr, 1mg dose with lockout of 6min... dose 12mg/hr. Tolerates moving side to side with 2 person assistance. Difficult for him to move due to LE and scrotal edema.\n\nGI: Abdomen is firm and distended with hypoactive bowel sound throughout. Quite tender to touch. NGT present and draining bilious material...600cc since 7am. No stool this shift, no complaints of nausea.\n\nPOST-OP: Midline surgical incision present, approximated with staples. Area is very erythematous/edematous with small to moderate amounts of green drainage present.\n\nCVS: Remains tachycardic with heart rate 120-130's, ST. Receiving lopressor 5mg q6hr and prn with minimal effect. B/P 120-130/systolic.\n\nRESP: Sats initially dropping to 88-89% on 2lnc this AM. Oxygen increased to 6l with good effect. Pt encouraged to turn, cough and deep breathe. Encouraging use of IS 10xq1hr. Pt. does not tolerate CPT. CXR done with results pending. Lungs with some I and E wheezes, decreased at the left base.\n\nSKIN: Duoderm intact over coccyx, not removed today. Pt encouraged to turn side to side.\n\nID: T max of 101.4 po. No further cultures done per housestaff. Flagyl added to antibiotic regime (vanco and merepenum).\n\nENDO: No sliding scale coverage necessary.\n\nSOCIAL: Mother and girlfriend in most of the day. They are appropriately concerned.\n\nPLAN: Transfer to SICU West pending bed availability.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-29 00:00:00.000", "description": "Report", "row_id": 1627320, "text": "focus hemodynmics\ndata: neuro: at the start of shift sitting up in the bed very lethargic. not answering any questions. moaning. as the shift progressed becoming more unresponsive. intubated at 0200am. pupils #3 and reacts equally. after being intubated propofol gtt added at 20mcg/kg/min.\n\nresp: breath sounds very wheezy. 02sat 92-96%. resp rate 20-30's. 100% non rebreather. using assessory muscles to breathe and becoming unresponsive.intubated at 0200am by anesthesia. procedure done fiberoptically due to severe lymphadeopathy around the throat. #7 nasal et tube placed. xray confirmed placement. on 70% fio2. last abg 7.36-50-146-29. suctioned for blood tinge sputum. wbc elevated to 15.6.\n\ncardiac: heart rate 120-140's. dr aware. lopessor held at 0400am due to bp < 100. bp 90's hct 26.9. k 3.9 and repleted with 40meq kcl iv. bp < 100. neo gtt added and titrated to keep bp> 100.\n\ngu: foley patent and draining amber colored urine. lasix gtt 2mg /hr. infusing. u.o 40-100cc/hr. scrotum swollen and elevated.\n\ngI abd distended. abd dsg intact and changed for lg amt of yellow drainage. stay sutures patent. npo. lg amt of liquid brown stool x2. fecal bag applied.\n\naaction: labs as ordered. npo. intubated and chest xray done. propofol gtt hanging. neo gtt infusing and titrated. lasix gtt infusing at 2mg/hr. potassium repleted x4. fecal bag applied. update to mother and healthcare proxy . ultrasound done tonite. results still pending.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-29 00:00:00.000", "description": "Report", "row_id": 1627321, "text": "Resp Care\nPt remains intubated. Pt was intubated via nasal and was reintubated orally due to ETT position above the carina (9cm). Pt placed on ARDS protocol. Pt had multiple seizures, which led to drop in sats and BP. Pt taken to CT for head, chest, abdomin and pelvic scans. Pt bronched and then taken back to OR. Current vent settings: A/C 480 x 26 15P 100%. Last ABG: 7.12/14/109/26. Recruitment done in AM and peep was adjusted from 8 to 15. Plan is for pt to get an esophageal ballon at some point. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-27 00:00:00.000", "description": "Report", "row_id": 1627317, "text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO: Pt alert, sleeping in long naps, but easily arousable. Oriented X 3 and follows commands appropriately.\nRESP: LS with coarse rhonchi heard at start of shift which improved post-IV lasix dose. Pt's pox now 98-99% on 6 liters via NC. Pt continues to get atrovent/Xopenex nebulizers for intermittent wheezing heard.Pt with congested cough which has been unproductive.\nCV: Pt HR remains in sinus tachycardia with rate ranging 110-118 over noc. BP maintaining at 110-120/60s, pt given 20 mg IVP lasix at secondary to fluid overload status. Lasix with excellent effect. Pt also continues to have + bilateral LE edema and scrotal edema as well. CVP 8.\nGI: Pt NPO with NGT to LCWS, putting out bilious fluid. Pt OOB X 2 and had 2 medium bowel movements today. Abdomen is firm and distended with positive, but hypoactive bowel sounds.\nGU: Pt urine output increased after lasix given.\nSKIN: Midline abdominal dressing clean,dry and intact. Duoderm changed to coccyx area which has healing abscess site and some superficial skin breakdown seen. Skin and sclera jaundiced in color.\nID: Pt afebrile overnoc. Remains on Vanco.flagyl and meropenum.\nPLAN:? further dosing of IV lasix, monitor labs, respiratory status. Monitor GI status, increase activity as tolerated,\n" }, { "category": "Nursing/other", "chartdate": "2176-07-28 00:00:00.000", "description": "Report", "row_id": 1627318, "text": "NSG NOTE\nPT ARRIVED TO SICU AT 5PM D/T TACHYCARDIA AND RESP DISTRESS. PE AS FOLLOWS:\n\nNEURO-LETHARGIC AT TIMES, RESTLESS AT OTHER TIMES. ORIENTED TO PERSON AND YEAR CONFUSED IN CONVERSATION. MAE. FOLLOWS COMMANDS.\n\nCV-HR 130'S, SINUS. LOPRESSOR GIVEN AND HR TRANSIENTLY DOWN TO 110'S. SBP STABLE. SKIN W+D. +PP. + ANASARCA. PBOOTS ON.\n\nRESP-ARRIVED IN RESP DISTRESS. + AUDIBLE WHEEZES AND INSP/EXP WHEEZES. ALB/ATROVENT NEB GIVEN WITH LITTLE EFFECT., XOPENEX GIVEN WITH SOME EFFECT. ABG SENT. SEE FLOWSHEET. O2 SAT IN 80'S DESPITE NC AND FACE TENT. 100% NRB PLACED AND O2 SAT IMPROVED. RESP LABORED WITH + USE OF ACCESSOTY MUSCLES. TEAM AWARE. WILL START LASIX GTT AND GIVEN ALBUMIN WHEN AVAIL.\n\nGI-ABD SOFT. ND. DSG C/D/I. HAD LIQ STOOL. + JAUNDICE. ON TPN.\n\nGU-VOIDING VIA FOLEY AMBER URINE. TO START LASIX GTT WHEN AVAIL.\n\nENDO-SSRI.\n\nCOMFORT-MSO4 PCA.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. FOLLOW RESP STATUS CLOSELY. TO HAVE US TONOC. LASIX AND ALBUMIN. SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-29 00:00:00.000", "description": "Report", "row_id": 1627319, "text": "Respiratory Care Note:\nPatient fiberoptically intubated lastnight electively due to severe lymphadenopathy around throat. He had initially presented to the unit in respiratory distress and placed on a lasix drip and mask BIPAP with minute ventilation 25-30lpm. He was intubated and placed on sedation and vent adjustments have been made as needed. He has a #7.0 nasal et tube that was advanced to 29cm at the right nare. Suctioned for small amounts of thick, blood-tinged sputum. Minute ventilation now around 24lpm. He was placed on a heated wire circuit to increase humidification. Albuterol MDI given x 8 puffs for mild exp wheezing and airtrapping as evidenced by waveforms on vent. Plan to continue supportive care and monitoring.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-23 00:00:00.000", "description": "Report", "row_id": 1627309, "text": "MICU/SICU Nursing Progress Note (1430-1900)\n\nPlease see FHPA for past medical history and carevue for all objective data.\nPt. is a 44 year old male admitted from Hospital for an ERCP due to presumed cholangitis, ?sepsis. Pt has a history of CLL (3yr ago), initially treated with naturopathic remedies, subsequently with rituxan. ( girlfriend is a naturopathic physician). Other PMH includes GERD and cholelithiasis.\nInitially seen at OSH due to abdominal pain and was fouond to have a perforated gastic ulcer (). Returned to OR () due to wound dehiscence. Subsequently exhibited rising bilirubin (8.6) and tachycardia.\n\nCNS: Pt. is alert, oriented and cooperative. Very anxious at times, constantly making requests. Very uncomfortable and fidgety in the bed. MAE's.\n\nCVS: Tachycardic to 140 without VEA. EKG done, sinus tach. Heart rate down to the 120's as he has defervesced. B/P stable at 110-130/syst. CVP of 17 after one liter fluid bolus.\n\nRESP: Lungs clear, although pt has a weak, congested cough...expectorating small amounts of thick, bile colored material. Sats of 96% on 2lnc.\n\nGI: Pt appers quite jaundiced, skin/sclera. Abdomen is firm and distended with hypoactive bowel sounds. Pt states he has not had a bowel movement since his original surgery. Pt. is vomiting intermittently and has been unable to take oral prep despite being medicated with zofran 4mg x 1. ?obstruction. To have abdominal/pelvic CT this eve. Bladder pressure of 18.\n\nID: Temp on admit was 101.4po. Pt quickly began complaining of being \"hot\", very restless, and temp spiked to 101.4 axillary. BC x 2 and urine culture sent. Vanco and merepenum have been initiated. Again, abd CT to look for source of infection.\n\nF and E: Foley catheter placed. Urine is dark amber, clear, approximately 50cc/hr.\n\nSurgical: Midline, approximated incision covered by DSD. area around sutures are erythematous, draining small amount of green drainage...evaluated by surgery.\n\nSOCIAL: Pt accompainied by his mother. She is very involved in his care and the patient requests that she remain in the room during procedures, etc. She has been waiting in the family room when asked, however. girlfriend is on her way in.\n\nPLAN: Abd CT to assess for infectious source/obstruction\n Follow hemodynamic parameters in light of possible sepsis.\n Support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-07-24 00:00:00.000", "description": "Report", "row_id": 1627310, "text": "Nursing Progress Note 1900-0700 hours:\n** Full code\n\n** allergy: nkda\n\n** access: R SC TLC\n\nIn Brief: 44yo M, pmh: CLL (diagnosed 3 years ago) and for which he was initially treated with naturopathic remedies as girlfriend/fiance is a naturopathic physician and then on Rituxan. Also with GERD, cholelithiasis. Occ. ETOH and heavy smoker in past.\n\nAdmit to Hosp on with abdominal distention and found to have free air-brought to OR and found to have perforated anterior gastric ulcer. Post-op course was c/b wound dehiscence and partial bowel obstruction-both of which were repaired in the or (had lysis of adhesions)and patch. S/P surgery with progressive hyperbilirubinemia and tachycardia.\n\nTx'd to for ? cholangitis with probable need for ERCP in setting of recently repaired perf gastric ulcer.\n\nNEURO: A & O x3. Able to follow commands. pearl at 2mm/brisk. At beginning of shift with increased pain-moaning and groaning and had difficulty tolerating any movement. Increased morphine PCA per order which was effective for pain relief. In and out of sleep toward morning and at times says nonsensical things.\n\nCV: ST with HR 100-140's. Rare pvc's. CVP 17-19. SBP 90's-150 with maps >60. Denies any chest pain or related symptoms. Started on lopressor q 6 hours which has improved HR but still 110's-120's. PP though difficult with ^^ edema.\n\nRESP: 3l nc with nebs q6. Initially breathing at rate in high 30's with sob. I/E wheezing throughout-some improvement with nebs. Able to cough up thick sputum when encouraged to do so. Laborous breathing at times before NGT placed due to distention. Does admit to sob with activity and can't tolerate lying flat pain and difficulty breating. Sats 92-98%. Noted LLL infiltrate. Unable to tolerate chest pt. Brought inc to bedside for when its appropriate. Encouraged to C and DB.\n\nGI: abd firm, tender, distended. At beginning of shift was attempting to drink CT contrast but was very nauseous and freq suctioning mouth with yankeur for small amts bilious emesis. Given compazine with fair relief. Spoke with md-surgery placed NGT to decompress stomach with immediate 750cc bile out and pt reported good moderate relief. hypoactive bs. Pt had small bm-co-worker cleaned so did not visualize dm but was told brown in color with small amt blood afterwards. md -guiac + pt is NPO. Pain mostly on left side. Has been on TPN x last 2 weeks from other hosp-md's just wanted fluids until nutrition rec's as may be some influence on ^^ bilirubin. Abd CT done to r/o abscess/cholantitis-preliminary findings are small bowel obstruction.\n\nGU: foley with amber, clear urine. UOP >30cc/hr. Generalized edema but marked in LE's, pedal, scrotal and penile. Elevated swollen areas.\n\nID: low grades overnight. Cont on meropenum. Mildly elevated LFT's, ^ bilirubin.\n\nSKIN: duoderm to coccyx. High risk with poor nutrition and edema.\n\nPSYCHOSOCIAL: Pt mother in on evenings. Fiance/girlfriend stayed overnight at bedside\n" }, { "category": "Nursing/other", "chartdate": "2176-07-24 00:00:00.000", "description": "Report", "row_id": 1627311, "text": "Nursing Progress Note 1900-0700 hours:\n(Continued)\n-updated on all plans of care.\n\nPLAN: -Await consult to see if ERCP needed\n -U/S of GB\n -f/u all cx data\n -cont med regimen and icu supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-26 00:00:00.000", "description": "Report", "row_id": 1627315, "text": "CONDITION UPDATE\nALERT, ORIENTED X 3. MAE WITH GENERALIZED WEAKNESS. C/O ABD PAIN BUT REPORTS GOOD EFFECT FROM MORPHINE PCA. VERY ANXIOUS RE: TURINGING/REPOSITIONING. DOES WELL WITH ENCOURAGMENT. T100.4. ST HR 130'S THIS EVE, DR AWARE. LOPRESSOR 10MG AROUND THE CLOCK STARTED WITH GOOD EFFECT, CURRENTLY HR 111. BP 100-120'S/40-60'S, TOLERATES LOPRESSOR WELL. CVP13-15. GENERALIZED EDEMA, BLE AND SCROTUM VERY EDEMDOUS. LUNGS COARSE WITH INSP/EXP WHEEZES, ALBUTEROL AND XOPENEX NEB TX Q6 WITH GOOD EFFECT. ABG DRAWN, PAO2 62, DR AWARE, SATS 93%, PLACED ON SHOVEL MASK AND SATS INCREASED >96%. DENIES SOB. CXR DONE, CONT TO SHOW LEFT PLUERAL EFFUSION. NO INCREASE IN PULMONARY EDEMA. ABD CONT TO BE DISTENDED, NGT TO LCS WITH BILOUS OUTPUT, +FLATUS. TPN INFUSING PER ORDER. SKIN INTACT, ABD DSG CHANGED. PLAN TO CONT TO MONITOR HEMODYNAMICS, MONITOR RESP STATUS, FOLLOW UP RE: IMAGING TODAY. PAIN MANAGMENT. MONITOR FLUID BALANCE.\n" }, { "category": "Nursing/other", "chartdate": "2176-07-26 00:00:00.000", "description": "Report", "row_id": 1627316, "text": "Nuero: pt arousable to voice. sleeping on and off thru-out day. alert and oriented x3, pt follows commands. pt at times pt becomes anxious.\n\npain: morphine pca decreased to 1.0mg every six minutes and a one hours limit of 10mg. pt pain level remains at \"3\" on scale of . pt does state this is an acceptable level of pain\n\npulm: pt on 5lnp. intermittently -out day has had audible wheezing , dr. aware and into assess patient., resp. therapy into assess patient. pt has recieved mutiple nebs(please see flowsheet). with effect.abg 7.45/36/72/28 dr. aware. chest pt done.\n\ncards: pt remains in st, hr 110-130's, dr. aware, pt has recieved lopressor with some effect.\n\ngi: pt npo. ngtube to lws draining bilous drainage. abd dsg with retention sutures, small amt of bilous drainage noted, dr. aware. pt went to mri and nuclear medicene today.\n\ngu: foley intact draining iteric colored urine.\n\nid: temp 10l.7 blood cultures, urine cultures sent. pt recieved tylenol supp. pt continues on vanco/flagyl, merepenum.\n\n\nf/e K 3.5 pt recieved 20meq kcl.\n\nsocial: pt family into visit.\n\nplan: continue to monitor vs, temp., chest pt, assess resp status, monitor pain management.\n" }, { "category": "ECG", "chartdate": "2176-07-27 00:00:00.000", "description": "Report", "row_id": 226895, "text": "Sinus tachycardia. Low limb lead QRS voltage is non-specific and may be a\nnormal variant. Since previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2176-07-24 00:00:00.000", "description": "Report", "row_id": 226896, "text": "Sinus tachycardia. Poor R wave progression that is non-diagnostic.\nGeneralized low QRS voltages. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2109-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774517, "text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for infiltrate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with history of small cell lung cancer, has febrile\n neutropenia. Coarse breath sounds diffusely.\n REASON FOR THIS EXAMINATION:\n Assess for infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Small-cell lung cancer, fever, neutropenia.\n\n IMPRESSION:\n\n 1) Left lower lobe patchy pneumonia.\n\n 2) Mild pulmonary edema.\n\n 3) Status post radiation for small-cell lung cancer with left perihilar\n opacity.\n\n COMMENT: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n There is increased patchy opacity seen in the left lower lobe indicating\n pneumonia. There is continued mild pulmonary edema.\n\n Again note is made of left perihilar opacity and opacity along the medial\n portion of the upper lobes indicating status post radiation for patient's\n known small-cell lung cancer.\n\n There is probably a small left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-23 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 774926, "text": " 4:57 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: progression of disease\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with small cell lung CA with mets to brain and bone s/p\n cerebellar mets resection and whole brain XRT.\n REASON FOR THIS EXAMINATION:\n progression of disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Small cell lung carcinoma and metastatic disease treated with\n surgery and radiation therapy.\n\n TECHNIQUE: Multiplanar pre and post contrast T1 weighted images, axial T2\n weighted, susceptibility and FLAIR images were obtained.\n\n FINDINGS: There is an enhancing right parafalcine mass that measures slightly\n under 1 cm in greatest dimension, unchanged from . There is adjacent\n dural enhancement. The appearance is most consistent with a small stable\n meningioma.\n\n There is no evidence of a new mass or new area of abnormal enhancement. There\n is a surgical defect in the left cerebellar hemisphere with traces of\n hemosiderin at the surgical margin. The overlying craniotomy/craniectomy is\n noted.\n\n The ventricles are unchanged in size. There is T2 hyperintensity diffusely in\n the deep cerebral white matter, the pons, and the left cerebellar hemisphere.\n The cerebral white matter abnormalities are more extensive than previously.\n\n Note is made of opacification of the mastoid air cells and air fluid levels in\n both maxillary sinuses. There is also opacification still of the ethmoid air\n cells.\n\n IMPRESSION:\n 1) There is no evidence of a new metastasis.\n 2) There is stable postoperative changes in the left cerebellar hemisphere.\n 3) There is more extensive T2 hyperintensity in the cerebral white matter\n perhaps related to the radiation therapy.\n 4) Note is made of air fluid levels in the maxillary sinuses and\n opacification of the mastoid air cells.\n 5) There is a stable small right parafalcine hemangioma.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-24 00:00:00.000", "description": "BONE SCAN", "row_id": 774910, "text": "BONE SCAN Clip # \n Reason: SCLC, WITH KNOWN METS TO BRAIN, T11, AND LEFT PELVIS, S/P RADIATION THERAPY. EVALUATE FOR PROGRESSION OSSEOUS METS.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient states she has had radiation and surgery for a\n intracranial metastasis, as well as radiation to her lung primary site, T11\n metastasis, and left hemipelvis metastasis. The patient is currently\n asymptomatic, without bone pain.\n\n COMPARISON: Bone scan.\n\n INTERPRETATION: Whole body views of the skeleton show no new foci of abnormally\n increased radiotracer uptake. There is improvement in the areas previously\n seen in the left pelvis (pubic/ischial region) and in T11. There is also\n improvement of the areas of abnormal radiotracer uptake previously seen in the\n proximal tibias bilaterally on .\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: No obvious new areas of metastasis. Improvement in previously seen\n metastases. /nkg\n\n\n , M.D.\n , M.D. Approved: WED 7:06 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2109-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774663, "text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with history of small cell lung cancer, has febrile\n neutropenia. Coarse breath sounds diffusely.\n REASON FOR THIS EXAMINATION:\n assess for chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Febrile neutropenia. Lung cancer, evaluate for CHF.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST: There is persistent elevation of the left\n hemidiaphragm, stable. The heart size is normal. There is no evidence of\n vascular congestion or pleural effusion. Slight area of increased opacity\n along the left paramediastinal region likely related to radiation change.\n\n IMPRESSION: No evidence of CHF. Stable changes left lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774564, "text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pneumonia or CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with history of small cell lung cancer, has febrile\n neutropenia. Coarse breath sounds diffusely.\n REASON FOR THIS EXAMINATION:\n Please eval for pneumonia or CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, coarse breath sounds.\n\n COMPARISONS: AP chest radiograph from .\n\n UPRIGHT AP CHEST RADIOGRAPH: The patient is rotated to the right on today's\n exam. Allowing for this, the heart size and mediastinal contours are stable\n in appearance. There has been a rapid resolution of the previously\n demonstrated patchy left lower lobe opacity. This dramatic improvement is\n more indicative of atelectasis, aspiration or pulmonary edema than of a\n pneumonia. No pleural effusions are identified. The osseous structures are\n unchanged.\n\n IMPRESSION: Rapid improvement of left lower lobe opacity favors atelectasis,\n aspiration, or pulmonary edema as source of opacity. No pneumonia is seen.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774438, "text": " 3:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with history of small cell lung cancer, has febrile\n neutropenia. Coarse breath sounds diffusely.\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Small cell lung cancer. Fever.\n\n Examination is limited due to respiratory motion.\n\n The heart size is normal. There is a mass-like area of opacity in the left\n hilum with adjacent areas of lung opacity that probably reflects radiation\n change. Note is made of ill-defined hazy increased opacities in the lower\n lung zones, right greater than left. No confluent consolidative changes are\n seen.\n\n There remains volume loss in the left hemithorax.\n\n IMPRESSION:\n 1. Post radiation changes in the left perihilar region.\n 2. Apparent hazy areas of increased opacity in the lower lobes, right greater\n than left. Due to the degree of motion, it is difficult to determine whether\n this is motion artifact or developing pneumonia. Repeat radiograph with\n improved technique would be helpful in this regard.\n\n" }, { "category": "Echo", "chartdate": "2109-12-20 00:00:00.000", "description": "Report", "row_id": 98555, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 59\nWeight (lb): 137\nBSA (m2): 1.57 m2\nBP (mm Hg): 125/64\nStatus: Inpatient\nDate/Time: at 14:54\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. Trivial mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2109-12-17 00:00:00.000", "description": "Report", "row_id": 280717, "text": "Sinus tachycardia. Low limb lead voltage. Early R wave progression. Since the\nprevious tracing of no significant change. Clinical correlation is\nsuggested.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-12-19 00:00:00.000", "description": "Report", "row_id": 1433444, "text": "Micu Progress Nursing Note: (11p-7a)\n\nNeuro: Alert and oriented times three; answers appropriately. Denies pain. However, although she did keep the nasal bi-pap on for the most part during the night, she did touch and attempt to adjust it frequently, and she did remove it 2-3 times.\n\nCV: ST, low hundreds to one twenties; no ectopy. BP stable, low hundreds to 130s over 50s to 60s. No extremity edema. Received one unit of PRBCs, and needs to receive one additional unit. On heparin at 1000 units until 3am when PTT drawn on eveings came back at 150. Heparin was shut off at that time, and was re-started at 0530. Labs were sent prior to restart of heparin. Heparin started at 800 units/hr at 0530.\n\nResp: Placed on nasal bipap, , at ~ midnight as she did not tolerate the full face mask bipap. She did tolerate the nasal bipap reasonably well. Blood gas at that time somewhat improved over previous one. See flow sheet for details of ABGs. Sats need to be kept at ~94%. Patient is a CO2 retainer. Receiving inhalers from RT approx. q one hour. Inspiratory/expiratory wheezes throughout, although lung sounds improve after resp. treatment. HOB placed 30-45 degrees to facilitate breathing. Placed on NC 2-3 liters at 0530. Gas will be drawn with patient on this modality.\n\nGI/GU: Foley MD order at 0200. Patient has not voided, although bed pan was offered. Remains NPO. Abdomen soft, bowel sounds present. No stool.\n\nEndocrine: Finger sticks q 6 hours, with sliding scale. See insulin flow sheet for details. Midnight sugar 164, covered with one unit regular insulin. Sugar at 0600 188, also covered with one unit reg. insulin.\n\nSkin: Intact. Bed bath given, turned and repositioned. ? of special bed if patient stays.\n\nPlan: Replace electrolytes as needed. One unit prbcs; monitor resp status.\n\n RN\n" }, { "category": "Nursing/other", "chartdate": "2109-12-19 00:00:00.000", "description": "Report", "row_id": 1433445, "text": "Respiratory Care Note:\n Patient tolerated nasal BIPAP fairly well today. 15/5 with 1lpm O2 bleed in. She received albuterol and atrovent med nebs Q2 hours. BS slightly improving but diffuse exp wheezes persist t/o with decreased LLL. Cough moist and non-productive. Early morning abg noted. Plan to continue on nasal BIPAP and Q2 nebs.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-19 00:00:00.000", "description": "Report", "row_id": 1433446, "text": "MICU/SICU NPN HD #3, ICU day #2\nS: \"This pinches my nose\"\n\nO:\n\nNeuro: pt is A&Ox3, forgetful, MAE, denies pain, OOB to chair with one assist\n\nResp: on BiPAP 15/5 most af day, intermittently compliant, q2h nebs, switched to 3L NP @ 1800. LS - diffuse insp/exp wheezes.\n\nCV: maintains Sr/ST 90's-110's, please see flowsheet for data\n\nSkin: oral mucosa coated with thrush\n\nGI/GU: abd soft, NT/ND, BS present, tolerating clear liquid diet, dietitian following, voiding qs in BR\n\nLines: #20 angio left FA, #20 angio right FA, left radial art line\n\nA:\n\nrisk for injury r/t forgetfulness\nhigh risk for infection r/t neutropenia\nrisk for altered nutrtion, LBR r/t poor caloric intake\n\nP:\n\ncontinue to monitor hemodynamic stability, continue resp rx q2h PRN, ADAT as per dietitian reccomendations\n" }, { "category": "Nursing/other", "chartdate": "2109-12-20 00:00:00.000", "description": "Report", "row_id": 1433447, "text": "Resp Care Note:\n\nPt given alb/atr as per order. Lung sounds coarse wheeze no significant change with treatment. Pt in NARD on 3LPM N/C.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-20 00:00:00.000", "description": "Report", "row_id": 1433448, "text": "NPN (NOC): PT SLEPT MOST OF NIGHT. RR IN 20'S, REG, SOMEWHT LABORED. I/E WHEEZES THROUGHOUT, + PROD COUGH. ABG UNCHANGED. AFEBRILE. LASIX 20 MG'S, THEN 40 MG'S GIVEN IV. UO DIFFICULT TO DETERMINE AS PT WAS INCONTINENT OF A LG AMT OF URINE X 2.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-20 00:00:00.000", "description": "Report", "row_id": 1433449, "text": "Respiratory Care:\n Patient with improving resp status. BS still with mild exp wheezing. Oxygenation good on 1lpm nasal cannula. Plan for possible dc to RNF today and to continue on med nebs Q4ATC.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-20 00:00:00.000", "description": "Report", "row_id": 1433450, "text": "MSICU NPN 1700-1900\n Alert but fidgety at times. Maintaining O2sats ~90-93 on RA but desats with exertion to high 80s. Expiratory wheezes throughout. Nebs now q4. Tol well until 6pm (2hrs after neb)she c/o that she wasn't getting enough O2. O2sats 88% at the time. Placed on 1L NC w/O2sats 92% but no subjective relief. RT to give additional neb tx.\n OOB-commode. Became sl dyspneic w/desat. Gd wt bearing but somewhat unsteady on feet. Inc of lg amt urine and had lg amt in commode. PO intake poor. Given 40Kcl in 500cc/NS and 40 po for K+ 2.9. Repeat K pnd.\n INR 9.2 this am. Given 5mg po Vit K. This eve it was ~8 and she received additional dose. Plan to hold Coumadin.\n Will be called out when able to go 4hrs between neb treatments.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-21 00:00:00.000", "description": "Report", "row_id": 1433451, "text": "Resp Care Note:\n\nPt received alb/atr via HHN as per order. Lung sounds coarse. Good nonprod cough. O2 sats stable. Pt in NARD on 1LPM N/C.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-21 00:00:00.000", "description": "Report", "row_id": 1433452, "text": "NPN see careview for details\n\nNEURO: AXOX3, episode where upon nurse found pt standing at beside in a puddle of urine. All 4 side rails were up.Pt didnt seem anxious re situation. Nurse explained to Pt the danger off fall risk when climbing over siderails.Pt verbalized understanding of instruction and pt was helped back into bed .All 4 side rails were up and bed alarms were put on for safety.\n\nC/V : SR-ST no ectopy Maintaining BP\n\nRESP: Cont to recieve Q 4hr nebs, w/ some exp wheezes and loose cough.Episode of tachypenia relieved w/ mso4 2mg IV.Maintining sATS OF 95-98% on 2liter NC.\n\nF/E/N: AM labs pending, INR back @ 2.6.\n\nPLAN: possible C/o to floor.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-18 00:00:00.000", "description": "Report", "row_id": 1433441, "text": "Respiratory Care Note\"\n Patient admitted to MICU this afternoon for incresed work of breathing, use of accessory muscles. RR 30s , HR 128, BS decreased air movement with audible IE wheezing. NT suctioned for small amounts of pale yellow tinged sputum. Sent for cultures as ordered. Plan for BIPAP as tolerated, med nebs and aggressive pul hygiene. So far, she tolerates the BIPAP mask well.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-18 00:00:00.000", "description": "Report", "row_id": 1433442, "text": "0655: 7p-7a END OF SHIFT NURSING NOTE\n\npt admitted to unit from w/ increasing resp distress. pt hx small lung ca w/ last round chemo last week. pt lives home w/ son. sob increasing over coarse of weekend, with admit to yesterday. upon arrival pt tachypnic in 30s w/ hr 130s and bp 90s.\n\nNEURO: alert and oriented x3. occas periods of slight confusion w/ climbing out of bed x1 w/ son at bedside and attempts x2. follows commands.\nRESP: tachypnic w/ audible wheezing and stridorous sounds. lung sounds in/exp wheezes, coarse rhonchi throughout. pt w/ weak congested cough that was nonproductive. pt was induced by r.t. for sputum specimen that was sent to lab. pt put on bipap of ps 15/fio2 0.40/peep 5. tolerated well w/ decrease in hr and rr. nebs given. when not on bipap, tolerated nc @ 3l.\nCARDIAC: st w/ no ectopy noted...rate 100-120s. left art line placed but does not correlate w/ nibp. bp 90-100s per nibp and aline 110-130s. no edema noted. skin warm and dry. afebrile. palpable pedal pulses. denies any c/o chest pain.\nGU/GI: abd soft, slightly distended w/ active bowel sounds. denies nausea. clear liquid diet...taking small sips water. foley placed around 1715 after pt did void x1 on bedpan.\n\npiv x2, rt forearm and lt forearm. pt started on heparin gtt at 1700. bolus given and started at 1000u/hr. (pt has hx of p.e.'s)\n\nfamily has been at bedside and updated on condition and plan of care. all questions answered.\n" }, { "category": "Nursing/other", "chartdate": "2109-12-18 00:00:00.000", "description": "Report", "row_id": 1433443, "text": "above note is from 7a-7p shift today\n" } ]

[ { "category": "Nursing/other", "chartdate": "2106-12-16 00:00:00.000", "description": "Report", "row_id": 1531467, "text": "NURSING UPDATE\nCV/HEME:\n HYPOTHERMIC ON ADMISSION FROM FLOOR, TEMP 92.2, WARMING BLANKET BELOW PT AND BAIR HUGGER ON TOP PULLED TEMP UP TO 98.1, ALL RAPIDLY INFUSED FLUIDS/PRODUCTS ADMINISTERED VIA LEVEL 1 WARMER.\n ALINE AND CENTRAL VENOUS INTRODUCER INSERTED INTO LT GROIN BY DRS AND . NS 3L BOLUS INFUSED AND ICA++ REPLETED X2.\n HCT RANGE 15.6-28, PLT RANGE 29-53, INR RANGE 3.3-0.6. TOTAL PRODUCTS TRANSFUSED TO THIS TIME: PRBC'S X 11, FFP X 4, PLTS X 2, CRYO X 1. ALSO ADMINISTERED FACTOR VII 3600U, AND PROTAMINE.\n\nNEURO:\n ON ADMISSION PT ALERT AND ORIENTED X3, EPISODES OF ANXIETY-> AGITATION AT TIMES. SEDATED ON PROPOFOL GTTS WITH GOOD EFFECT FOR INTUBATION.\n\nRESP:\n INTUBATED, MEDS UTILIZED PROPOFOL AND SUCC. BREATH SOUNDS DIMINISHED ON LT SIDE, CXR SHOWED ETT IN RT MAINSTEM, PULLED BACK 3CM BY RRT, BREATH SOUNDS IMPROVED ON LT SIDE. FOLLOW UP CXR DONE, RESULT PENDING. SXN THICK TAN PLUGS.\n\nGU/RENAL:\n HUO 0-10CC, CLEAR YELLOW. LASIX 100MG IV X1 WITH NO EFFECT. BLADDER PRESSURE 19.\n\nGI:\n ABDOMEN VERY DISTENDED BUT STILL SOFT, TENDER AND PAINFUL ON PALPATION PRIOR TO SEDATION. BOWEL SOUNDS HYPOACTIVE, NO BM.\n\nSOCIAL:\n FAMILY IN TO VISIT. SIGNIFICANT OTHER IS LPN, IS QUITE DISTRESSED OVER PT CONDITION. THE COUPLE HAVE SEVERAL CHILDREN BETWEEN THEM, THEY APPEAR CLOSE AND SUPPORTIVE, VERY CARING TOWARD PT. WILL NEED SOCIAL WORK CONSULT.\n\nPLAN:\n CONTINUE TO MONITOR FOR HYPOVOLEMIA/CONTINUED BLEEDING. TEAM WILL DISCUSS PLAN FOR SURGERY/ANGIO TODAY. CONTINUE TO CHECK LABS Q2H.\n" }, { "category": "Nursing/other", "chartdate": "2106-12-16 00:00:00.000", "description": "Report", "row_id": 1531468, "text": "Pt traveled to IR today. He has received blood via warmer.\nSxed for mod amount sputum. BS equal with ET tube at 18cm.\nhe was weaned form A/C to SIMV, then PSV. His spont. resp. effort is good. but his general condition remains poor he is not for extubation at this time\n" }, { "category": "Nursing/other", "chartdate": "2106-12-16 00:00:00.000", "description": "Report", "row_id": 1531469, "text": "NEURO; OFF PROPOFOL THIS AM PER TRANSPLANT TEAM, VERY LETHARGIC MOST OF AM, BUT MAE, DOES NOT OPEN EYES TO VOICE OR SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS, WEAK GAG AND COUGH BUT PRESENT, RESTLESS AND SL AGITATED AFTER RETURN FROM ANGIOGRAPHY AND WAS MEDIC WITH ATIVAN AND DILAUDID, REMAINED RESTLESS MOST OF TIME, OCCAS BITING ON ET TUBE, PROPOFOL CAN BE USED PER TRANSPLANT TEAM BUT ONLY UP TO 20 MCG AND TAKE OFF EVERY FEW HRS TO EVALUATE\n\nCARDIOVASCULAR; TEMP 98-97, TX WITH 3 UNITS PRBC, HCT 23-29, HR 90;SR, HAS BEEN HAVING OCCAS PVCS THIS LAST HR, LYTES HAD BEEN CHECKED, K 5.0, MG LEVEL AND CA LEVEL OKAY, NO REPLETION; SYS BP 130-110 MOST OF SHIFT, HAS DECRESED TO 90-88 THIS PAST HR, TX TEAM AND SICU TEAM NOTIFIED, PT WILL RECEIVE 500CC NSS BOLUS, CVP 13-15, PAN CULTURED TODAY, INTRODUCER PLACED RT IJ IN ANGIO,\n\nRESPIR; COARSE-RHONCHOROUS BREATH SOUNDS, SX FOR SMALL AMTS WHITE-LIGHT YELLOW SECRETIONS, AGONAL BREATHING THIS PM, DESPITE SEDATION FOR VENT CONTROL, ABGS LAST DONE EARLY PM REFLECT RESPIR ALKALOSIS, ON CPAP WITH 20 PS BUT 02 SAT DECREASING TO 92%, RESPIR APEARED LABORED, PLACED ON SIMV AND FIO2 INCRESED TO 60% WITH TV600\nAND HR 20, CXR BEING DONE AT PRESENT, (ET TUBE PULLED BACK EARLIER SINCE ET TUBE STILL IN RT MAINSTEM),\n\nRENAL ANURIC UNTIL AFTER ANGIO, APPROX 100 CLEAR UNRINE OUTPUT OVER SEVERAL HRS, CONTINUES WITH MINIMAL AMTS, URINE FOR CULT SENT, BLADDER PRESSURE 15\n\nGI;; NO BOWEL SOUNDS, ABD FIRM AND DISTENDED, FECAL SMEAR BUT NOT BM\n\nPLAN; RX HYPOTENSION, UTILIZE SEDATIN FOR VENT CONTROL WHEN APPROPRIATE, LYTES , CHECK WITH TEAM FOR FURTHER LAB ORDERS, MONITOR URINE OUTPUT\n" }, { "category": "Nursing/other", "chartdate": "2106-12-17 00:00:00.000", "description": "Report", "row_id": 1531470, "text": "NURSING UPDATE\nCV:\n SR TACHY IN 120'S. DROPPED BP TO 70'S, MAP 40'S DOPAMINE GTTS INFUSED BRIEFLY THEN CHANGED TO LEVOPHED GTTS. VASOPRESSIN ADDED LATER. MULT FLUID BOLUSES OF NS AND D5W/150MEQ BICARB. MULTIPLE AMPS BICARB IVP ALSO. HCT DOWN TO 11, PLTS 21, INR UP TO 2.3, PTT 123. PRODUCTS TRANSFUSED THIS SHIFT: PRBC'S X12, CRYO X2, FFP X4 AND FFP GTTS STARTED @ 50CC/H, FACTOR VII, PLTS X2.\n\nRENAL/GU:\n BLADDER PRESSURES 16-23. HUO 0-10CC. CREAT 2.5.\n\nID:\n SEPTIC PICTURE, ANTIBIOTIC REGIMEN STARTED. HYPOTHERMIC, TEMP DOWN 95.0, BAIR HUGGER AND WARMING BLANKET APPLIED, PAN CX SENT.\n\nGI:\n ABDOMINAL USS DONE - VERY LARGE RETROPERITONEAL HEMATOMA SEEN. NGT PASSED BY MD, IRRIGATED BUT SCANT BLOOD ONLY IN ASPIRATE, NGT REMOVED. BOWEL SOUNDS HYPOACTIVE->ABSENT. ABDOMEN VERY DISTENDED AND FIRM. NO BM.\n\nENDO:\n GLUCOSE RNAGE 82-279, SLIDING SCALE INSULIN COVERAGE. CORTISOL STIM TEST DONE.\n\nNEURO:\n EARLY NOC RESPONDING TO PHYSICAL STIMULATION ONLY, MOVING EXTREMITIES SLIGHTLY SPONTANEOUSLY, WITHDRAWING AND GRIMACING TO PAIN. PROPOFOL GTTS RESTARTED FOR SEDATION AND VENT COMPLIANCE.\n\nRESP:\n BREATH SOUNDS COARSE, SATS 97-100%, AIR HUNGRY. ACIDOSIS METABOLIC, VENT SUPPORT CHANGED TO PCV IN ATTEMPT TO COMPENSATE.\n\nSOCIAL:\n FAMILY CONTACT BY DR . WIFE AT BEDSIDE AT THIS TIME, VERY DISTRESSED. CHAPLAIN CONTACT. SHOULD BE HERE BY 8AM.\n\nDR IN CONSTANT ATTENDANCE THROUGH NOC.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n" }, { "category": "Nursing/other", "chartdate": "2106-12-17 00:00:00.000", "description": "Report", "row_id": 1531471, "text": "Ol Neuro sedated on propofol 20 mcg/kg/min received ativan .5mg IV q 6hr\nCVS Hct 30.7 down to 26.2 received 2uPRBC repeat hct pnding. Plt ct 57 tx 1u plts repeat plts to be done at 1800. INR 1.3 FFP continuous at 50cc q hr. Calicium repleted q 2hr prn scale, mag repleted, K+ 4.4, Na 137. On norepi titrate to keep map > 60 titrated most of shift down presently on .25mcg/kg/min, vasopression at .04u/min. cvp 17. Anasarca. IV sites blding. PP doppler\nResp PCV 60% peep 10 RR 20 lungs coarse diminished bases rt>lt sx min bldy secretions abg 7.39/35/82/-\nGI abd firm distended BS hypoactive no stool\nGU bladder press 27 u/o 0-10cc > 34liters + since admit to icu BUN 48 cr 2.8\nID temp max 101.3 flagyl, + levo as ordered cultures pnding\nendo started on insulin gtt\nsocial family members in most of day doctors have discussed pt condition in detail with sign other HCP she understands the gravity of the situation. Social worker involved.\naccess RT IJ quad lumen/LTF aline/LTF intro/ lt w 18g, rtu 18g\na. ESLD, retroperitoneal bld, ?septic, ARF, hyperglycemic\np. check hct q2hr tx <25, FFP at 50cc qhr keep INR <2, keep Plt >80\nnorepi and vasopressin titrate to keep map > 60, na bicarb gtt at 100cc qhr poss. going for TIPS procedure today\ngive antibx as ordered, check temp, wbc, follow cx\nmonitor u/o, lytes, bun cr, bladder pressures, poss cvvh renal following\ninsulin gtt BS q 1hr\nsupport family and patient\n" }, { "category": "Nursing/other", "chartdate": "2106-12-17 00:00:00.000", "description": "Report", "row_id": 1531472, "text": "Pt remains on current vent settings, see carevue for details. Peep increased to 12. Pt may need to go on CVVHD tonight.\n" }, { "category": "Nursing/other", "chartdate": "2106-12-18 00:00:00.000", "description": "Report", "row_id": 1531473, "text": "Resp Care Note:\n\nPt cont intub with OETT sedated and on mech vent as per Carevue. Lung sounds coarse and dim bibasilar R>L; suct sm off white sput. MDI given as per order. Pt with worsening oxygenation on PCV switched to APRV and able to slowly improve oxygenation however pt remains with significant oxygen deficit[a/A ratio .13]. Pt started on CAVH. Pt cont with significant fluid overload and firm abd. Cont APRV wean FIO2 as tol.\n" }, { "category": "Nursing/other", "chartdate": "2106-12-18 00:00:00.000", "description": "Report", "row_id": 1531474, "text": "Update\nO:See carevue flowsheet for specifics.\n Pt w esld & retroperitoneal bld . Continues w persistent anemia, progressive worsening hypoxemia, hepatic and renal failure req aggressive resuscitation w pressor support(levophed ^ amts & pitressin gtts),cvvhd,as well as multiple bld products.\n\nneuro: sedated on prpfol. 20-30mcg/kg/min perl @2mm brisk. No response to nailbed pressure. Anasarca.\n\ncv: sr to rare pvc.Remains on levo and pitressin.Titrating levo to goal mbp 55.Distal pulses faint palp dp's feet .Quadruple lumen line rij- difficulty obtain cvp w mult products,gtts infusing. Manual flushed cvp line w no appreciable imprvment in waveform.\n\nresp: progressive worsening of pao2 and sats on cmv mode unresponsive to conventional changes in peep-> changed to aprv ventilation mode w initial drop in bp and ^^ O2 req to 100% transiently.bbs coarse distant throughout. Lavage and suct for scant to sm amts dk tan bl tinged sputum.Metab acidosis correction w nahco3 gtt; acidosis now controlled w cvvhd(* initiated at 2400).\n\ngi: no ngt d/t hx of esoph varices. abd edematous soft no active bowel snds audible.\nAbd ultrasound done at bedside overnight- no signif findings.\nendo:glucoses labile. initially on insulin gtt now hypoglycemic req d50 x 2 overnight- and aware.\n\ngu/renal: anuric and several liters positive. Cvvhd initiated at midnight w goal of getting pt even to slt negative-> pfr rate titrated as tol to 300ml/hr.\n\nheme/id: continues on ffp gtt for goal inr ~1.5 or<. hct 21-28+ 4 units prbc overnight. Id- subnl temp req bair hugger. Pan cult on a.m. - results pending. Quadrple antibx coverage.\n\nPsychosocial/Family: Signif other-> -is hcp and aware of poor prognosis. Several children in to visit early evening and also aware of pt poor prognosis and asking approp questions. Emotional support given.Social work in contact w S.O. during day for additional emot support.\n\nA/P: pt w esld w very poor prognosis cont to req aggressive interventions & ^^ pressor support to achieve mbp ~55. cvvhd -goal is to per renal and sicu team-attempt even to slt neg i/o status if tolerates. Check lytes,coags, abg q4h and prn. Glucoses q2h and rx as ordered. Code status to be discussed w S.O. today w team.\nCont to support w aggressive icu care/managemnt.\n" }, { "category": "Nursing/other", "chartdate": "2106-12-18 00:00:00.000", "description": "Report", "row_id": 1531475, "text": "Resp Care\nPt remains on APRV-parameters noted. Due to hemodynamic instability, Phigh weaned to 25 and Plow weaned to 0. Blood pressure increased by small degree. Following change, ABG showed adequate ventilation and improved oxygenation. Lastest ABG shows compensated metabolic acidosis. Alb/atro MDI x 3. Will continue APRV at this time.\n" }, { "category": "Radiology", "chartdate": "2106-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888616, "text": " 12:19 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: where is the tip of the ETT?\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis s/p intubation\n\n REASON FOR THIS EXAMINATION:\n where is the tip of the ETT?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:39 A.M , clip is 387-2393.\n\n HISTORY: Hepatic cirrhosis. Where is tip of the new endotracheal tube.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the endotracheal tube is in the right main bronchus and the tip should\n be withdrawn at least 5 cm to the thoracic inlet. Heart size normal. Lungs\n generally low in volume but clear of any focal abnormality. No pneumothorax.\n\n Findings of a subsequent chest radiograph reported concurrently were discussed\n with Dr. by telephone at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-15 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 888572, "text": " 3:01 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do CT abd/pelvis to r/o retroperitoneal bleed.\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep C cirrhosis, now with hypotension and Hct drop.\n Please r/o RP bleed.\n REASON FOR THIS EXAMINATION:\n Please do CT abd/pelvis to r/o retroperitoneal bleed.\n CONTRAINDICATIONS for IV CONTRAST:\n CRI\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Abdomen CT.\n\n HISTORY: 57-year-old man with hep C and cirrhosis, now hypotensive with\n hematocrit drop.\n\n TECHNIQUE: Multidetector CT through the abdomen and pelvis without contrast.\n\n Comparison made to prior study dated .\n\n FINDINGS: In the limited images throughout the bases of the lungs, there is a\n mild right pleural effusion.\n\n The liver is shrunken and nodular. There is no splenomegaly. The\n gallbladder, pancreas, kidneys and left adrenal gland are unremarkable. There\n is a stable cystic lesion measuring 30 x 35 mm in the right adrenal gland.\n\n The aorta is normal in caliber.\n\n There has been interval increase in the ascites.\n\n In the right retroperitoneum, there is a high-density collection with large\n hemorrhage located from the level of the lower pole of the right kidney going\n to the right hemipelvis measuring approximately 9.8 x 5.5 x 23 cm (AP x\n transverse x cephalocaudal dimension). It involves the right ilio-psoas\n muscles and displaces the right kidney anteriorly and superiorly.\n PELVIC CT: The bladder and sigmoid colon are unremarkable.\n\n There is free fluid and retroperitoneal lymphadenopathy.\n\n BONE WINDOWS: There are no concerning bone lesions suggestive of degenerative\n changes in the lower lumbar spine.\n\n IMPRESSION:\n 1. Right-side retroperitoneal hematoma.\n 2. Interval increase in the amount of ascites.\n 3. Cirrhotic liver.\n 4. Right pleural effusion.\n 5. Unchanged right adrenal cyst.\n (Over)\n\n 3:01 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do CT abd/pelvis to r/o retroperitoneal bleed.\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "ECG", "chartdate": "2106-12-07 00:00:00.000", "description": "Report", "row_id": 211525, "text": "Sinus bradycardia\nConsider left atrial abnormality\nProminent precordial U waves - are nonspecific but clinical correlation is\nsuggested for possible in part metabolic/drug effect\nSince previous tracing of , sinus bradycardia absent\n\n" }, { "category": "ECG", "chartdate": "2106-12-11 00:00:00.000", "description": "Report", "row_id": 211524, "text": "Sinus rhythm\nNo change from previous\n\n" }, { "category": "Radiology", "chartdate": "2106-12-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 888103, "text": " 7:00 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: PLEASE PERFORM an abd US with DOPPLERS and also mark a spot\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis, hx of ascites, and now with delta MS\n REASON FOR THIS EXAMINATION:\n PLEASE PERFORM an abd US with DOPPLERS and also mark a spot for paracentesis if\n a there is enough fluid for paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and ascites. Change in mental status.\n\n COMPARISON: .\n\n FINDINGS: Grayscale and Doppler son of the right upper quadrant were\n performed. The liver is micronodular and cirrhotic, as noted previously.\n There is no intrahepatic or extrahepatic biliary ductal dilatation. A known\n right adrenal mass is again noted. Evaluation of four quadrants of the\n abdomen for ascites reveals a small amount of ascites, mostly perihepatic.\n This amount is too small to mark for paracentesis.\n\n The main, right and left portal veins are patent with normal hepatopetal\n direction of flow and normal waveforms. The main, right and left hepatic\n arteries are patent with normal hepatopetal direction of flow and normal\n waveforms. The mid, right and left hepatic veins are patent with normal\n hepatofugal direction of flow and normal waveforms.\n\n IMPRESSION:\n 1. Cirrhosis.\n 2. Unchanged right adrenal mass.\n 3. Small amount of ascites, which is insufficient to be marked for\n paracentesis.\n 4. Patent portal veins, hepatic veins, and hepatic arteries with normal\n direction of flow and waveforms.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2106-12-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888109, "text": " 8:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: enal for PNA\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis and delta MA\n REASON FOR THIS EXAMINATION:\n enal for PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:09 PM ON .\n\n HISTORY: Cirrhosis. Possible pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Lungs remain low in volume but there is no discrete consolidation. Increase\n in caliber of the hila and mediastinal vessels accompanied by minimal\n interstitial abnormality argues for volume overloaded, but there is no frank\n air space edema or pleural effusion. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888901, "text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: access for pulmonary edema\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis s/p intubation, now w/ fulminant liver\n failure\n REASON FOR THIS EXAMINATION:\n access for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of hep C cirrhosis with fulminant liver failure and intubation.\n\n Endotracheal tube is 5 cm above carina. Tip of the Quinton catheter overlies\n right brachiocephalic vein. No pneumothorax. There is a left pleural\n effusion with associated atelectasis at the left base.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-16 00:00:00.000", "description": "NON-TUNNELED", "row_id": 888672, "text": " 9:53 AM\n CENTRAL LINE PLCT Clip # \n Reason: please place triple lumen catheter under fluoro\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n *** Please note that the initial report under this clip number belonged to\n this patient's mesenteric study and has been moved to the proper clip. The\n report for the central line placement will be dictated and a report will\n follow. ry\n\n\n 9:53 AM\n CENTRAL LINE PLCT Clip # \n Reason: please place triple lumen catheter under fluoro\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESLD/retroperitoneal bleed\n REASON FOR THIS EXAMINATION:\n please place triple lumen catheter under fluoro\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 57-year-old man with retroperitoneal bleed. Needs\n angiogram to access the right-sided retroperitoneal bleeding.\n\n PROCEDURE/FINDINGS: The procedure was performed by Drs. and .\n Dr. , the attending radiologist was present and supervising throughout\n the procedure.\n\n After the risks and benefits were explained to the patient's family, written\n informed consent was obtained. The patient was placed supine on the\n angiographic table. The right groin was prepped and draped in the standard\n sterile fashion. Preprocedure timeout was performed to confirm the patient's\n name, procedure, and site. Using palpatory and fluoroscopic guidance, a 19\n gauge single needle was used to puncture the right common femoral artery. A\n 0.035 guidewire was advanced through the needle into the aorta using\n fluoroscopic guidance. The needle was exchanged for a 5 French vascular\n sheath, which was attached to continuous sidearm flush. An Omniflush catheter\n was then placed over the wire into the abdominal aorta and subsequently the\n right common iliac artery and arteriogram was performed. There was no\n extravasation of the contrast was identified. Depending on the diagnostic\n findings, no further intervention procedure was needed. The catheter and the\n sheath were then removed. Hemostasis was achieved by direct manual pressure\n for 15 minutes.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: No active bleeding was identified during the arteriogram.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-16 00:00:00.000", "description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM", "row_id": 888673, "text": " 9:54 AM\n MESENTERIC Clip # \n Reason: embolize source of right sided retroperitoneal bleeding\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n Contrast: OPTIRAY Amt: 145\n ********************************* CPT Codes ********************************\n * EA 1ST ORDER ABD/PEL/LOWER EXT PELVIS SEL/SUPERSEL A-GRAM *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ESLD/retroperitoneal bleed\n REASON FOR THIS EXAMINATION:\n embolize source of right sided retroperitoneal bleeding\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 57-year-old man with retroperitoneal bleed. Needs\n angiogram to access the right-sided retroperitoneal bleeding.\n\n PROCEDURE/FINDINGS: The procedure was performed by Drs. and .\n Dr. , the attending radiologist was present and supervising throughout\n the procedure.\n\n After the risks and benefits were explained to the patient's family, written\n informed consent was obtained. The patient was placed supine on the\n angiographic table. The right groin was prepped and draped in the standard\n sterile fashion. Preprocedure timeout was performed to confirm the patient's\n name, procedure, and site. Using palpatory and fluoroscopic guidance, a 19\n gauge single needle was used to puncture the right common femoral artery. A\n 0.035 guidewire was advanced through the needle into the aorta using\n fluoroscopic guidance. The needle was exchanged for a 5 French vascular\n sheath, which was attached to continuous sidearm flush. An Omniflush catheter\n was then placed over the wire into the abdominal aorta and subsequently the\n right common iliac artery and arteriogram was performed. There was no\n extravasation of the contrast was identified. Depending on the diagnostic\n findings, no further intervention procedure was needed. The catheter and the\n sheath were then removed. Hemostasis was achieved by direct manual pressure\n for 15 minutes.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: No active bleeding was identified during the arteriogram.\n\n" }, { "category": "Radiology", "chartdate": "2106-12-17 00:00:00.000", "description": "P US ABD LIMIT, SINGLE ORGAN PORT", "row_id": 888797, "text": " 3:59 AM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: Please mark for STAT paracentesis.\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis, hx of ascites, and now with delta MS\n\n REASON FOR THIS EXAMINATION:\n Please mark for STAT paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, history of ascites, change in mental status.\n\n LIMITED ABDOMINAL ULTRASOUND: One view of the lower abdomen shows large\n amount of ascites. A spot was marked for paracentesis to be performed by the\n clinical team.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888875, "text": " 5:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for worsening pulmonary edema\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis s/p intubation, now w/ fulminant liver\n failure\n REASON FOR THIS EXAMINATION:\n Please assess for worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 5:36 P.M. ON \n\n HISTORY: Cirrhosis. Liver failure. Assess for pulmonary edema.\n\n IMPRESSION: AP chest compared to , at 7:04 p.m.:\n\n Tip of the ET tube is at the upper margin of the clavicles approximately 5.5\n cm from the carina, 2 to 3 cm above optimal position. Left lower lobe\n collapse is new, and mild pulmonary edema has developed. There is no\n pneumothorax. A right jugular line transmits a catheter to the thoracic\n inlet.\n\n Dr. was paged to discuss these findings at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888626, "text": " 5:07 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n -76 BY SAME PHYSICIAN\n : check ETT position\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis s/p intubation\n\n REASON FOR THIS EXAMINATION:\n check ETT position\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:09 A.M., :\n\n HISTORY: Cirrhosis. Check ET tube position following intubation.\n\n IMPRESSION: AP chest compared to 12:39 a.m:\n\n Endotracheal tube still ends in the right main bronchus and should be\n withdrawn 5 cm for optimal placement. Progressive atelectasis in the left\n lower lobe is not surprising. The heart is normal size. There is no\n appreciable pleural effusion.\n\n Findings were discussed with Dr. by telephone at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-18 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 888884, "text": " 1:10 AM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: Extend on bleeding and hydronephrosis\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis, very large retroperitoneal bleed\n REASON FOR THIS EXAMINATION:\n Extend on bleeding and hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, retroperitoneal hematoma. Please evaluate for\n hydronephrosis.\n\n LIMITED PORTABLE ABDOMINAL ULTRASOUND: The right kidney measures 11 cm and\n contains multiple thin-walled rounded anechoic simple renal cysts. The left\n kidney measures 11.2 cm. There is no evidence for hydronephrosis. Small\n amount of ascites is seen. Within the right lateral abdomen, a heterogeneous\n fluid collection consistent with the patient's known retroperitoneal hematoma\n is seen.\n\n IMPRESSION: No evidence for hydronephrosis. Ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2106-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 888757, "text": " 6:39 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : ETT adjusted, ?CHF\n Admitting Diagnosis: HEPATIC ENCEOPHALOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis s/p intubation\n\n REASON FOR THIS EXAMINATION:\n ETT adjusted, ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Adjustment of endotracheal tube, hepatitis C.\n\n COMPARISON: , at 6:09.\n\n SEMIUPRIGHT AP VIEW OF THE CHEST: The endotracheal tube has been withdrawn\n slightly and now lies approximately 3.7 cm from the carina. Low lung volumes\n are again demonstrated. The cardiac and mediastinal contours are unchanged.\n The appearance of the lungs is stable from the prior exam with\n flap/consolidation within the left lower lobe. Left costophrenic angle is\n excluded from the study. No pneumothorax is demonstrated.\n\n IMPRESSION: Satisfactory repositioning of endotracheal tube.\n DFDdp\n\n" }, { "category": "Nursing/other", "chartdate": "2106-12-18 00:00:00.000", "description": "Report", "row_id": 1531476, "text": "NEURO; ON PROPOFOL EARLIER IN SHIFT, PRESENTLY OFF SECONDARY TO HYPOTENSION, PT IS UNRESPONSIVE AT PRESENT, RT PUPIL MORE BRISK THAN LEFT DOES NOT OPEN EYES SPONTANEOUSLY OR MOVE EXTREMITIES SPONTANEOUSLY, VERY WEAK GAG REFLEX WHEN SUCTIONED,\n\nCARDIOVASCULAR; HR 110-118 ST, BP LABILE (GOAL HAD BEEN FOR MAP OF 55 BUT CHANGED TO SYS OF 90 IN ORDER TO PLL OFF FLUID FOR CVVHD THERAPY), PRESENTLY ON MAX DOSE OF LEVOPHED, NEO AT 2 MCG/KG/MIN, VASOPRESSIN AT 2.4 UNITS/HR, COAGULOPATHIC, PLT COUNT DOWN TO 46-RECEIVED PLT TX, 2 UNITS FFP IN ADDITION TO CONTINUOUS GTT AT 100CC/HR, ALONG WITH CRYOPRECIPITATE, RPT HCT THIS PM WAS 16-GIVEN 4 UNITS PRBC VIA RAPID INFUSER, NO FURTHER LAB WORK TO BE DONE PER FAMILY MEETING, TEMP 97-97.6, HUGGER ON, NEO STARTED TODAY AFTER LEVO MAXED,\n\nRESPIR; COARSE BREATH SOUNDS, OCCAS RHONCHOROUS IN UPPER LOBES, REMAINS ON APRV MODE VENTILATION, ABGS REFLECT COMPENSATED RESPIR ALKALOSIS WITH METAB ACIDOSIS,\n\nRENAL; U/O 5-10CC THIS SHIFT, CVVHD CLOTTED THIS PM, RESTARTED, NOT ABLE TO ACHIEVE NEG OUTPUT, TRANSPLANT TEAM INFORMED EARLIER, AFTER FAMILY MEETING AND HEALTH CARE PROXY () WISH TO STOP FURTHER TX AND CVVHD, CVVHD TERMINATED,\n\nENDOCRINE; BS 80-68, RX WITH 1/2 AMP D50 FOR 68 GLUCOSE, PRESENTLY 95\n\nGI; NO BOWEL SOUNDS, SOFT DISTENDED ABDOMEN, NO BM, NO FLATUS\n\nPLAN; PT IS DNR, FAMILY MEMBERS AT BEDSIDE, NO FURTHER LAB TESTS OR BLOOD PRODUCTS PER FAMILY WISHES AND ORDER FROM DR. , PLASMA TX STOPPED, CVVHD TERMINATED, PRESSORS REMAIN ON BUT ? WILL STOP FURTHER TITRATION (DR. WILL COME DOWN AND ASSESS AND TALK TO FAMILY), NEOB CALLED AND CASE DECLINED\n" }, { "category": "Nursing/other", "chartdate": "2106-12-18 00:00:00.000", "description": "Report", "row_id": 1531477, "text": " \n PT AT THIS POINT HYPOTENSIVE BP 62/40 SAO2 78 HR 78 TEMP 96 AX FAMILY AT BEDSIDE DRIPS UP LEVO NEO AND VASO AT MAX ALLOWED DOSE MD ORDER FAMILY AND MD CAME TO THIS AGGREEMENT OF CMO STATUS THAT ENTAILS REMOVING ALL VASOACTIVE DRUGS AND PLACE PT ON CPAP MODE AND ALLOW THIS PT TO AT PEACE ALL FAMILY MEMBERS IN TOTAL AGGREEMENT WITH THIS DECISION\n PT WENT IN TO ARREST STAT TIME OF DEATH FAMILY AT BEDSIDE MD AWARE PT NOT A ORGAN TRANSPLANT CANIDATE NO AUTOPSY NO ME CASE\n" } ]

[ { "category": "ECG", "chartdate": "2180-11-27 00:00:00.000", "description": "Report", "row_id": 261968, "text": "Coarse atrial fibrillation with rapid ventricular response. Right ventricular\nhypertrophy. Compared to the previous tracing ventricular rate is less regular\nmaking this likely atrial fibrillation. The other findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2180-11-26 00:00:00.000", "description": "Report", "row_id": 262186, "text": "Atrial tachycardia with 2:1 block. Incomplete right bundle-branch block.\nProbable right ventricular hypertrophy. Compared to the previous tracing\nthe rhythm is now more compatible with atrial tachycardia. The other\nfindings are similar.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2180-11-23 00:00:00.000", "description": "Report", "row_id": 262187, "text": "Multifocal atrial tachycardia and frequent ventricular ectopy. Biatrial\nabnormality. Consider right ventricular hypertrophy as previously recorded\non . Followup and clinical correlation are suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2186-05-01 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1005971, "text": " 4:09 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with intubated\n REASON FOR THIS EXAMINATION:\n ett\n ______________________________________________________________________________\n WET READ: JKPe MON 4:21 AM\n ETT should be advanced\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubated.\n\n SUPINE CHEST RADIOGRAPH\n\n FINDINGS: Comparison is made to examination at 12:30 a.m. on same day. In\n the interval, the patient has been intubated with endotracheal tube\n terminating 7 cm from the carina and orogastric tube terminating within the\n stomach with its tip not well visualized. The lungs are better inflated and\n remain clear, without evidence of pneumonia, edema, or effusion. Mild\n calcifications noted within the intrathoracic aorta, with the cardiac\n silhouette appearing unremarkable. Slight irregularity is noted involving the\n posterior right third rib, which may reflect old trauma.\n\n IMPRESSION:\n\n No acute cardiopulmonary process. Endotracheal tube slightly high and would\n benefit from advancement.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-05-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1006082, "text": " 5:28 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval proper placing for shunt\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with tonsilar herniation s/p shunt\n REASON FOR THIS EXAMINATION:\n pls eval proper placing for shunt\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post shunt.\n\n COMPARISON: Multiple studies, the most recent MRI dated .\n\n TECHNIQUE: Non-contrast head CT. Coronal and sagittal reformatted views were\n displayed.\n\n CT OF THE HEAD WITHOUT CONTRAST: Interval placement of right frontal approach\n ventriculostomy catheter with tip within the third ventricle. The size of the\n ventricles appear unchanged when compared to the MRI dated , at\n 12:38 and slightly larger when compared to a CT head dated , at\n 1:35 a.m. There is no shift of normally midline structures. The degree of\n ascending transtentorial herniation and descending tonsillar herniation\n appears unchanged when compared to today's MRI.\n Tiny pneumocephalus likely related to the catheter placement.\n\n Post-surgical changes within the soft tissues overlying the right frontal\n lobe and the skin staples.\n\n IMPRESSION:\n 1. Interval placement of ventriculostomy catheter as described above.\n 2. Unchanged ascending transtentorial and descending tonsillar herniation.\n and dilation of the ventricles especially the temporal horns compared to\n the MR done 4 hours earlier but increased compared to the Ct head done at\n 1.35AM. Close followup to be considered.\n\n The findings were discussed with neurology resident at the time of the\n dictation by dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2186-05-01 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1006066, "text": " 3:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for ETT placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with intubation\n REASON FOR THIS EXAMINATION:\n pls eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with intubation.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The endotracheal tube has been advanced and now\n lies 5.8 cm above the carina. The nasogastric tube courses inferiorly beyond\n the limits of this examination. The cardiomediastinal silhouette is stable.\n The pulmonary vasculature is normal. There is no focal consolidation,\n pneumothorax, or pleural effusion.\n\n IMPRESSION: Endotracheal tube lies 5.8 cm above the carina in appropriate\n position.\n\n\n" }, { "category": "Radiology", "chartdate": "2186-05-01 00:00:00.000", "description": "MRA BRAIN W/O CONTRAST", "row_id": 1006039, "text": " 11:43 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: pls eval for edema, ischemia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with COPD, IVDU, +barbituates on tox, CT scan with enlarged\n ventricles, and ? edema in post fossa.\n REASON FOR THIS EXAMINATION:\n pls eval for edema, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old female with history of IV drug use and prior reversible\n encephalopathy, now with positive tox screen for barbiturate use and suspected\n hydrocephalus on CT.\n\n COMPARISON: Non-contrast head CT. and ; MR head without and\n with IV gadolinium, , , and .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain pre- and post\n the uneventful administration of IV gadolinium. MRA of the brain was\n performed with time-of-flight imaging and multiplanar reformations and 3D\n reconstructions.\n\n MR OF THE BRAIN WITHOUT AND WITH IV GADOLINIUM: Extensive FLAIR hyperintense\n signal abnormality is noted to predominantly affect white matter of the\n bilateral parietooccipital lobes as well as both cerebellar hemispheres. FLAIR\n abnormality is also noted of the right thalamus, right caudate, pons, and\n right frontal cortex and subcortical white matter. There is no evidence of\n diffusion abnormality associated with the areas of FLAIR hyperintensity. Mild\n leptomeningeal enhancement is noted of the bilateral parietooccipital regions\n and cerebellum. The lateral ventricles, particularly the temporal horns, as\n well as third ventricle have increased in size compared to MR of .\n There is evidence of ascending transtentorial and descending tonsillar\n herniation with mass effect upon the fourth ventricle. The sulci of the\n posterior fossa are effaced. Periventricular FLAIR hyperintensity around the\n lateral ventricles is new compared to and compatible with\n transependymal edema related to hydrocephalus.\n\n TIME-OF-FLIGHT MRA OF THE HEAD AND CIRCLE OF : A focal aneurysm is\n noted of the right internal carotid artery at the junction of the cavernous\n and supraclinoid portions which on axial view measures 6 x 4 mm. There is no\n other evidence of aneurysm, dissection, vascular malformation, or\n hemodynamically significant stenosis. The circle of is patent.\n\n IMPRESSION:\n 1. Extensive hyperintense FLAIR signal abnormality symmetrically involving\n predominantly the white matter of the parietooccipital regions as well as\n right frontal lobe, right caudate, right thalamus, pons, and cerebellum\n without associated diffusion abnormality is thought most likely due to\n posterior reversible leukoencephalopathy. Mild leptomeningeal enhancement of\n (Over)\n\n 11:43 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: pls eval for edema, ischemia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the parietooccipital regions is probably related to PRES. Findings are thought\n much less likely to represent infection, although this cannot be definitively\n excluded.\n 2. Evidence of cerebellar edema which causes mild obstructive hydrocephalus\n and early ascending transtentorial and descending tonsillar herniation.\n 3. Aneurysm at the junction of the cavernous and supraclinoid portions of the\n right internal carotid artery measures 6 x 4 mm on axial view.\n\n These findings were discussed with Dr. at 2 p.m. on .\n Findings were also reviewed by telephone with Dr. of neurosurgery at 3\n p.m. on .\n\n" }, { "category": "ECG", "chartdate": "2186-05-05 00:00:00.000", "description": "Report", "row_id": 172066, "text": "Sinus rhythm. Prolonged Q-T interval. T wave inversions in leads V1-V4.\nCannot exclude ischemia. Clinical correlation is suggested. RSR' pattern\nin leads V1-V2 is non-specific. Non-specific inferolateral T wave flattening.\nBorderline low voltage in the limb leads. Compared to the previous tracing\nof ventricular premature beats are absent. Anterior T wave inversions\nare present. Decreased voltage in the limb leads and the Q-T interval is\nlonger.\n\n" }, { "category": "ECG", "chartdate": "2186-05-01 00:00:00.000", "description": "Report", "row_id": 172067, "text": "Sinus rhythm with bigeminal PVCs\nLateral ST changes are nonspecific\nSince previous tracing of the same date, bigeminal ventricular premature\ncomplexes noted\n\n" }, { "category": "ECG", "chartdate": "2186-05-01 00:00:00.000", "description": "Report", "row_id": 172068, "text": "Sinus rhythm. Ventricular ectopy. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing there is no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2186-05-01 00:00:00.000", "description": "Report", "row_id": 172069, "text": "Artifact is present. Sinus rhythm. Frequent ventricular ectopy. Diffuse\nnon-specific ST-T wave changes. Compared to the previous tracing the sinus\nrate is faster and ventricular ectopy is new.\nTRACING #1\n\n" }, { "category": "Physician ", "chartdate": "2186-05-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 320445, "text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 53 year-old woman with hx of COPD (with recent admission for COPD with\n exacerbation)\n She is now intubated and sedated, and history is obtained from ED notes\n and family. She initially came to the ED with confusion, stating that\n she \"felt like she was retaining CO2\" and with 10/10 headache.\n In the ED, her vital signs included temp 95.7, HR 65, BP 237/75, RR 12,\n Pulse ox 95% RA. A TNG infusion was started for hypertension. She was\n treated with bronchodilators and BiPAP because she reported feeling as\n if she was retaining CO2 (but ABG 7/40 /45 / 74). She also noted\n abdominal pain and blurry vision. She developed increasing confused and\n agitation and was intubated for combativeness. Her ED course was also\n notable for an episode of bradycardia to the 30s.\n LP in ED showed rbc 39 - 63, wbc with ~40% PMNs, total protein 158,\n glucose 94, negative gram stain.\n Additional medications received include ipratropium neb, albuterol neb,\n nitro gtt, ativan 1mg IV x 1, naloxone .4mg IV x 1, ceftriaxone 2g IV x\n 1, vancomycin 1mg IV ativan, propofol for sedation, etomidate,\n .\n Upon arrival to the , pt is intubated and sedated.\n Patient admitted from: ER\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Ordered here: ativan, hydralazine, CHG, acyclovir, SQI, prednisone 50,\n tiotropium, advair, albuterol\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:44 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 96 (77 - 96) bpm\n BP: 152/77(94) {138/77(94) - 191/106(123)} mmHg\n RR: 23 (19 - 23) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 1,150 mL\n PO:\n TF:\n IVF:\n 130 mL\n Blood products:\n Total out:\n 0 mL\n 2,285 mL\n Urine:\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,135 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 30%\n RSBI: 58\n SpO2: 94%\n ABG: 7.54/37/94./27/9\n PaO2 / FiO2: 313\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 179 K/uL\n 44.8 %\n 15.9 g/dL\n 120 mg/dL\n 0.7 mg/dL\n 14 mg/dL\n 27 mEq/L\n 95 mEq/L\n 2.9 mEq/L\n 136 mEq/L\n 15.6 K/uL\n [image002.jpg]\n 06:36 AM\n 09:32 AM\n 11:40 AM\n WBC\n 15.6\n Hct\n 44.8\n Plt\n 179\n Cr\n 0.7\n TC02\n 31\n 33\n Glucose\n 120\n Other labs: PT / PTT / INR:11.1/24.9/0.9, Ca++:8.4 mg/dL, Mg++:2.3\n mg/dL, PO4:3.3 mg/dL\n Fluid analysis / Other labs: see HPI for LP\n tox with methadone and barbiturates\n Imaging: CXR without infiltrate; (+) hyperinflation\n Assessment and Plan\n 53 y/o woman with\n Suspect that the major differential diagnosis here is hypertensive\n encephalopathy (PRES), encephalitis (e.g. HSV), and subarachnoid\n hemorrhage (not seen on CT). The finding of elevated protein in the\n CSF suggests that this is a meaningful intracranial process rather than\n a red .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 07:21 AM\n 20 Gauge - 07:23 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2186-05-01 00:00:00.000", "description": "Physician Attending Admission Note", "row_id": 320459, "text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 53 year-old woman with hx of COPD (with recent admission for COPD with\n exacerbation) now admitted from ED with hypertension and confusion,\n intubated for agitation.\n She is now intubated and sedated, and history is obtained from ED notes\n and family. She initially came to the ED with confusion, stating that\n she \"felt like she was retaining CO2\" and with 10/10 headache. In the\n ED, her vital signs included temp 95.7, HR 65, BP 237/75, RR 12, Pulse\n ox 95% RA. A TNG infusion was started for hypertension. She was\n treated with bronchodilators and BiPAP because she reported feeling as\n if she was retaining CO2 (but ABG 7/40 /45 / 74). She also noted\n abdominal pain and blurry vision. She developed increasing confused and\n agitation and was intubated for combativeness. Her ED course was also\n notable for an episode of bradycardia to the 30s.\n LP in ED showed rbc 39 - 63, wbc with ~40% PMNs, total protein 158,\n glucose 94, negative gram stain.\n Additional medications received include ipratropium neb, albuterol neb,\n nitro gtt, ativan 1mg IV x 1, naloxone .4mg IV x 1, ceftriaxone 2g IV x\n 1, vancomycin 1mg IV ativan, propofol for sedation, etomidate,\n Upon arrival to the , pt is intubated and sedated.\n Patient admitted from: ER\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Ordered here: ativan, hydralazine, CHG, acyclovir, SQI, prednisone 50,\n tiotropium, advair, albuterol\n Past medical history:\n Family history:\n Social History:\n admission with hypertension/PRES/abnormal MRI\n COPD\n Hep C, Hep B\n Hx IVDA, on methadone maintenance\n Hx seizure d/o with PRES\n OSA\n GERD\n hyperlipidemia\n Unobtainable. As reviewed in OMR: Aunt - history of CVA.\n Mother - Endometrial \n Father - \n Unobtainable. As reviewed in OMR, she reported former tobacco and\n other drugs, now quiescent.\n Review of systems:\n Sedated.\n Flowsheet Data as of 12:44 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 96 (77 - 96) bpm\n BP: 152/77(94) {138/77(94) - 191/106(123)} mmHg\n RR: 23 (19 - 23) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 1,150 mL\n PO:\n TF:\n IVF:\n 130 mL\n Blood products:\n Total out:\n 0 mL\n 2,285 mL\n Urine:\n 625 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,135 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 30%\n RSBI: 58\n SpO2: 94%\n ABG: 7.54/37/94./27/9\n PaO2 / FiO2: 313\n Physical Examination\n On exam she is not responsive, but is receiving propfol. Pupils are\n symmetric and reactive and brainstem reflexes intact. There are no\n cutaneous rashes but there are tatoos. Lungs are clear. Heart is\n regular with an S4, and a murmur that sounds mitral. Abdomen is soft.\n Labs / Radiology\n 179 K/uL\n 44.8 %\n 15.9 g/dL\n 120 mg/dL\n 0.7 mg/dL\n 14 mg/dL\n 27 mEq/L\n 95 mEq/L\n 2.9 mEq/L\n 136 mEq/L\n 15.6 K/uL\n [image002.jpg]\n 06:36 AM\n 09:32 AM\n 11:40 AM\n WBC\n 15.6\n Hct\n 44.8\n Plt\n 179\n Cr\n 0.7\n TC02\n 31\n 33\n Glucose\n 120\n Other labs: PT / PTT / INR:11.1/24.9/0.9, Ca++:8.4 mg/dL, Mg++:2.3\n mg/dL, PO4:3.3 mg/dL\n Fluid analysis / Other labs: see HPI for LP\n tox with methadone and barbiturates\n Imaging: CXR without infiltrate; (+) hyperinflation\n CT is interpreted as\nno acute intracranial process,\n but with the\n attending\ns final notes\nThe temporal horns appear slightly\n larger than on the prior study and there is questionable effacement of\n the sulci in the posterior fossa.\n Assessment and Plan\n 53 y/o woman with hypertension, agitation, mild hypothermia (in ED),\n mild leucocytosis, and elevated CSF protein and red cells. I suspect\n that the major differential diagnosis here is hypertensive\n encephalopathy (PRES), encephalitis (e.g. HSV), and subarachnoid\n hemorrhage (not seen on CT but caught via LP). The finding of elevated\n protein in the CSF suggests that this is a truly meaningful\n intracranial process rather than a red .\n We have adequately controlled her blood pressure (152/77), and will\n treat for potentially life-threatening infectious causes (acyclovir for\n potential HSV, ampicillin for listeria, and vanco/CTX for other\n bacteria). HSV encephalitis is certainly possible. I doubt bacterial\n meningitis, but her CSF could be consistent with a very early process.\n Would d/c ABX if cultures remain negative in a few days.\n I am more concerned about this being PRES or hemorrhage, and we will\n pursue urgent MRI for additional narrowing of the diagnosis. We will\n consult neurology given her prior complicated history.\n Her COPD does not appear to be playing a major role. We will continue\n inhaled steroids and her prednisone taper, but be watchful for need for\n stress dose steroids if electrolytes and hemodynamics decompensate.\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control: insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 07:21 AM\n 20 Gauge - 07:23 AM\n Comments:\n Prophylaxis:\n DVT: boots for now; SQH unless hemorrhage seen on MRI\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 55 min\n CRITICAL CARE STAFF ADDENDUM\n 2pm\n She has developed an intermittent but substantial cuff leak; chest\n x-ray confirmed ET in adequate placement, and cuff does not appear to\n have ruptured.\n By report, MRI in interpreted as showing substantial edema with a some\n uncal herniation, as well as a small amount of obstructive\n hydrocephalus (although ventricles do not look that large on my\n review).\n She has received mannitol.\n Her neurologic exam has been markedly fluctuating, ranging from the\n loss of responsiveness and of some brainstem reflexes (cough, gag,\n corneal) to having spontaneous purposeful movement.\n We have consulted neurology and neurosurgery.\n The most likely scenario appears to be PRES. Neurosurgery is\n recommending a ventriculostomy at this point.\n The neurosurgeon and I have discussed all of this in detail with\n patient\ns daughter, who is a neurosurgical PA.\n CCTime: 60 minutes\n" }, { "category": "Nursing/other", "chartdate": "2186-05-02 00:00:00.000", "description": "Report", "row_id": 1407154, "text": "Respiratory note:\nPt received from on AC 400/16/5. Pt remained on current mode through the night. Sx for scant amt of tan secretions. Pt starting to wake up. Good RSBI. Plan to wean pt to PS, will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-02 00:00:00.000", "description": "Report", "row_id": 1407155, "text": "***TSICU NURSING ADMISSION NOTE -0700***\n--please see carevue for exact data--\n\n53yo F w/ extensive PMH (see FHP) discharged from on s/p COPD flare, pt readmitted from ED w/ HA, altered MS, blurred vision & intubated for airway protection, pt also became combative prior to intubation. BP 237/75, HR 65, O2sat 95% RA. pt started on Nitro gtt. pt had one episode of brady to 30s. LP completed, bld cxs pending. pt to 4, MICU. MRI/Head CT--> hyperintense flair of parietoccipital regions, cerebellar edema, hydrocephyalus & early transtentorial & tonsillar herniation. increased changed in MS noted, R ventriculostomy placed, pt tx' to TSICU approx under Neuro Med.\n\n**see FHP for PMH/Preadmission MEDS**\n\n*ROS:\n\n*NEURO: pt sedated on Propofol gtt @ 30mcg/kg/min. R EVD, transduced 10@ tragus-- ICP >20, notify HO & open drain for to allow minimal drainage. ICP 14-24, CPP 29-58 (Aline waveform w/ fling, does not correlate w/ NBP or auscultated BP)--clear drainage noted. EVD site w/ staples, clean & dry, transparent dsg intact. pt does not communicate or follow commands. MAE's, withdraws to painful stim, =strength, move on bed. PERRLA-- 3-5mm, brisk. +cough, weak gag. no seizures or other neuro s/s noted. Mannitol ordered q6hrs & Keppra ordered q12. no c/o pain, pt appears comfortable. PRN Ativan available for breakthrough agitation.\n\n*CV: SR-ST, Frequent Ventricular Bigeminy & PVCs. HR 80s-110s. ABP 80s-140s. NBP 100-160s. (no correlation between cuff & ABP). SBP >160 w/ agitation. Goal SBP 140-160 per neuro med. +weak pedal pulses. PIV x4 for access, RR Aline w/ fling-- low diastolic pressures. compression sleeves for prophylaxis.\n\n*RESP: pt intubated. ETT (7.5), 23@lip. CMV 400/16/5. RR 20s. SaO2 96-100%. LS coarse/exp wheezes w/ dim bases bilaterally. minimal tan thick secretions. oral care provided per VAP protocol.\n\n*GI: pt NPO. SS OGT to LCWS. min bilious drainage. abdomen soft/slightly distended/nontender. +BS. -BM. PPI for prophylaxis.\n\n*GU: Foley, adequate amts light yellow urine. Mag & K repleted\n\n*ENDO: Humalog SS. min coverage needed.\n\n*ID: Tmax 99.5. pt on ampicillin, ceftriaxone, vanco & levofloxacin for prophylaxis.\n\n*SOCIAL: pts daughter in at start of shift. spoke w/ Neuro Med MDs-- all questions RE: pts status, prognosis & POC answered & understood.\n\n*PLAN: ?central line placement? cont to monitor hemodynamics, maintain SBP 140-160s. cont q1hr checks, assess for any changes in neuro exam. maintain ICPs <20, open to drain as needed. monitor control fld status, resp status, BS. assess for adequate pain control. cont to support pt & family.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-02 00:00:00.000", "description": "Report", "row_id": 1407156, "text": "nursing 0700-present\nEvents: Q 1 hr neuro checks, Changed to CPAP + PS and then back to CMV secondary to patient tachypneic and tachy. TF started. Tachy- HR 120's and then given 5mg IV lopressor- HR then to the 80's. Propofol 20-60mcg/kg/min. Ventriculostomy opened to continous drain.EEG done.\n\nROS:\n\nNeuro: neuro checks Q1hr. Sometimes opens eyes slightly to voice. Does not follow commands. Pulses weak 2+ bilaterally. Withdraws to pain in all extremities. MAE's. Ventriculostomy 10cm@tragus- opened to drain and draining clear CSF.EVD site with staples- intact no drainage to area noted- transparent dressing.ICP-'s- 20's with agitation from propofol-goes back down once propofol resumed. If ICP >20 notify HO. PERRL-3-6mm, brisk. +cough gag impaired. No seizures noted. mannitol and Keppra ordered. propofol gtt titrated from 20-60mcg/kg/min and now at 40mcg. CPP's ranging from 50's-100's.\n\nCVS: A line for most of the day not correlating with NIBP or ausculated BP- leak in pressure bag changed and now correlating better. CPP taken from NIBP. CPP 50-100's. SBP 90-160, DBP 60-90's. Pt becomes hypertensive when off propofol for neuro checks-SBP 190's. This am- ventricular bigeminy, and frequent PVC's- this afternoon Sinus Tachy with no PVC's noted. ABP 80-180's. 5mg Iv lopressor given for HR 125- after HR 87. Goal SBP 140-160. R A line, PIV x4. IV hydralazine sch.\n\nResp: weened to CPAP+PS tolerated well for a few hours and then patient became more tachypneic sats dropped to high 80's (88%) HR 130's. Pt placed back on CMV- 30% with 5 peep. ETT #7.5 23 @lip. RR-20-30's. Sats 88-97%. Oral care per VAP protocol. LS wheezy to clear upper bilat and diminished lower bilat. Suctioned for white-tan thick secretions. rotated ETT today.\n\nGI/GU: started replete with fiber @20- now at 40cc/hr with goal 80- increase Q4hrs- last increased 1800- 30cc water flushes Q8h. OGT. +BS. No BM. Abd soft/distended.IV PPI. Foley patent clear yellow. K- 3.3- 10 meq KCL given IV. Phosp-2.3 will give 15mmol IV.\n\nEndo: covered per Humalog SSI.\n\nID: t max 99.7- on IV ampicillin, ceftriaxone, vanco.\n\nSocial: daughter is a neruosurg PA, she and patient's boyfriend were here to visit.\n\nPlan: ween vent as tolerated. Ween propofol as tolerated. Monitor CPP, ICP, SBP, HR. Suction as needed. Neuro checks Q1hr. maintain SBP 140-160's, Provide emotional support for family. increase tubefeed to goal.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-02 00:00:00.000", "description": "Report", "row_id": 1407157, "text": "Respiratory Care Note\nPt received on AC. Pt weaned to PSV as noted. BS slightly coarse bilaterally. Pt suctioned for moderate amts thick, tan secretions. Pt was more tachypneic on PSV with RR in 30-35 - ABG on PSV revealed respiratory alkalosis with a PaO2 of 60. Pt placed on AC - follow up ABG on AC was unchanged except for PaO2 which is now 70. RR decreased to 25-28 on AC. Pt seems more comfortable. Plan to continue on current settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-03 00:00:00.000", "description": "Report", "row_id": 1407158, "text": "Respiratory Therapy\nPt presents orally intubated on full ventilatory support, tachypneic and tachycardic. BS clear throughout. ABG reveals a resp. alkalosis. Methedone resumed W good effect. RSBI 75 plan: wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-04 00:00:00.000", "description": "Report", "row_id": 1407163, "text": "T/SICU Nursing Progress Note\nS: \"will you help me? am I getting better?\"\nO: Review of systems\nNeuro: as shift progressed pt became much more interactive and brighter. Speaking coherently, asking about her health and what has happened to her. Able to state her name and hospital name. Follows commands with normal strength of arms and legs. Perrla. Continues on keppra without any obvious seizures. R sided ventriculostomy in place, leveled to 20cm at the tragus, continuously open. Drains small amount of clear straw colored CSF. Waveform sharp. ICP 9-15. Mannitol continues with last serum osmol 298. Initially on neo to keep cpp >60, currently off. On qd methadone.\nCVS: art line dampens (catheter kinks outside skin), neo weaned off and now sbp 120-140. Sinus rhythm, when pt asleep may fall to 40's.\nRESP: on 35% shovel mask with RR 16-20, coarse breath sounds, at times wheezes. Receiving albuterol and atrovent nebs. Congested productive cough of thick blood tinged yellow sputum. Sats 92-94%\nRENAL: Mannitol as above. K+low but pt not taking pos yet, has limited iv access with no central line so not repleted. Urine output 40-180cc/hr. Fluids kvo'd.\nGI: belly soft, +flatus. Tolerating sips of water this morning. On protonix for prophylaxis.\nHeme: hct 38, venodynes and sq heparin in use.\nID: on kefzol and acyclovir. t max 98.9.\nskin: R arm with reddness from previous infiltrated iv, otherwise intact.\nLINES: R Radial art line and two L arm peripheral ivs. To have PICC place this morning.\nSocial: no calls from family tonight.\nA: 53 year old woman s/p cerebral edema and encephalopathy, now with icp wnl and improving mental status. Limited iv access.\nP: continue to monitor neuro status. Advance diet today as tolerated. To have PICC placed. If stable, may be candidate for step down unit.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-04 00:00:00.000", "description": "Report", "row_id": 1407164, "text": "nursing 1200-present\nEvents: Given 10mg IV lasix this am. A line dc'd. Clear liquid diet advance to regular diet as tolerated.\n\nROS:\nNeuro: Pt A/OX3 MAE's indep. Follows commands. PERRL 4-6mm brisk. +cough. pulses weak bilaterally. Right EVD 20@tragus clamped- CSF clear. C/O HA x1 and given tylenol with good effect- pt sleeping now after it was given.ICP 5-14.\n\nCVS: HR 60-100's NSR-ST. no ectopy noted. BP 90-130's/40-70's. A febrile. PIV x2. Given 10 IV lasix today.\n\nResp: Pt on 35% face tent sats >93%. Pt has hx of sleep apnea and needs to wear CPAP at night when sleeping. Pt has own machine here. LS coarse upper bilat and diminished lower bilat.\n\nGI: BS present +flatus.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2186-05-04 00:00:00.000", "description": "Report", "row_id": 1407165, "text": "adddendum\nGI: tolerating clear liquids and does not want to eat anything else. IVF KVO.\nGU: 10mg IV lasix given today. Urine clear yellow.\nEndo: Covered per humalog SS.\nSocial: daughter is in neuro for . Boyfriend at bedside.\nPlan: tranfer to step down unit. Monitor VS. Maintain sats. Wear CPAP at night for sleep apnea. Respiratory notified about CPAP. D/C EVD . Get oob.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-04 00:00:00.000", "description": "Report", "row_id": 1407166, "text": "Respiratory Care:\nPt had a neb this AM and an MDI with A/A this eve. She is presently on HER personal BiPap machine and has been called out to neuro floor\nwith monitoring.. Otherwise she has been snoozing all day.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-03 00:00:00.000", "description": "Report", "row_id": 1407159, "text": "***TSICU NURSING PROGRESS NOTE 7A-7P***\n--please see carevue for exact data--\n\n*EVENTS: pt tachypneic 38, tachy 120s, SBP 170s @ appprox 2115-->ABG sent, resp alk (no significant changes from previous ABGs, ABG 0530 improved-->7.47, 35, 86). CXR obtained-->improvement from admission XR MD . Fentanyl given x1 w/ effect, PRN Fentanyl ordered.\n\n*ROS:\n\n*NEURO: pt sedated on Propofol @ 30mcg/kg.min. R EVD, site WNL, 10 @ tragus, open to drain w/ clear drainage, 0-20cc/hr. CPP 60s-90s (NBP MAPs followed). ICP 4-7. pt not communicating, will open eyes to voice/stim. does not follow commands, MAE's on bed, localizes/ withdraws to painful stim. impaired gag, strong cough. PERRLA, 2-6mm, brisk. +corneals. no seizures or other s/s noted. pt cont's on Keppra & Mannitol. PRN Ativan & Fentanyl available for agitation/pain.\n\n*CV: NSR-ST. HR 80s-110s. NBP 90s-103s/50-70s. 10mg IV lopressor ordered q4hrs. +weak pedal pulses. skin warm/dry/intact. compression sleeves for prophylaxis. PIV x4 for access. R Radial Aline WNL.\n\n*RESP: pt intubated. ETT (7.5) 23 @ lip. CMV 400/16/5/40%. RR 20s-30s. SaO2 95-85%. LS coarse-clr bilaterally. minimal white thin secretions. oral care provided per VAP protocol.\n\n*GI: pt w/ OGT. TF @ goal 80cc/hr. min residuals. abdomen softly distended/nontender. +BS. -BM. PPI for prophylaxis.\n\n*GU: Foley, adq amts light yellow urine. NS KVO. K & Phos repleted.\n\n*ENDO: Humalog SS. min coverage needed\n\n*ID: Tmax 99.5. pt conts on vanco, ceftriaxone & ampicillin for prophylaxis\n\n*SOCIAL: no family contact overnight\n\n*PLAN: cont q1hr neuro checks, ICP monitoring & assess for any changes in neuro exam. ?CPAP & PS w/ stable hemodynamics, resp status?--RSBI 75. ?bowel regimen? assess for adequate pain control/comfort--?begin home methadone regimen?? cont to monitor/control hemodynamics, resp status, BS. titrate propofol gtt to approp sedation. cont to support pt & family.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-03 00:00:00.000", "description": "Report", "row_id": 1407160, "text": "nursing 0700-present\nEvents: R EVD clamped this am 10@ tragus, then this afternoon 20@tragus and unclamped.CT of head done. KCL repleted- 40mep PO for K3.6. Propofol turned stopped at 1600 for extubation. BP low SBP 80's- after staring patient back on methadone- Started on a Neo drip. Neuro checks changed to Q2hrs. Resp weened to CPAP and then extuabted.IV abx dc'd except acyclovir. Metroprolol switched to PO.\nROS:\nNeuro: Pt Q2hr neuro checks. While on propofol following commands but inconsistently. Opening eyes to voice. Impaired gag and intact cough. Propofol shut off at 1300 and kept off secondary to patient started methadone and BP dropped to SBP 80's. MAE's. R EVD 20@tragus and draining- CSF clear. Now extubated pt follows commands and nods yes or no to questions. PERRL 3-6mm brisk bialterally. CPP 48-87. CPP 48 MD Dr. into see patient and started on Neo gtt. ICP-. No seizures noted.\n\nCVS: HR- 50-100's NSR, SB,ST. No ectopy noted BP 80-120's/40-70's. BP dropped to 80's and CPP dropped at 1300 PT started on Neo gtt now currently @ 1mcg/kg/min. Was ranging from 1.5-1.8mcg/kg/min. Metoprolol switched to PO- held for Decreased BP. K repleted 40mep KCl PO. R rad A line WNL. PIV x3. P boots for prophylaxsis. Weak pulses 2+ bilaterally.\n\nResp: Weened to CPAP and then extubated at 1800. Now on 35% face tent. BS clear upper bilat, and dimin lower bilat. Suctioned for thin white secretions.\n\nGI: Replete with fiber at goal 80cc/hr. No residuals. Abd soft distended. +BS. Started on BM meds today. OGT dc'd. -BM. PPI for prophylaxsis. positive flatus.\n\nGU: foley patent and draining clear yellow urine. NS KVO,\n\nEndo: covered with Humalog SS.\n\nID: t max 100.4. All IV abx dc'd except Acyclovir. will start cefazolin tonight for EVD drain.\n\nSocial: daughter and here to visit today. daughter talked to neurology team.\n\nPlan; Monitor respiratory status. Monitor BP, CPP, ICP, sats. Continue bowel regimen. Continue to provide emotional support to patient and family. q 2 hour neuro checks.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-03 00:00:00.000", "description": "Report", "row_id": 1407161, "text": "Respiratory Care Note\nPt received on AC as noted. BS diminished throughout. Pt suctioned for small amts of thick secretions. Pt weaned to PSV 5/5 - Pt tolerated well with VT ranges 500-600 and RR in the teens. Subglottic suctioning done prior to extubation. Pt extubated to cool aerosol without incident.\n" }, { "category": "Nursing/other", "chartdate": "2186-05-04 00:00:00.000", "description": "Report", "row_id": 1407162, "text": "Respiratory Therapy\nPt presents on .35 cool aerosol FT. BS end expiratory wheezes on rt, crackles Lt base which progressed to coarse rhonchi. Pt able to clear W SPC, Nebs given, No significant change in BS.\n" } ]

[ { "category": "Echo", "chartdate": "2136-11-28 00:00:00.000", "description": "Report", "row_id": 70850, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Pre cardioversion\nHeight: (in) 72\nWeight (lb): 220\nBSA (m2): 2.22 m2\nBP (mm Hg): 132/79\nStatus: Inpatient\nDate/Time: at 13:50\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild spontaneous echo contrast is seen in the body of the left\natrium. No mass/thrombus is seen in the left atrium or left atrial appendage.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus is seen in the right\natrium or right atrial appendage. A left-to-right shunt across the interatrial\nseptum is seen at rest.\n\nLEFT VENTRICLE: LV systolic function appears depressed.\n\nAORTA: There are simple atheroma in the aortic arch. There are simple atheroma\nin the descending thoracic aorta.\n\nAORTIC VALVE: A bioprosthetic aortic valve prosthesis is present. The\nprosthetic aortic leaflets appear normal No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications.\n\nConclusions:\nMild spontaneous echo contrast is seen in the body of the left atrium. No\nmass/thrombus is seen in the left atrium or left atrial appendage. No mass or\nthrombus is seen in the right atrium or right atrial appendage. A\nleft-to-right shunt across the interatrial septum is seen at rest through the\nflap of the fossa ovalis consistent with the presence of a PFO/ASD. LV\nsystolic function appears at least mildly depressed (segmental function not\nfully assessed). There are simple atheroma in the aortic arch. There are\nsimple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve\nprosthesis is present. The prosthetic aortic leaflets appear normal No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-22 00:00:00.000", "description": "Report", "row_id": 1598962, "text": "CSRU Admission Note\nS/O: 64 yo male s/p R suboccipital revision craniotomy with microvascular decompression .\n PMH: Noted to be in a flutter on EKG , also preop .\n IMI \n CABG X 4 \n Redo CABG X 6 and bovine AVR \n HTN\n High chol\n Gout\n Trigeminal neuralgia\n 60 pk yr smoker, quit X 20 yrs\n glasses of wine/day\n Allergies: NKDA\n Meds: Lasix 40 qd, celebrex 200 qd, prednisone 1 qd, zestril 10 qd, allopurinol 500 qd, metoprolol 25 , asa 325 qd, trazadone 50 qd, tegretol 200 tid.\n Social: Lives with wife on farm.\n OR Course: 3 episodes AF 150 rx with lopressor 1 mg each time, then HR to 40s. On IV NTG.\n ROS: Neuro: Intact. C/O headache incisional at first, then more generalized (pt states from NTG). Med with MSO4 2 mg IV, then 6 mg SQ with some relief and tylenol 650 mg po.\n CV: AFlutter as fast as 110 on admission rx with esmolol 50 mg and lopressor 2 mg IV. Pt c/o chest pain , NTG increased to 1.5 mcg/kg and pt given .4 NTG sl x2. Also given lopressor 25 mg po. A flutter slowed to 70s with occl pvcs. BP 130-150. NTG increased to as high as 4 mcg/kg with little change in chest pain, but significant worsening of headache (22/10). NTG decreased to 2 mcg/kg with chest pain down to 2/10, and headache to . Mg repleted. First CPK 61, troponin <.3.\n Resp: Dry face mask changed to 4lNP with SAO2 95-98%, RR 12-20, clear BS.\n Renal: UO 40/hr on RL 85/hr. BUN/Cr 22/1, K 4.1, ICa 1.13.\n Heme: Hct 38.\n ID: Temp 97. Oxacillin for 4 postop doses.\n GI: NPO except for meds. On zantac IV.\n Endo: Glu 172.\n Skin: Intact.\n Family: Wife in to visit.\nA: Remains in a flutter. Chest pain resolving.\nP: Cont IV NTG as tol by pt. Keep vent response < 80. Analgesia for head and chestpain. Follow enzymes and ekgs. Neuro checks. Anticoagulation and chem or elec conversion when appropriate postop.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-23 00:00:00.000", "description": "Report", "row_id": 1598963, "text": "CSRU Progress\nS/O: Neuro: Intact. Headache .\n CV: HR 70-90 Aflutter with PVCs, occasional bursts to 110. No further lopressor given. BP as low as 80/45, now 120/65. NTG up to 4 mcg/kg with severe headache. Off when BP low. Now at .25 mcg/kg. CPK 71.\n Resp: RR 16, clear BS, SAO2 97% on 4lnp.\n Renal: UO 40/hr.\n Heme: Pneumoboots.\n ID: T100, on oxacillin.\n GI: Sips of water.\n Endo: Glu 120s.\n Skin: Intact.\nA: Chest pain improved. Remains in A flutter.\nP: Rate control, transfer to floor, increase activity. ?when can be anticoagulated for chem or elec conversion.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-23 00:00:00.000", "description": "Report", "row_id": 1598964, "text": "transfer note\nsee icu assessment sheet for past/present medical hx., vs range in icu today = t 100.4, p 79-93, bp 120/65-150/73, r 18-20, cardiac: pt in a -flutter with occasional pvc's, c/o mild cp this am x 2 tx with 2 mg iv mso4 x 1 with relief for each episode, cardiology in and aware, ekg done, pt on low dose iv ntg gtt(26 mic/min) due to c/o headache from ntg, cp tx with iv mso4 and no sl ntg or increasing gtt, ck/troponin sent at 1100, prior ck/troponin negative for mi, respiratory: bs + all lobes and clear with slight crackles to bases, 20 mg iv lasix given this am at 1100, on 2 l np, sats 94-98, no c/o sob, gi: dat tol fair, no stool, c/o nausea at 1230-tx with 2 mg iv zofran, gu: foley cath dc'd at 0930, dtv by 1730, uo adequate prior to foley being dc'd, dry wt = 96.4 kg, today's wt = 100.1 kg, neuro: perl, oriented x 3, following commands, moving all extremities, head dsg d&i with sm amt old bloody drainage, other: venodyne bts on, ha tx with po tylenol x 2, labs from = hct 38, k 4.1, bs 172, bun 22, cr 1.0, L periph iv LR at 5 cc/hr with iv ntg gtt\n" }, { "category": "ECG", "chartdate": "2136-11-29 00:00:00.000", "description": "Report", "row_id": 160154, "text": "Sinus tachycardia. Left atrial abnormality. Intraventricular conduction delay.\nST segment depressions in leads I, aVL and V5-V6 consistent with possible\nanterolateral ischemia. Compared to the previous tracing the junctional escape\nrhythm is no longer present.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2136-11-29 00:00:00.000", "description": "Report", "row_id": 160155, "text": "Probable junctional escape with occasional premature ventricular contractions.\nUnderlying right bundle-branch block pattern. Compared to the previous tracing\nthe escape rhythm is new and sinus rhythm is no longer present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-11-23 00:00:00.000", "description": "Report", "row_id": 160387, "text": "Underlying atrial flutter with 4:1 A-V conduction and occsaional ventricular\npremature contractions. Compared to tracing #1 the ventricular rate has slowed.\nNo other diagnostic interval changes.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-11-22 00:00:00.000", "description": "Report", "row_id": 160388, "text": "Atrial flutter with variable block, average ventricular response rate 96.\nQS deflections in leads VI-V3 consistent with previous anterior myocardial\ninfarction. Frequent ventricular premature beats. Compared to the previous\ntracing of the rate has increased and the ventricular premature beats\nare new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2136-11-22 00:00:00.000", "description": "Report", "row_id": 160389, "text": "Atrial flutter with 4:1 A-V conduction. Since the previous tracing of \nventricular ectopy is no longer seen, but no other changes have occurred. Old\ninferior and anteroseptal myocardial infarctions and voltage criteria for left\nventricular hypertrophy persist.\n\n" }, { "category": "ECG", "chartdate": "2136-11-29 00:00:00.000", "description": "Report", "row_id": 160382, "text": "Normal sinus rhythm. Intraventricular conduction delay. Q waves in\nleads III and aVF consistent with previous inferior myocardial infarction.\nPoor R wave progression. Probable previous anterior myocardial infarction.\nCompared to the previous tracing of atrial flutter is no longer\npresent. Otherwise, no diagnostic interim change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2136-11-26 00:00:00.000", "description": "Report", "row_id": 160383, "text": "Atrial flutter with variable block with occasional ventricular premature beats.\nCompared to the previous tracing of , there has been no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2136-11-25 00:00:00.000", "description": "Report", "row_id": 160384, "text": "Atrial flutter\n - premature ventricular contractions\nProbable inferior infarct - age undetermined\nIntraventricular conduction delay\nPoor R wave progression\nSince last ECG, no significant change\n\n" }, { "category": "ECG", "chartdate": "2136-11-24 00:00:00.000", "description": "Report", "row_id": 160385, "text": "Atrial flutter. Compared to the previous tracing no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2136-11-23 00:00:00.000", "description": "Report", "row_id": 160386, "text": "Atrial flutter. Frequent ventricular premature beats. Compared to the previous\ntracing of ventricular response to atrial flutter has increased.\nInferior myocardial infarction pattern persists of undetermined age.\nVentricular ectopy is of the same patterning.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2136-11-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 746903, "text": " 5:28 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate parenchyma. baseline CXR for amiodarone ini\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD, s/p craniotomy, AFlutter, s/p cardioversion.\n Currently being started on amiodarone.\n REASON FOR THIS EXAMINATION:\n please evaluate parenchyma. baseline CXR for amiodarone initiation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of coronary artery disease, A-flutter, status post\n cardioversion, status post craniotomy, currently started on Amiodarone.\n Baseline chest xray for Amiodarone.\n\n PA and lateral views of the chest demonstrate post mediansternotomy changes.\n The heart is slightly enlarged. The mediastinal silhouette is unremarkable.\n Linear opacities are seen in the left lung base, likely representing scarring\n or linear atelectasis. No consolidation is seen. No pulmonary nodule or\n interstitial markings is noted. There is no pleural effusion or pneumothorax.\n The visualized bony and soft tissue structures are unremarkable.\n\n IMPRESSION: Small area of scarring and/or linear atelectasis in the left lung\n base, otherwise clear lungs. Mild cardiomegaly. Status post mediansternotomy.\n\n" }, { "category": "Radiology", "chartdate": "2136-11-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 746565, "text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest pain, mild fever\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with CAD, s/p craniotomy\n REASON FOR THIS EXAMINATION:\n chest pain, mild fever\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST:\n\n CLINICAL INDICATION: Fever and chest pain following craniotomy procedure.\n\n The patient has had previous medial sternotomy and valve replacement\n procedure. The heart is upper limit of normal in size for technique. Low\n lung volumes accentuate the pulmonary vascularity. There are patchy and\n linear bibasilar opacities. No pleural effusion or pneumothorax is evident on\n this single projection.\n\n IMPRESSION: 1) Patchy and linear basilar opacities, probably due to\n atelectasis in a recently post operative patient. Aspiration is not excluded\n in the appropriate clinical setting.\n\n 2) Difficulty assessing cardiovascular status of the patient due to low lung\n volumes. Repeat radiograph with improved lung volumes may be helpful to\n better assess pulmonary vascularity.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2110-06-10 00:00:00.000", "description": "Report", "row_id": 1578243, "text": "See ICU admission history.\n\n76 year old female S/P angioplasty/stenting X2 of left SFA admitted from the cath lab holding area. Pt tolerated procedure well but in holding area became hypotensive to 70's systolic. Responded to 1.5L IVF and to CT SCAN stat which demonstrated retroperitoneal bleed. HCT 30. Pt asymptomatic aside hypotension. Received 300 mg plavix in CCL.\nALso, had 6 hours of IV NA Bicarb gtt in holding area.\nArrives denying back pain,CP/SOB. Right groin clean and dry. Lower extremities warm with + doppler pulses.\nNSR with non-labile cuff BP.\nO2 at 4L. + gag + cough\nTaking po liquids. Refusing solid food at this time \"I am not hungry\".\n\nAdmit to ICU for serial HCTS. Next due at 2100.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2110-06-11 00:00:00.000", "description": "Report", "row_id": 1578244, "text": "NURSING\n VSS OVERNIGHT. AFEBRILE. TWO TRANSIENT DROPS IN SBP TO 89 WHILE ASLEEP, WHEN AWAKE SBP IMMEDIATELY ROSE TO >100 SYSTOLIC. HCT DROPPED TO 25 OVERNIGHT, TEAM AWARE, TREATED WITH I UNIT RBC'S. POST TRANSFUSION HCT TO BE DRAWN AT 0600.\n POSITIVE LOWER EXTRTEMITY PULSES VERY WEAK, ABLE TO PALPATE. FEMORAL SITE CLEAN, DRY, INTACT. NO CHANGE OVERNIGHT. LOWER ABDOMEN SOFTLY DISTENDED, TENDER TO PALPATION. NO COMPLAINTS OF PAIN UNLESS ABDOMEN IS BEING PALPATED FIRMLY.\n REFUSED PO MEDS LAST NIGHT, SAYING \"I'LL TAKE THEM TOMORROW, I JUST WANT TO SLEEP.\" ALSO REFUSED TO GET WASHED UP UNTILL TODAY.\n POST TRANSFUSION HCT AT 0600. CONTINUE Q 4/HR HCTS UNTILL TEAM ORDERS CHANGE. MONITER HEMODYNAMICS.\n" }, { "category": "Nursing/other", "chartdate": "2110-06-11 00:00:00.000", "description": "Report", "row_id": 1578245, "text": "7a-7p\nsee transfer note\n" }, { "category": "ECG", "chartdate": "2110-06-10 00:00:00.000", "description": "Report", "row_id": 191230, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2110-06-10 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 916763, "text": " 2:55 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: R/O retroperitoneal bleeed. No contrast\n Field of view: 33\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with recent RT CFA puncture, peripheral angio/intervention.\n Hypotensive, painful RT groin. Pt in cardiac cath lab holding area \n REASON FOR THIS EXAMINATION:\n R/O retroperitoneal bleeed. No contrast\n CONTRAINDICATIONS for IV CONTRAST:\n recent angio\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Peripheral angiography via right common femoral artery approach,\n now hypotensive with painful right groin.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the abdomen and pelvis.\n\n CT OF THE ABDOMEN: There are emphysematous changes of the lung bases with\n superimposed atelectasis and scarring. The visualized pericardium appears\n unremarkable. Extensive coronary artery calcifications are identified. Non-\n contrast examination limits assessment of the abdominal organs. The liver,\n adrenal glands, spleen, and pancreas appear unremarkable. Gallstones are seen\n within the gallbladder lumen without evidence of gallbladder wall edema or\n pericholecystic fluid. The kidneys appear symmetric without hydronephrosis.\n Contrast is seen within the collecting systems bilaterally, consistent with\n recent angiography. A 1.3-cm hypodensity in the left kidney is incompletely\n characterized. The loops of small and large bowel appear normal in caliber.\n There is extensive atherosclerosis of the abdominal aorta and its major\n branches. No free air or free fluid is seen within the abdomen. There is some\n nonspecific perinephric stranding. No obvious mesenteric or retroperitoneal\n lymphadenopathy is identified.\n\n CT OF THE PELVIS: There is a large right-sided retroperitoneal hematoma\n measuring at least 9.2 x 6.4 cm, causing mass effect on the bladder. A Foley\n catheter is seen within the bladder lumen. The uterus and rectum appear\n unremarkable. Bilateral common iliac stents are identified. The lack of\n intravenous contrast prevents the assessment of possible active extravasation\n into the hematoma.\n\n The osseous structures demonstrate healed fractures of the inferior pubic rami\n bilaterally. Degenerative change of the spine is identified.\n\n IMPRESSION:\n 1. Large right-sided retroperitoneal hematoma.\n 2. Cholelithiasis.\n 3. Emphysematous change of the lung bases.\n\n Findings discussed with the clinical team caring for the patient.\n (Over)\n\n 2:55 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: R/O retroperitoneal bleeed. No contrast\n Field of view: 33\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" } ]

[ { "category": "Radiology", "chartdate": "2125-03-07 00:00:00.000", "description": "EMBO TRANSCRANIAL", "row_id": 821439, "text": " 8:07 AM\n CAROT/CEREB Clip # \n Reason: SAME DAY SURGERY. START TIME 12:30. Coil embolization of a\n Contrast: OPTIRAY Amt: 229\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL TRANSCATH PLCT STENTS, INITIAL *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY TRANSCATH INTRO STENT *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with a right internal carotid artery aneurysm.\n REASON FOR THIS EXAMINATION:\n SAME DAY SURGERY. START TIME 12:30. Coil embolization of a right ICA\n aneurysm.\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Previously clipped left internal carotid artery\n ophthalmic aneurysm and untreated inferiorly pointing left internal carotid\n artery paraclinoid aneurysm and untreated right internal carotid artery medial\n hypophyseal aneurysm.\n\n POSTOPERATIVE DIAGNOSIS: Same status post stent-mediated coil embolization of\n the left internal carotid artery paraclinoid inferiorly pointing aneurysm and\n evidence of small recurrence at the neck of the previously clipped aneurysm of\n the left internal carotid artery ophthalmic aneurysm and unchanged appearance\n of the right internal carotid artery medial hypophyseal aneurysm.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Ms. is a patient who has had intractable headaches and\n cervical pain. She was noted to multiple intracranial aneurysms and has\n previously undergone surgical clipping of her left internal carotid artery\n ophthalmic aneurysm. She had a more proximally located inferiorly pointing\n aneurysm which could not be visualized at the time of surgery. Accordingly she\n is undergoing this procedure in an attempt to treat the aneurysm using a\n Neuroform stent-mediated coil embolization given the wide neck of the\n aneurysm.\n\n CONSENT: The patient and her husband was given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient and her husband understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The left and right groin areas were\n (Over)\n\n 8:07 AM\n CAROT/CEREB Clip # \n Reason: SAME DAY SURGERY. START TIME 12:30. Coil embolization of a\n Contrast: OPTIRAY Amt: 229\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prepped and draped in the usual sterile fashion. A 19-gauge single-wall needle\n was then used to puncture the right and left common femoral arteries, and upon\n the return of brisk arterial blood, a 5 Fr vascular sheath was inserted over a\n guidewire and kept on a heparinized saline drip. Next, a diagnostic catheter\n was used to selectively catheterize the following vessels: right common\n carotid artery, right internal carotid artery, left common carotid artery, and\n left internal carotid artery. At this point injection of the bilateral common\n carotid arteries showed no evidence of dissection or injury in the carotid\n bifurcation in the neck. Injection of the right internal carotid artery showed\n unchanged appearance of the previously visualized 4 mm aneurysm in the\n supraepophyseal location. Injection of the left internal carotid artery showed\n that the previously clipped aneurysm at the left internal carotid artery\n ophthalmic origin which had previously been shown on postsurgical angiography\n to no residual had developed a 1.5 mm shelf of raised neck consistent\n with recurrence of the neck. There is no aneurysm filling of the dome and the\n ophthalmic artery remains patent. Evaluation of the inferiorly pointing\n aneurysm across from the previously coiled aneurysm revealed it to be\n approximately 4 mm and to a small daughter aneurysm. Accordingly this\n was chosen as the target aneurysm for treatment rather than the contralateral\n right one. At this point two 5 Fr guidecatheters were placed into the left\n internal carotid artery origin. Through one an SL-10 microcatheter was used to\n selectively catheterize the aneurysm after it had been appropriately steam\n shaped over a wire. Then the second guidecather was used to advance the\n Neuroform stent over the Accelerator 14 wire. As the wire was placed distally\n into an M-3 middle cerebral artery branch the stent was deployed\n intracranially across the neck of the aneurysm. This enabled jailing of the\n microcatheter in position inside the aneurysm under the stent. This enabled us\n to deploy coils into the aneurysm neck. At this point the microcatheter was\n withdrawn from the aneurysm. Angiograht was performed after each of the coil\n deployments and a series of angiographic runs were performed in a single plane\n and biplane angiographic views after the microcatheter was removed from the\n aneurysm. These showed excellent results with no evidence of distal branch\n occlusion.\n\n IMPRESSION: Left internal carotid artery inferiorly pointing aneurysm status\n post GDC coil embolization with help of a Neuroform stent.\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2125-03-07 00:00:00.000", "description": "Report", "row_id": 152413, "text": "Sinus arrhythmia.\nNormal ECG\nSince previous tracing of , no significant change\n\n" } ]

[ { "category": "Radiology", "chartdate": "2114-07-02 00:00:00.000", "description": "PERSANTINE MIBI", "row_id": 835324, "text": "PERSANTINE MIBI Clip # \n Reason: 46 Y/O MAN WITH DIABETES, CHRONIC RENAL INSUFFICIENCY AND NSTEMI ONE WEEK AGO.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Forty-six year old man with diabetes, chronic renal insufficiency and\n NSTEMI one week ago.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\n administered IV.\n\n INTERPRETATION:\n Image Protocol: Gated SPECT.\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress images show enlargement of the LV cavity. At stress, there are no\n myocardial perfusion defects identified. Resting perfusion images show slight\n enlargement of LV cavity, but less prominent than at stress. At rest, there are\n no myocardial perfusion defects identified.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Dipyridamole administration is 55%. Wall motion is normal.\n\n As compared to prior exercise MIBI dated , the enlargement of the LV\n cavity is slightly more prominent today.\n\n IMPRESSION: 1) No myocardial perfusion defects. EF of 55%. 2) Enlargement of\n the LV cavity is worse at stress than at rest and may represent balanced three\n vessel ischemia or other type of cardiomyopathy. Enlargement of the LV cavity\n during stress is slightly more pronounced than on the prior study.\n /nkg\n\n\n , M.D.\n , M.D. Approved: 9:57 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "ECG", "chartdate": "2114-07-03 00:00:00.000", "description": "Report", "row_id": 196208, "text": "Sinus rhythm. Left atrial enlargement. Left ventricular hypertrophy. Delayed\nperecordial R wave progression. There is likely variation in the precordial\nlead placement as compared to the previous tracing of and no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2114-07-01 00:00:00.000", "description": "Report", "row_id": 196209, "text": "Sinus rhythm. Left atrial enlargement. Left ventricular hypertrophy.\nNon-specific ST segment abnormalities. Slight Q-T interval prolongation, new\ncompared to the previous tracing of . In addition, the rate has slowed.\nOtherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2114-06-29 00:00:00.000", "description": "Report", "row_id": 196210, "text": "Sinus rhythm. Left atrial enlargement. Non-specific inferior T wave changes.\nLeft ventricular hypertrophy by voltage. U waves are present. Compared to the\nprevious tracing ST-T wave changes are less.\n\n" }, { "category": "Nursing/other", "chartdate": "2114-06-26 00:00:00.000", "description": "Report", "row_id": 1377813, "text": "Nursing Admit/Progress Note 1800-1900\nThis 46yo man with hx uncontrolled HTN, CHF, CRI, Addison's, IDDM/DKA, Troponin leaks. He presented to EW @ 1100 with C/O malaise with N/V X 2 days. Glucose 422 and pt started on Insulin qtts. When gap decreased, attempted to control glucose with sliding scale without success. Gap widened (FS 496 after lunch ) and insulin qtts restarted. Pt also noted to have EKG changes on admit in ant/lat leads, with Troponin .69, MB/CK 93. Pt given Integrelin and started on Heparin qtts. Following PTT > 150 and Heparin stopped, with repeat PTT pending.\n\nReview of Systems:\nNeuro: AAO X 3, MAEE, transferring stretcher-> bed without assist. Pt denies pain.\nResp: Sating 100% on 2l NC, RR 21 and regular. Lungs clear.\nCV: HR 65-75SR without ectopy. BP 120-140/70's. Rec'ing NS @ 125ml/hr.\nGI: Bowel snds present, abd soft. Pt states appetite is good.\nEndo: Insulin qtts initially @ 4u/hr, increased to 8u/hr with FSG 469.\nGU: Pt has not voided since admit to unit.\nSocial: Pt lives alone and gives sister-in-law as closest relative. Valuables locked in unit safe and pt given receipt.\nPlan: Cont to closely monitor glucose levels, titrating insulin approp. ? restart Heparin qtts.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-27 00:00:00.000", "description": "Report", "row_id": 1377814, "text": "NPN 1900-0700\nAssumed care of pt at , pt sitting on edge of bed voices no c/o's. Pt is A/Ox3, please refer to carevue flowsheet for complete and ongoing assessment. Exam as follows:\n\nNERUO: Pt is A/Ox3, moves all extremities. Pt able to assist himself from the bed to the chair. Pupils are equal and reactive and strength is equal to all 4 extremities. Pt able to voice his needs.\n\nRESP: Lungs are clear bilat. Pt requesting O2 to be removed during the night. Pts sats greater than 97% after removal. Bilat chest expansion noted. Pt with occasional cough, non-productive.\n\nCV: Monitor reveals NSR- w/o ectopy. Pt slight hypertensivex2 BP cycles but normalizes once pt is relaxed in the bed. Pt on po HTN meds. PIVx3 are patent. Pt has 2+ pedal edema, states his last dose of lasix was on Sunday. Pt started on a Heparin drip at 0300. Will monitor PTT closely. Pt afebrile during the night.\n\nGI: Abd is soft and nondistended. Pt taking po well. Ate 80% of dinner and drinking diet gingerale w/o problem. Pt is NPO this am for possible procedure. No BM during the night. + bowel sounds heard to all 4 quads. Pt remains on an insulin drip. During the night, FSBS in the 60's and drip was turned off for one hour but restarted and infusing at rate according to carevue.\n\nGU: Pt able to stand at edge of bed and voids in the urinal w/o difficulty. Pt voiding in good amts.\n\nSKIN: grossly intact, pt with edema to legs\n\n\nPlan: Cont to monitor FSBS every hour and adjust insulin drip as needed. Cont to monitor PTT every 6 hours and adjust heparin as per protocol. cont to follow electrolytes. Pt may go for a cardiac cath once blood sugars are better controlled.\n\nSOCIAL: No calls or contact with family or friends during the night.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-27 00:00:00.000", "description": "Report", "row_id": 1377815, "text": "Nursing Progress note 0700-1900\nReview of Systems:\n\nNeuro: AAO X 3, moving independently btwn bed and chair without difficulty. No C/O pain, dizziness or weakness. Pt appropriate and pleasant.\n\nResp: Sating 99% on RA with RR 13-25 and regular. Lungs clear.\n\nCV: HR 59-72SR with rare PVC's. SBP in AM > 200. Nifedipine started @ 0800 and Hydralazine increased from 50->75mg Q6hrs with BP trending down to BP 118/71 @ 1700. Ptt from 0600 31.3, so Heparin increased to 1200u/hr after bolus of 1100u per protocol. Repeat PTT @ 1400 150, so Heparin stopped X 1hr and then restarted @ 800u/hr per protocol. Next PTT to be drawn @ 2300 tonight.\n\nGI: Pt with good appetite. Bowel snds present, no BM since admit. Pt to be NPO after MN for ? cardiac cath in AM.\n\nEndo: Insulin qtts to be titrated to off, while insulin sliding scale started @ noon. Pt rec'd 2u Humalog @ 1200. FSG @ 1600 68 and Insulin qtts stopped and pt given OJ. At 1500 FSG 121. At 1800 FSG 201(after just eating dinner) and pt given Humalog 4u.\n\nGU: Pt voiding yellow/clear urine without difficulty. However, fluid balance MN->1700 +2.3liters, and LOS balance 3480ml. Pt with 2+ edema bilat in lower extremeties. Pt rec'ing D5 .45NS @ 125ml/hr cont IV.\n\nSocial: Pt speaking with several friends by phone, no visitors. Pt voicing anxiety re ? cardiac cath and possible dialyzing.\n\nPlan: Repeat PTT @ 2300. Cont freq finger stick glucose levels. Attempt to maintain glucose levels within target range via sliding scale. NPO after MN for ? cardiac cath in AM.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377816, "text": "NPN 1900-0700\nAssumed care of pt at 1900. Pt sitting up in a chair and has finished eating his dinner. Pt voices no c/o's. Please refer to carevue flowsheet for complete and ongoing assessment. Exam as follows:\n\nNeuro: Pt A/Ox3, very pleasant and cooperative with cares. Pt independently moving from bed to chair and back to bed. Pt able to control his IV's and monitor cables with transfer. Pt denies pain or dizziness. Pupils are equal and reactive.\n\nResp: Lungs are clear thru-out with bilat equal breath sounds. Pt remains on room air with good O2 sats.\n\nCV: Monitor reveals NSR-Sbrady most of the night w/o ectopy. SBP better controlled during this shift. Pts SBP was in the 90's for a couple of hours. Pts HTN meds were increased plus he received his nifedipine starting on which he normally takes. With the 0400 and 2200 dose of Hydralazine, nurse opted to give 50mg vs 75mg like he was on previous shift vs. holding the whole dose. Pts BP has remained stable and within limits. Pt conts on Heparin drip. Drip was increase to 1100units/hr and PTT was sent at 0600 today. Will adjust accordingly. Feet remain with edema. Pt afebrile during the night.\n\nGI: Abd is soft round and nontender. +Bs heard to all 4 quads. Pt NPO this am for possible procedure. NO BM since admission, but pt does not feel the need to go. Pt had to be restarted on his insulin drip. Pts blood sugars are very labile. Earlier in the shift they were in the 400's and following protocol drip was titrated, but this am blood sugar was 64 but pt denies any symptoms. Insulin drip was turned off.\n\nGU: Pt voids easily in the urinal w/o difficulty. Pt drinking po well. Pt is positive on the fluid side, team aware. He usually takes lasix but has not received any during admission.\n\nSocial; Pt talks to many friends on the phone. Pt is very anxious about having cardiac cath done. At current, pt wishes to get his blood sugars under better control and have the cath done after . Pt is afraid of the outcome regarding his kidneys.\n\nPlan: cont with finger sticks, Monitor PTT and adjust heparin drip accordingly. Allow pt to vent his concerns.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377817, "text": "Blood sugar\nBlood sugar at 0700 is 59, pt is not sweating and only c/o's of feeling weak. Pt given po fluids with good results.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377818, "text": "MICU A Nursing Progress Note\n\nPlease see carevue and nursing transfer note for all objective data and review of systems. Essentially, insulin gtt restarted briefly this AM and then dc'ed at 1100. IVF dc'ed and pt. is taking a renal/ diet without difficulty. Initially covered with 4u regular insulin at 1330 for blood glucose of 240, 4u regular and 8u NPH given at 1700 with blood glucose of 220. Remains in MICU at this time to follow fingersticks q2hr. Plan is to transfer to the floor later this evening.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377819, "text": "Transfer\nNo change in assessment. Pt has been taking a nap since this nurse arrived. Currently sitting on edge of bed and talking on the phone. Pt denies any pain. Blood sugars have been better controlled today since off insulin drip. Pt just received 10units of Regular Insulin for blood sugar of 263. Pt transfered to floor via wheelchair on a monitor.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377820, "text": "Correction\nPt was given 10 units of Humalog not Regular insulin.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377821, "text": "Valuables\nPts Valuable slip from Micu-A safe removed and taken with pt to the next floor for there safe.\n" }, { "category": "Nursing/other", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 1377822, "text": "Transfer on hold\nPt ready for transfer but bed management called and requested pt stay in the unit because they need floor beds more than unit beds. Pt connected back to monitor and exam is unchanged. Pt eating a bedtime snack. voices no c/os'\n\n" }, { "category": "Nursing/other", "chartdate": "2114-06-29 00:00:00.000", "description": "Report", "row_id": 1377825, "text": "ADDENDUM - SODIUM LEVEL IMPROVED OVER THE COURSE OF THE DAY - REGULAR DOSE OF LASIX/METOLOAZONE ON CONTINUE HOLD AT PRESENT DESPITE INCREASED LOWER LEG OEDEMA - CONTINUES TO REFUSE CARDIAC CATH [DESPITE RULING IN FOR M.I ON THIS ADMISSION] RENAL FUNCTION STABLE\n" }, { "category": "Nursing/other", "chartdate": "2114-06-30 00:00:00.000", "description": "Report", "row_id": 1377826, "text": "npn 7p-7a (see also careview flownotes for objective data:\n\ndx: DKA; CRI; htn\n\nneuro:\na/o x3; moves all extremities independently, equally; PERLA;\n\nc-v:\nhrt NSR via cardiac monitor; remains on hep SQ tid to prevent DVT's;\n continues to have uncontrolled hypertension; recieved anti-hypertensives as ordered, yet sbp up to 199 at approx 03:00; MD notified, stated to give a.m. dose hydralazine at 03:00 instead of waiting until time of 05:00;\n continues to have significant bilateral lower extremity edema;\n\nresp:\nlungs clear bilat; Room air;\n\ng-i:\nFSBS elevated after evening snack of 8 saltines; received hs NPH and SS as ordered; new sliding scale ordered later after 23:00; will clarify in a.m. d/t FSBS down to 85 at 04:20;\n\ng-u: voiding quantity sufficient per bedside urinal;\n\nskin:\nintact;\n\nLABS:\n12 a labs showed very slight rise in creatinine; also mild elevation in serum K+; because of receiving insulin at 22:00, expect K+ to decrease abit;\n\nPLAN:\n1) check a.m. labs\n2) possible c/o if labs stable\n3) continue to follow FS's closely until controlled\n\n\n" }, { "category": "Nursing/other", "chartdate": "2114-06-29 00:00:00.000", "description": "Report", "row_id": 1377823, "text": "NPN 1900-0700\nAssumed care of pt at 1900. Pt lying supine in the bed taking a nap. When awake later, pt denied any pain. Please refer to carevue flowsheet for complete and ongoing assessment. Exam as follows:\n\nNeuro: completely intact. Pt able to move from bed to chair and back independently. Denies any pain.\n\nResp: Lungs are clear thru-out and remains on RA\n\nCV: Monitor reveals NSR-sbrady during this shift. SBP is controlled nicely with all of his antihypertensive meds. Abefrile during the night. Bilat pitting edema to both legs. Pt has been off his lasix since Sunday. Pt off heparin drip and started on SC heparin\n\nGI: Abd is soft round and nontender. +BS heard to all quads and pt eating all of his meals. Pt had a BM yesterday in the am. Pt had to be restarted on his insulin drip again this am. Pt is not getting enough NPH coverage during the night. Pts insulin drip was stopped during the evening and he was given 10units of NPH at 1700. Pt was given 10units of Humalog at 2330 for his blood sugar of 268. At 0200 blood sugar was 218(just checking to make sure it was not getting higher). Blood sugar at 0530 registered \"critical High\" on the machine and labs sent down. Insulin drip restarted at 8units/hr and will titrate accordingly and pt will go back on Q1 hour fingersticks. is following pt, they need to re-evualate his schedule.\n\nGU: Pt voiding in the urinal w/o difficulty. Specimen sent to the lab this am.\n\nSocial: Pt makes many calls on the phone to family and friends.\n\nPlan: Pt needs to be better controlled with his blood sugars. Cont to monitor blood sugars every 1 hour.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2114-06-29 00:00:00.000", "description": "Report", "row_id": 1377824, "text": "NURSING NOTE 0700HRS - 1700HRS\n\nEVENTS - ONGOING UNSTABLE DIABLETES, INCESEASED INSULIN/OBSERVE BLOODS SUGARS\n\n\n\nNEURO - A/O X3 - MINIMAL ASSISTANCE - OOB TO CHAIR - DENIES ANY PAIN\n\n\nRESP - LUNGS CLEAR, SATS >98% RR SATISFACTORY NO COMPLAITS OF SOB\n\n\nENDO - RECEIVED ON INSULIN DRIP THIS AM @ 16CC/HR AS LEVEL >400 IV FLUIDS @ 100CC/HR AND NPO - GRADUALLY REDUCED AND INSULIN DRIP TITRATED AS PROTOCOL - REVIWED BY TEAM DRIP STOPPED, INCREASED DOSE OF NPH GIVEN AND ALLOWED TO TAKE DIET, TO RECEIVE HUMALOG [AS PER S/S] PRE MEAL TIMES - RELATIVELY STABLE THIS PM - SEE CAREVIEW FOR DATA - REGIME REVIWED X2 TODAY\n\n\nCVS - INCREASED DOSE OF HYDRALAZINE FOR SYSTOLIC >170 THIS AM - BY 1300HRS FEELING SLIGHTLY LIGHTHEADED B/P LOW AT 90 SYSTOLIC PATIENT - BOLUS 250CCN/S GIVEN WITH SOME EFFECT REPEATED X1 THIS PM - SYSTOLIC PRESENTLY 90-100 HYARALAZINE NOT GIVEN AT 1600HRS - TO CONTINUE TO REVIEW - FOR REDUCED DOSE IN THE FUTURE\nH/R 60-70 BPM NO ECTOPICS\nAFEBRILE\nCHEM 7 REPEATED EVERY 4HRS WHILST BLOOD SUGARS UBSTABLE [ NEXT DUE @ 200HRS]\n\n\nGI -\n X1 BOWEL MOTION - EATING WELL\n\n\nGU - PASSING GOOD AMOUNTS OF URINE THIS AM - NOT PASSED URINE THIS PM DESPITE BOLUSES AND FLUID ENCOURAGEMENT - TO CONTINUE TO OBSERVE\n\nSKIN - INTACT\n\nLINES - X2 PERIPHERALS PATENT\n\nSOACIAL - MANY FRIENDS PHONING\n\n\nPLAN - ?? CALL OUT TO FLOOR/ TRANSFER LETTER DONE\n" }, { "category": "ECG", "chartdate": "2114-06-28 00:00:00.000", "description": "Report", "row_id": 196447, "text": "Sinus rhythm. Left atrial abnormality. Prominent precordial QRS voltage is\nnon-specific but consider left ventricular hypertrophy. Prolonged QTc interval.\nDiffuse ST-T wave abnormalities with modestly prominent U waves. Clinical\ncorrelation is suggested for possible metabolic/drug effect. Since the previous\ntracing of further ST-T wave changes are present.\n\n" }, { "category": "ECG", "chartdate": "2114-06-26 00:00:00.000", "description": "Report", "row_id": 196448, "text": "Sinus rhythm\nLong QTc interval\nConsider left atrial enlargement\nSeptal ST elevation - ? due to left ventricular hypertrophy\nInferior ST-T changes are nonspecific\nLeft ventricular hypertrophy with ST-T wave changes\nSince previous tracing, QRS changes in lead V3 - ? lead placement\n\n" }, { "category": "ECG", "chartdate": "2114-06-27 00:00:00.000", "description": "Report", "row_id": 196449, "text": "Sinus rhythm\nPoor R wave progression - ? due to left ventricular hypertrophy, anteroseptal\nmyocardial infarction or lead placement\nInferior T wave changes are nonspecific\nLeft ventricular hypertrophy with ST-T wave changes\nSince previous tracing, ST depression in leads V5-V6 resolved\n\n" }, { "category": "ECG", "chartdate": "2114-06-25 00:00:00.000", "description": "Report", "row_id": 196450, "text": "Sinus rhythm. Left atrial abnormality. Prolonged QTc interval. Left ventricular\nhypertrophy with ST-T wave abnormalities. Poor R wave progression could be due\nin part to left ventricular hypertrophy, but consider also prior anteroseptal\nmyocardial infarction. Inferolateral ST-T wave abnormalities are non-specific\nand could be due in part to left ventricular hypertrophy, but cannot exclude\nischemia. Clinical correlation is suggested. Since the previous tracing earlier\nthis date further ST-T wave changes are present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2114-06-25 00:00:00.000", "description": "Report", "row_id": 196451, "text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy by voltage.\nPoor R wave progression is non-specific and could be due in part to left\nventricular hypertrophy, but consider also prior anteroseptal myocardial\ninfarction. Prolonged QTc interval. Modest non-specific inferior T wave\nchanges. Clinical correlation is suggested. Since the previous tracing\nof precordial QRS voltage is more prominent.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2187-04-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 452892, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight\n s/p 4 u pRBCs\n hct checked mid-transfusion, 20->19.2\n hemodynamically and symptomatically stable overnight\n History obtained from Patient, Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n zofran\n pantoprazole 40 \n tylenol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 60 (60 - 86) bpm\n BP: 99/55(66) {86/49(59) - 100/64(71)} mmHg\n RR: 12 (6 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,225 mL\n PO:\n TF:\n IVF:\n 3,100 mL\n Blood products:\n 1,125 mL\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 157 K/uL\n 106 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 112 mEq/L\n 140 mEq/L\n 22.9 %\n 8.7 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n WBC\n 9.2\n 8.7\n Hct\n 19.7\n 22.9\n Plt\n 158\n 157\n Cr\n 0.8\n Glucose\n 106\n Other labs: Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 33 yo M recent history of UGIB presents with melena and hct drop.\n 1. GIB:\n - GI service following\n - urgent endoscopy this morning\n - 2 more pRBCs + FFP\n - q 4 hct x 24 hours until hct stabilizes\n - will need reports, including h pylori data\n 2. FEN:\n - NPO for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2187-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452851, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Received the pt from ED w/ second unit of PRBC\ns running, After\n finishing the second unit hct is 19.8. No bowel movements no N/V. BP\n 85-95/45-61.\n Action:\n Received 2units of PRBC\ns and 2lit fluid bolus. Calcium repleted.\n Response:\n S/P hct pending. Still BP remains the same.\n Plan:\n Check Q4h Hct and transfuse as necessary. Possible EGD in AM\n" }, { "category": "Physician ", "chartdate": "2187-04-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 452831, "text": "Chief Complaint: Dark stool, lightheadedness\n HPI:\n Pt is a 33 yo Mandarin speaking M with no PMH except for a recent\n duodenal ulcer and upper GI bleed, seen at one week ago, who\n presents with dark stool and lightheadedness. He and his wife state\n that he was recently admitted 1 week ago at with dark stool and\n anemia. He was diagnosed with a duonenal ulcer there after being given\n a medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n started at transfer.\n .\n On arrival to the floor, patient feels well and denies any abd pain,\n nausea. He does endorse the feeling of needing to use the bathroom and\n mild lightheadedness\n .\n ROS: As per above. Otherwise negative\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Prilosec 40mg \n Past medical history:\n Family history:\n Social History:\n Duodenal Ulcer: recently diagnosed at \n No history of GI bleeding or other GI disorders\n Smokes ppd. Denies EtoH. Married and lives in . Works as\n Sushi Chef in .\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 02:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (77 - 85) bpm\n BP: 100/56(66) {100/56(66) - 100/56(66)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 100%\n Total In:\n 2,375 mL\n PO:\n TF:\n IVF:\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,775 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n VS: afebrile, BP 98/55, HR 84, RR 17, 100%RA\n Gen: lying in bed, relaxed, pale, NAD\n HEENT: EOMI, anicteric sclera, MM dry op clear\n Neck: supple, no LAD\n Heart: RRR no m/r/g\n Lungs: CTAB no wheezes rales or crackles\n Abd: thin, soft, NT/ND + BS no rebound or guarding\n Ext: warm, well perfused no pitting edema. 2+ DP pulses\n Skin: no rash or ecchymoses\n Neuro: CN intact, alert and oriented and mentating well.\n Labs / Radiology\n [image002.jpg]\n 140 / 108 / 27 / 100 AGap=12\n 4.0 / 24 / 1.0\n .\n 14.7 \\ 6.8 / 234\n / 20.0 \\\n .\n N:88.8 L:9.1 M:1.6 E:0.4 Bas:0.1\n .\n PT: 13.7 PTT: 30.4 INR: 1.2\n Colonoscopy :\n A single sessile 5 mm polyp of benign appearance was found in the\n rectum. A single-piece polypectomy was performed using a cold forceps.\n The polyp was completely removed.\n .\n EKG: Sinus tachycardia at 105bpm, nl axis and intervals. Good R wave\n progression. STE in aVL, small Q waves inferiorly. No priors for\n comparison\n Assessment and Plan\n A/P: 33 yo M with recent duodenal ulcer diagnosed at presents with\n dark stool, lightheadedness, and anemia.\n .\n .\n Acute Blood Loss Anemia/GI Bleed: Most consistent with upper GI bleed\n given dark stool, anemia, and recent duodenal ulcer diagnosed at .\n Likely cause is recurrent bleed. No obvious history of liver disease\n to suggest varices. No wretching to suggest Mallor-. Recent\n colonoscopy unremarkable here last year. VS currently stable though\n profoundly anemic. Receiving 2 units PRBCs currently\n - GI consult -> urgent EGD\n - xfuse additional 2 units PRBCs now\n - Active T/S\n - Xfusing 2 units PRBCs -> will give additional unit PRBCs\n - Agressive IVF prn\n - 2 large bore PIV\n - IV PPI\n - NPO for now\n - Obtain records -> ulcer biospy sent for H. pylori\n .\n Leukocytosis: Likely acute inflammation from GI Bleed. No signs of\n infection currently.\n - Cont to trend\n .\n FEN: NPO, IVF, monitor electrolytes\n .\n Access: 2 PIV\n .\n Ppx: Boots, PPI.\n .\n Code: FULL\n .\n Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2187-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452836, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2187-04-15 00:00:00.000", "description": "ICU Event Note", "row_id": 452828, "text": "Clinician: Attending\n I have and examined the patient. I have discussed the case with Dr.\n and agree with the findings and plan as documented in his note.\n Briefly, 33 year old man (Mandarin speaking) who was recently admitted\n at with a GIB found to have a duodenal ulcer who now presents with\n repeat GIB. This am, had melena and felt light headed so he came to\n the ED. Had no abdominal pain, nausea or vomiting. Denies alcohol or\n NSAIDs. On arrival to the ED, hemodynamically stable. His first\n hematocrit was 20. NGL with red clot which cleared. Received two\n liters of normal saline and two units of PRBC in the ED.\n On exam, comfortable with heart rate 77, BP 88/49, 100% on room air.\n Abdomen is soft with normoactive bowel sounds, non-tender and non\n distended. EKG without ischemic changes. Hematocrit -- 20 --> 19\n after 2 units of blood. Platelets 234, normal coags.\n He is a 33 year old with a recurrent UGIB, most likely his duodenal\n ulcer although other etiologies are possible.\n Problems:\n 1. UGIB - Plan for endoscopy this morning. Will give him two more\n units packed red cells now and recheck hct. If becomes more\n tachycardic, then will move to emergent EGD. Continue IV PPI, has two\n large bore IVS. Will get records from re: h. pylori.\n 2. Prophy - boots\n 3. Full code\n Total time spent: 35 minutes\n Patient is critically ill.\n" }, { "category": "Physician ", "chartdate": "2187-04-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 452822, "text": "Chief Complaint: Dark stool, lightheadedness\n HPI:\n Pt is a 33 yo Mandarin speaking M with no PMH except for a recent\n duodenal ulcer and upper GI bleed, seen at one week ago, who\n presents with dark stool and lightheadedness. He and his wife state\n that he was recently admitted 1 week ago at with dark stool and\n anemia. He was diagnosed with a duonenal ulcer there after being given\n a medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n started at transfer.\n .\n On arrival to the floor, patient feels well and denies any abd pain,\n nausea. He does endorse the feeling of needing to use the bathroom and\n mild lightheadedness\n .\n ROS: As per above. Otherwise negative\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Prilosec 40mg \n Past medical history:\n Family history:\n Social History:\n Duodenal Ulcer: recently diagnosed at \n No history of GI bleeding or other GI disorders\n Smokes ppd. Denies EtoH. Married and lives in \n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Jaundice\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 02:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (77 - 85) bpm\n BP: 100/56(66) {100/56(66) - 100/56(66)} mmHg\n RR: 17 (17 - 21) insp/min\n SpO2: 100%\n Total In:\n 2,375 mL\n PO:\n TF:\n IVF:\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,775 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n VS: afebrile, BP 98/55, HR 84, RR 17, 100%RA\n Gen: lying in bed, relaxed, pale, NAD\n HEENT: EOMI, anicteric sclera, MM dry op clear\n Neck: supple, no LAD\n Heart: RRR no m/r/g\n Lungs: CTAB no wheezes rales or crackles\n Abd: thin, soft, NT/ND + BS no rebound or guarding\n Ext: warm, well perfused no pitting edema. 2+ DP pulses\n Skin: no rash or ecchymoses\n Neuro: CN intact, alert and oriented and mentating well.\n Labs / Radiology\n [image002.jpg]\n 140 / 108 / 27 / 100 AGap=12\n 4.0 / 24 / 1.0\n .\n 14.7 \\ 6.8 / 234\n / 20.0 \\\n .\n N:88.8 L:9.1 M:1.6 E:0.4 Bas:0.1\n .\n PT: 13.7 PTT: 30.4 INR: 1.2\n Colonoscopy :\n A single sessile 5 mm polyp of benign appearance was found in the\n rectum. A single-piece polypectomy was performed using a cold forceps.\n The polyp was completely removed.\n .\n EKG: Sinus tachycardia at 105bpm, nl axis and intervals. Good R wave\n progression. STE in aVL, small Q waves inferiorly. No priors for\n comparison\n Assessment and Plan\n A/P: 33 yo M with recent duodenal ulcer diagnosed at presents with\n dark stool, lightheadedness, and anemia.\n .\n .\n Acute Blood Loss Anemia/GI Bleed: Most consistent with upper GI bleed\n given dark stool, anemia, and recent duodenal ulcer diagnosed at .\n Likely cause is recurrent bleed. No obvious history of liver disease\n to suggest varices. No wretching to suggest Mallor-. Recent\n colonoscopy unremarkable here last year. VS currently stable though\n profoundly anemic.\n - GI consult -> urgent EGD\n - Active T/S\n - Xfusing 2 units PRBCs -> will give additional unit PRBCs\n - Agressive IVF prn\n - 2 large bore PIV\n - IV PPI\n - NPO for now\n - Obtain records -> ulcer biospy sent for H. pylori\n .\n Leukocytosis: Likely acute inflammation from GI Bleed. No signs of\n infection currently.\n - Cont to trend\n .\n FEN: NPO, IVF, monitor electrolytes\n .\n Access: 2 PIV\n .\n Ppx: Boots, PPI.\n .\n Code: FULL\n .\n Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2187-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 453143, "text": "Chief Complaint: Duodenal ulcer GIB\n 24 Hour Events:\n ENDOSCOPY - At 08:00 AM\n two acute cratered ulcers ranging in size from 8mm to 10mm were found\n in the duodenal bulb. A visible vessel suggested recent bleeding. A\n gold probe was applied for hemostasis successfully.\n Records from >>>> + bx for h.pylori>>>>started triple therapy\n HCT 26 at 1400 s/p 6 units, initial HCT 20, stable at 27 overnight\n maintenance IVF and started on clears\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.3\nC (97.3\n HR: 58 (57 - 100) bpm\n BP: 104/71(78) {93/47(58) - 114/73(82)} mmHg\n RR: 12 (8 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 8,797 mL\n 700 mL\n PO:\n 320 mL\n TF:\n IVF:\n 4,571 mL\n 700 mL\n Blood products:\n 1,906 mL\n Total out:\n 5,500 mL\n 1,650 mL\n Urine:\n 4,900 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,297 mL\n -950 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 201 K/uL\n 9.8 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.8 %\n 6.9 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n 02:19 PM\n 06:13 PM\n 10:12 PM\n 05:01 AM\n WBC\n 9.2\n 8.7\n 6.9\n Hct\n 19.7\n 22.9\n 26.1\n 25.8\n 27.8\n 26.8\n Plt\n 158\n 157\n 201\n Cr\n 0.8\n 0.7\n Glucose\n 106\n 101\n Other labs: PT / PTT / INR:12.8/33.9/1.1, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.1 mg/dL\n Imaging: none\n Microbiology: none\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n A/P: 33 yo M with recent duodenal ulcer diagnosed at presents with\n dark stool, lightheadedness, and anemia.\n .\n Acute Blood Loss Anemia/GI Bleed: Most consistent with upper GI bleed\n given dark stool, anemia, and recent duodenal ulcer diagnosed at .\n Likely cause is recurrent bleed. No obvious history of liver disease\n to suggest varices. No wretching to suggest Mallor-. Recent\n colonoscopy unremarkable here last year. VS currently stable though\n profoundly anemic. Receiving 2 units PRBCs currently\n - Active T/S\n - received 6 units PRBC, last transfusion yesterday AM, HCT stable at\n 25-27, HCT\n - 2 large bore PIV\n - IV PPI>>> switch to PO\n - advance to regular\n - Obtain records -> ulcer biopsy + H. pylori\n - Cont triple therapy for H. pylori\n - f/u GI recs\n .\n Leukocytosis: Likely acute inflammation from GI Bleed. No signs of\n infection currently.\n - resolved\n .\n FEN: IVF, monitor electrolytes, regular diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453166, "text": "33 year old male, primarily mandarin speaking, understands English,\n admit with black stool +dizziness, palpitations.\n Recent admission to last week with GI Bleed, EGD, duodenal ulcer\n and H.pylori.\n PMH: GI bleed with duodenal ulcer\n ALLERGIES: NKA\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abd soft flat, +bs, no stool, no GI complaints, 9a hct 28, clear liquid\n breakfast\n Action:\n Advance diet to regular\n Response:\n Stable hct, no evidence of bleeding\n Plan:\n Follow hct, follow tolerance to advanced diet, stable for transfer to\n medical floor\n EGD done on showing no active bleed. Areas of previous bleeding\n cauterized during procedure.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 67.6 kg\n Daily weight:\n 70.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed, Smoker\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:66\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 3,950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:01 AM\n Potassium:\n 3.5 mEq/L\n 05:01 AM\n Chloride:\n 112 mEq/L\n 05:01 AM\n CO2:\n 25 mEq/L\n 05:01 AM\n BUN:\n 9 mg/dL\n 05:01 AM\n Creatinine:\n 0.7 mg/dL\n 05:01 AM\n Glucose:\n 101 mg/dL\n 05:01 AM\n Hematocrit:\n 28.7 %\n 08:42 AM\n Valuables / Signature\n Patient valuables: Cell phone with patient.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 787\n Transferred to: CC 721\n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2187-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 453245, "text": "Chief Complaint: Duodenal ulcer GIB\n 24 Hour Events:\n ENDOSCOPY - At 08:00 AM\n two acute cratered ulcers ranging in size from 8mm to 10mm were found\n in the duodenal bulb. A visible vessel suggested recent bleeding. A\n gold probe was applied for hemostasis successfully.\n Records from >>>> + bx for h.pylori>>>>started triple therapy\n HCT 26 at 1400 s/p 6 units, initial HCT 20, stable at 27 overnight\n maintenance IVF and started on clears\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.3\nC (97.3\n HR: 58 (57 - 100) bpm\n BP: 104/71(78) {93/47(58) - 114/73(82)} mmHg\n RR: 12 (8 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 8,797 mL\n 700 mL\n PO:\n 320 mL\n TF:\n IVF:\n 4,571 mL\n 700 mL\n Blood products:\n 1,906 mL\n Total out:\n 5,500 mL\n 1,650 mL\n Urine:\n 4,900 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,297 mL\n -950 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 201 K/uL\n 9.8 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.8 %\n 6.9 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n 02:19 PM\n 06:13 PM\n 10:12 PM\n 05:01 AM\n WBC\n 9.2\n 8.7\n 6.9\n Hct\n 19.7\n 22.9\n 26.1\n 25.8\n 27.8\n 26.8\n Plt\n 158\n 157\n 201\n Cr\n 0.8\n 0.7\n Glucose\n 106\n 101\n Other labs: PT / PTT / INR:12.8/33.9/1.1, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.1 mg/dL\n Imaging: none\n Microbiology: none\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n A/P: 33 yo M with recent duodenal ulcer diagnosed at presents with\n dark stool, lightheadedness, and anemia.\n .\n Acute Blood Loss Anemia/GI Bleed: Most consistent with upper GI bleed\n given dark stool, anemia, and recent duodenal ulcer diagnosed at .\n Likely cause is recurrent bleed. No obvious history of liver disease\n to suggest varices. No wretching to suggest Mallor-. Recent\n colonoscopy unremarkable here last year. VS currently stable though\n profoundly anemic. Receiving 2 units PRBCs currently\n - Active T/S\n - received 6 units PRBC, last transfusion yesterday AM, HCT stable at\n 25-27, HCT\n - 2 large bore PIV\n - IV PPI>>> switch to PO\n - advance to regular\n - Obtain records -> ulcer biopsy + H. pylori\n - Cont triple therapy for H. pylori\n - f/u GI recs\n .\n Leukocytosis: Likely acute inflammation from GI Bleed. No signs of\n infection currently.\n - resolved\n .\n FEN: IVF, monitor electrolytes, regular diet\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n Stable since endoscopy yesterday where identified two gastric ulcers.\n H pylori positive\n started on therapy. Agree with switch to PO PPI,\n advance diet as tolerated. Remainder of plan as above.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:20 ------\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453154, "text": "33 year old male, primarily mandarin speaking, understands English,\n admit with black stool +dizziness, palpitations.\n Recent admission to last week with GI Bleed, EGD, duodenal ulcer\n and H.pylori.\n PMH: GI bleed with duodenal ulcer\n ALLERGIES: NKA\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abd soft flat, +bs, no stool, no GI complaints, 9a hct 28, clear liquid\n breakfast\n Action:\n Advance diet to regular\n Response:\n Stable hct, no evidence of bleeding\n Plan:\n Follow hct, follow tolerance to advanced diet, stable for transfer to\n medical floor\n" }, { "category": "Physician ", "chartdate": "2187-04-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 453104, "text": "Chief Complaint: Duodenal ulcer GIB\n 24 Hour Events:\n ENDOSCOPY - At 08:00 AM\n two acute cratered ulcers ranging in size from 8mm to 10mm were found\n in the duodenal bulb. A visible vessel suggested recent bleeding. A\n gold probe was applied for hemostasis successfully.\n Records from >>>> + bx for h.pylori>>>>started triple therapy\n HCT 26 at 1400 s/p 6 units, initial HCT 20, stable at 27 overnight\n maintenance IVF and started on clears\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.3\nC (97.3\n HR: 58 (57 - 100) bpm\n BP: 104/71(78) {93/47(58) - 114/73(82)} mmHg\n RR: 12 (8 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 8,797 mL\n 700 mL\n PO:\n 320 mL\n TF:\n IVF:\n 4,571 mL\n 700 mL\n Blood products:\n 1,906 mL\n Total out:\n 5,500 mL\n 1,650 mL\n Urine:\n 4,900 mL\n 1,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,297 mL\n -950 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 201 K/uL\n 9.8 g/dL\n 101 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 141 mEq/L\n 26.8 %\n 6.9 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n 02:19 PM\n 06:13 PM\n 10:12 PM\n 05:01 AM\n WBC\n 9.2\n 8.7\n 6.9\n Hct\n 19.7\n 22.9\n 26.1\n 25.8\n 27.8\n 26.8\n Plt\n 158\n 157\n 201\n Cr\n 0.8\n 0.7\n Glucose\n 106\n 101\n Other labs: PT / PTT / INR:12.8/33.9/1.1, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.1 mg/dL\n Imaging: none\n Microbiology: none\n Assessment and Plan\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n A/P: 33 yo M with recent duodenal ulcer diagnosed at presents with\n dark stool, lightheadedness, and anemia.\n .\n Acute Blood Loss Anemia/GI Bleed: Most consistent with upper GI bleed\n given dark stool, anemia, and recent duodenal ulcer diagnosed at .\n Likely cause is recurrent bleed. No obvious history of liver disease\n to suggest varices. No wretching to suggest Mallor-. Recent\n colonoscopy unremarkable here last year. VS currently stable though\n profoundly anemic. Receiving 2 units PRBCs currently\n - Active T/S\n - received 6 units PRBC, last transfusion yesterday AM, HCT stable at\n 25-27, HCT\n - 2 large bore PIV\n - IV PPI>>> switch to PO\n - advance to regular\n - Obtain records -> ulcer biopsy + H. pylori\n .\n Leukocytosis: Likely acute inflammation from GI Bleed. No signs of\n infection currently.\n - resolved\n .\n FEN: NPO, IVF, monitor electrolytes\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2187-04-16 00:00:00.000", "description": "ICU Fellow Progress Note - MICU", "row_id": 453142, "text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 33 y/o M with recent GI bleed, admitted with recurrent bleed from\n duodenal ulcers.\n 24 Hour Events:\n EGD yesterday AM revealed 2 duodenal ulcers, visible vessel seen s/p\n Gold probe treatment.\n H. pylori positive at so started on treatment.\n Hct q4h yest was stable at 26-27.\n History obtained from Patient, Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n protonix , clarithromycin, amoxicillin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.4\nC (97.5\n HR: 66 (57 - 93) bpm\n BP: 112/69(80) {93/47(58) - 116/74(83)} mmHg\n RR: 17 (8 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70.4 kg (admission): 67.6 kg\n Total In:\n 8,797 mL\n 1,107 mL\n PO:\n 320 mL\n 360 mL\n TF:\n IVF:\n 4,571 mL\n 747 mL\n Blood products:\n 1,906 mL\n Total out:\n 5,500 mL\n 3,000 mL\n Urine:\n 4,900 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,297 mL\n -1,893 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 201 K/uL\n 101 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 9 mg/dL\n 112 mEq/L\n 141 mEq/L\n 28.7 %\n 6.9 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n 02:19 PM\n 06:13 PM\n 10:12 PM\n 05:01 AM\n 08:42 AM\n WBC\n 9.2\n 8.7\n 6.9\n Hct\n 19.7\n 22.9\n 26.1\n 25.8\n 27.8\n 26.8\n 28.7\n Plt\n 158\n 157\n 201\n Cr\n 0.8\n 0.7\n Glucose\n 106\n 101\n Other labs: PT / PTT / INR:12.8/33.9/1.1, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 33 y/o M w/upper GI bleed secondary to duodenal ulcers, now stable.\n Will continue protonix, treat h.pylori as well. Can decrease frequency\n of Hct check to .\n ICU Care\n Nutrition:\n Comments: clear liquids\n Glycemic Control: Blood sugar well controlled\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453229, "text": "33 yo man admit with GI bleed, recent GI bleed with Duodenal ulcer.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct 28, abd soft, +bs, +flatus, no stool, no n/v\n Action:\n Diet advacnced to regular\n Response:\n Hemodynamically stable, hct stable, tolerating advanced diet\n Plan:\n Waiting for bed on medical floor, follow hct, signs/sympotoms of\n bleeding\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453039, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct this everning 27.8. BP and HR\n stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate clear liquids well, cont PO antibiotics for H.Pylori\n Response:\n BP and HR stable.\n Plan:\n cont follow HCT q4hr, possible c/o.\n" }, { "category": "Nursing", "chartdate": "2187-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452966, "text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct from AM labs 22. BP and HR stable.\n Action:\n Endoscopy beginning of shift showing old points of bleed; cautarized.\n Tolerated procedure well. Received 1 unit of platelets and 2 PRBCs.\n Response:\n BP and HR stable. Hct increased to 26.\n Plan:\n Will start PO antibiotics for H.Pylori in addition to IV protonix.\n Q 6hr hcts.\n" }, { "category": "Nursing", "chartdate": "2187-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 452967, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct from AM labs 22. BP and HR stable.\n Action:\n Endoscopy beginning of shift showing old points of bleed; cautarized.\n Tolerated procedure well. Received 1 unit of platelets and 2 PRBCs.\n Response:\n BP and HR stable. Hct increased to 26.\n Plan:\n Will start PO antibiotics for H.Pylori in addition to IV protonix.\n Q 6hr hcts.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453038, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct this everning 27.5 BP and HR stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate clear liquids well, cont PO antibiotics for H.Pylori\n Response:\n BP and HR stable.\n Plan:\n cont follow HCT q4hr, possible c/o.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453092, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct this everning 27.8. BP and HR\n stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate clear liquids well, cont PO antibiotics for H.Pylori\n Response:\n BP and HR stable. Morning HCT 26.8\n Plan:\n cont follow HCT q4hr, possible c/o.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453081, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct this everning 27.8. BP and HR\n stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate clear liquids well, cont PO antibiotics for H.Pylori\n Response:\n BP and HR stable. Morning HCT 26.8\n Plan:\n cont follow HCT q4hr, possible c/o.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453259, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. No stool. ABD soft, +flatus. Hct at 1600\n 318. BP and HR stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate regular diet well, cont PO antibiotics for H.Pylori and\n PRotonix Po\n Response:\n BP and HR stable.\n Plan:\n cont follow HCT. signs of bleeding\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453260, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. No stool. ABD soft, +flatus. Hct at 1600\n 31.1. BP and HR stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate regular diet well, cont PO antibiotics for H.Pylori and\n PRotonix Po\n Response:\n BP and HR stable.\n Plan:\n cont follow HCT. signs of bleeding\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 67.6 kg\n Daily weight:\n 70.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed, Smoker\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:61\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 61 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,129 mL\n 24h total out:\n 5,200 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:01 AM\n Potassium:\n 3.5 mEq/L\n 05:01 AM\n Chloride:\n 112 mEq/L\n 05:01 AM\n CO2:\n 25 mEq/L\n 05:01 AM\n BUN:\n 9 mg/dL\n 05:01 AM\n Creatinine:\n 0.7 mg/dL\n 05:01 AM\n Glucose:\n 101 mg/dL\n 05:01 AM\n Hematocrit:\n 31.1 %\n 04:17 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7 CC787\n Transferred to: CC702\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453257, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. No stool. Hct this everning 27.8. BP and\n HR stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate clear liquids well, cont PO antibiotics for H.Pylori\n Response:\n BP and HR stable. Morning HCT 26.8\n Plan:\n cont follow HCT q4hr, possible c/o.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453258, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. No stool. ABD soft, Hct at 1600 318. BP\n and HR stable.\n Action:\n Endoscopy done at 4/12 showing old points of bleed; cautarized.\n Tollerate regular diet well, cont PO antibiotics for H.Pylori and\n PRotonix Po\n Response:\n BP and HR stable.\n Plan:\n cont follow HCT. signs of bleeding\n" }, { "category": "Nursing", "chartdate": "2187-04-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 453019, "text": "33 yo Mandarin speaking M with no PMH except for a recent duodenal\n ulcer and upper GI bleed, seen at one week ago, who presents with\n dark stool and lightheadedness. He and his wife state that he was\n recently admitted 1 week ago at with dark stool and anemia. He\n was diagnosed with a duonenal ulcer there after being given a\n medication for arthritis -> ibuprofen. His Hct was 29.3 there. He\n states that he was given 5 units PRBCs at that time, was stabilized,\n and was discharged on prilosec. He had been doing otherwise well until\n yesterday when he noted a dark BM in the toilet. Additionally, he felt\n lightheadedness with palpitations as well, denying any\n nausea/vomitting, or abdominal pain. He denies recent NSAID use.\n .\n In the ED, initial VS 97.7, HR 117, BP 117/53, RR 20, 100%RA. Abd\n benign. Guaiac postive brown stool. Given 2 liters NS. HR and BP\n improved. His Hct was 20. He was given Protonix 40mg IV. NG lavage\n showed some old clot but no BRB. He did not have a BM but did\n urinate. BP 116/70, HR 92 prior to transfer. 2 units of PRBCs were\n and admitted to MICU 7 for further management.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active signs of bleeding. Hct from AM labs 22. BP and HR stable.\n Action:\n Endoscopy beginning of shift showing old points of bleed; cautarized.\n Tolerated procedure well. Received 1 unit of platelets and 2 PRBCs.\n Response:\n BP and HR stable. Hct increased to 26.\n Plan:\n Will start PO antibiotics for H.Pylori in addition to IV protonix.\n Q 4hr hcts. Will start clr liquids tonight.\n" }, { "category": "Physician ", "chartdate": "2187-04-15 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 453009, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight\n s/p 4 u pRBCs\n hct checked mid-transfusion, 20->19.2\n hemodynamically and symptomatically stable overnight\n History obtained from Patient, Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n zofran\n pantoprazole 40 \n tylenol\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 60 (60 - 86) bpm\n BP: 99/55(66) {86/49(59) - 100/64(71)} mmHg\n RR: 12 (6 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,225 mL\n PO:\n TF:\n IVF:\n 3,100 mL\n Blood products:\n 1,125 mL\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: Conjunctiva pale\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Cool\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 8.0 g/dL\n 157 K/uL\n 106 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 112 mEq/L\n 140 mEq/L\n 22.9 %\n 8.7 K/uL\n [image002.jpg]\n 02:50 AM\n 06:15 AM\n WBC\n 9.2\n 8.7\n Hct\n 19.7\n 22.9\n Plt\n 158\n 157\n Cr\n 0.8\n Glucose\n 106\n Other labs: Ca++:7.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 33 yo M recent history of UGIB presents with melena and hct drop.\n 1. GIB:\n - GI service following\n - urgent endoscopy this morning\n - 2 more pRBCs + FFP\n - q 4 hct x 24 hours until hct stabilizes\n - will need reports, including h pylori data\n 2. FEN:\n - NPO for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:05 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :\n Total time spent: 30 minutes\n Patient is critically ill\n Addendum: pt underwent EGD this morning with 2 ulcers, areas of oozing\n cauterized. Pt currently without N/V/abd pain. Hct this afternoon up\n appropriately after transfusion.\n" }, { "category": "Nursing", "chartdate": "2187-04-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 453171, "text": "33 year old male, primarily mandarin speaking, understands English,\n admit with black stool +dizziness, palpitations.\n Recent admission to last week with GI Bleed, EGD, duodenal ulcer\n and H.pylori.\n PMH: GI bleed with duodenal ulcer\n ALLERGIES: NKA\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Abd soft flat, +bs, no stool, no GI complaints, 9a hct 28, clear liquid\n breakfast\n Action:\n Advance diet to regular\n Response:\n Stable hct, no evidence of bleeding\n Plan:\n Follow hct, follow tolerance to advanced diet, stable for transfer to\n medical floor\n EGD done on showing no active bleed. Areas of previous bleeding\n cauterized during procedure.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 67.6 kg\n Daily weight:\n 70.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed, Smoker\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:66\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 3,950 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:01 AM\n Potassium:\n 3.5 mEq/L\n 05:01 AM\n Chloride:\n 112 mEq/L\n 05:01 AM\n CO2:\n 25 mEq/L\n 05:01 AM\n BUN:\n 9 mg/dL\n 05:01 AM\n Creatinine:\n 0.7 mg/dL\n 05:01 AM\n Glucose:\n 101 mg/dL\n 05:01 AM\n Hematocrit:\n 28.7 %\n 08:42 AM\n Valuables / Signature\n Patient valuables: Cell phone with patient.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 787\n Transferred to: CC 721\n Date & time of Transfer: \n ------ Protected Section ------\n Error in room assignment; floor bed not yet assigned as of 1400.\n ------ Protected Section Addendum Entered By: , RN\n on: 14:10 ------\n" }, { "category": "ECG", "chartdate": "2187-04-14 00:00:00.000", "description": "Report", "row_id": 225540, "text": "Sinus tachycardia. Otherwise, tracing is within normal limits. No previous\ntracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2169-04-18 00:00:00.000", "description": "Report", "row_id": 1578990, "text": "s/p avr\ns: \"it's better\"\no: continues sr ist degree avb, without vea. sbp 110's levo @ .025mcq.extubated @ 2100 without incident. 2230 abg pending. presently on 50% open face mask with o2 sats >99%. rr14-18 when awake, bs bibasilar crackles recieved 20 mg ivp lasix per dr. with 55 ml uo x 1 hour. insulin gtt @ 4 units. 2 gm magnesium x1. family translated and pt understands some english, calm, denies pain.\na: increased uo with lasix, levo wean slowly - being tolerated.\nP: monitor comfort, hr and rythm, sbp- slow wean of levo as tolerated,pp, ct drainage, labs, i+o, uo, as per orders, abg and glucose pending\n" }, { "category": "Nursing/other", "chartdate": "2169-04-19 00:00:00.000", "description": "Report", "row_id": 1578991, "text": "NEURO ALERT ORIENTED SPEAKS SOME ENGLISH UNDERSTANDS SIMPLE QUESTIONS ANSWERS APPROPRIATLY IN ENGLISH MOVING FREQUENTLY IN BED TURNING SIDE TO SIDE NO DEFECITS FOLLOWS COMMANDS WITHOUT DIFFICULTY\n\nC/V NSR 1ST DEGREE AVB NO ECT EPICARDIAL WIRES ATRIAL INTACT SENSING AND CAPTURING WELL VENTRICULAR WIRES CUT DURING DSG CHANGE MD NOT NEEDED HR AND B/P STABLE EXTRA WIRE AT BEDSIDE LEVOPHED WEANED AND DC/D TOL WELL CO/CI WNL DSG CHANGED FOR SMALL AMTS SANG DRAINAGE CHEST CONCAVE BILAT MOVEMENTS NOTED\n\nRESP TOL OPEN FACE MASK WELL ABG WNL CHANGE TO NC 4L SATS 100% BS FAINT CRACKLES AT BASES NONPRODUCIVE COUGH CT INTACT DRAINING SMALL AMTS SEROSANG 40CC X1 WITH TURN NO SOB OR RESP DISTRESS NOTED TAKING DEEP BREATHS FREQ WITH ENCOURAGMENT ATTEMPTED IS WITH DIFFICULTY ATTEMPT WITH FAMILY TODAY\n\nBS INSULIN DRIP MAINTAINED FOR ELEVATED BS TOL WELL 8 UNITS HOURLY AT PRESENT\n\nPLAN CONTINUE TO MAINAIN HEMODYNAMICS MONITOR BS WITH INSULIN DRIP\n" }, { "category": "Nursing/other", "chartdate": "2169-04-19 00:00:00.000", "description": "Report", "row_id": 1578992, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, ITALIAN SPEAKING GENTLEMAN THAT DOES UNDERSTAND SOME ENGLISH. DENIES PAIN. OOB TO CHAIR WITH ASSIST X2, SLIGHTLY UNSTEADY ON FEET. PEERL.\nCARDIAC: CONT. TO BE IN NSR WITH NO ECTOPY. CO/CI CONT. TO BE EXCELLENT, SWAN & CORDIS D/C'D. NON-INVASIVE CUFF PRESSURES CORRELATING WITH , D/C'D WITHOUT DIFFICULTY. WIRES-> BOX, (V-WIRES TO BE RE-SPLICED BY SHORTLY). + BPPP, 2 PERIPH IV'S INTACT.\nRESP: BS CLEAR THRU-OUT, USING IS, STRONG NON-PRODUCTIVE COUGH. CT'S D/C'D BY N. TEPAROW, PCXRAY DONE. O2 AT 4L NP WITH SAT'S >97%.\nGI/GU: HOURLY URINES CONT. TO BE >25CC OF AMBER COLOR URINE. + BS THRU-OUT, BS CONT. TO BE >200, INSULIN GTT CURRENTLY AT 14U/HR, PLAN TO RESTART NPH THIS AM.\nSOCIAL: FAMILY CALLED, WILL BE IN LATER TODAY.\nPLAN: TX TO F6 LATER THIS AM. CONT. TO MONITOR BS CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2169-04-18 00:00:00.000", "description": "Report", "row_id": 1578989, "text": "s/p avr\no: cardiac: a paced to ist degree avb (pr interval .26) with isolated pvc's, k 3.6 recieved 40 meq kcl x 1.sbp requiring levo presently being weaned @ .045mcq with sbp 90-120's(which is goal). increased ct drainage 110-150 ml q1/2hour therefore recieved 2 upc for initial hct 22-24,repeat hct 24 recieved #3 upc. 50 mg protamine x 2-act 127. 4uffp,and 5 pk plts.total ct drainage 800 ml, ct drainage <20ml q 30 minutes . ct dsgs d+i. +pp, recieved 2.5 l lr.ci>2.3.\n resp: remains intubated fully supported, propfol off @ 1700, o2 sats on 40% >100%. abg good see flow. peep coninues on 10 due to initial bleeding.\n neuro: propofol dc'd @ 1700, opens eyes and squeezes hands when i hold them. pt is italian speaking and nephew is to come into interpret wake and wean. perl.\n gi: ogt to lcs +placement, absent bowel sounds.\n gu: uo 30's last 2 hours.\n endo: sliding scale insulin 6 units x 2 glucose >200. insulin gtt began @ 1830.\n pain: mso4 2-4 mg x 3.\n social: wife and son-in-law to visit and updated, nephew to come to interpret.\na: bleeding has stopped, slowly waking, requiring levo,\nP: monitor comfort, hr and rythym, sbp, ct drainage, pp, dsgs, i+O, labs, wean levo as per orders.\n\n" }, { "category": "ECG", "chartdate": "2169-04-26 00:00:00.000", "description": "Report", "row_id": 158437, "text": "Normal sinus rhythm, rate 79 with atrial premature beats. First degree\nA-V block. Compared to tracing #1, no diagnostic changes.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2169-04-26 00:00:00.000", "description": "Report", "row_id": 158438, "text": "Normal sinus rhythm, rate 63. There is one ventricular premature beat.\nPoor R wave progression in the precordial leads consistent with anterior\nmyocardial infarction, age undetermined. ST segment coving in leads V2-V3 and\nT wave inversions in leads I, aVL and V4-V6. Cannot exclude anterolateral\nischemia. Compared to the previous tracing of atrial pacing is no\nlonger seen and ST segment depressions in leads V4-V6 have improved.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2169-04-18 00:00:00.000", "description": "Report", "row_id": 158439, "text": "Undetermined rhythm\n- demand atrial pacing\nPossible inferior infarct - age undetermined\nLateral ST-T changes offer additional evidence of ischemia\nNo previous report available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2169-04-17 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 758114, "text": " 10:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PULMONARY EDEMA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with\n REASON FOR THIS EXAMINATION:\n preop for aortic valve replacement in am\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for aortic valve replacement.\n\n COMPARISON: None\n\n CHEST, PA AND LATERAL: There is cardiomegaly as well as increase in the\n pulmonary vascularity and a perihilar haze. There are bilateral interstitial\n infiltrates as well as blunting of both costophrenic angles. The latter is\n suggestive of bilateral small pleural effusions. There also is a\n density superior to the right hilum on the frontal projection that correlates\n to fluid confined within the major fissure on the lateral projection. Overall\n the patient has the appearance of cardiac failure. There are degenerative\n changes of the thoracic spine.\n\n IMPRESSION: Congestive heart failure. Fluid within the right major\n fissure.\n\n" }, { "category": "Radiology", "chartdate": "2169-04-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758216, "text": " 8:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR, POD #1, mediastinal tubes pulled. Please r/o effusi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old man with AS, POD#1 from AVR, mediastinal tubes just pulled.\n REASON FOR THIS EXAMINATION:\n s/p AVR, POD #1, mediastinal tubes pulled. Please r/o effusions amd\n pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: One day s/p aortic valve replacement. Assess for effusions and\n ptx.\n\n Comparison: .\n\n AP CHEST: In the interval since the prior study, the patient has undergone\n aortic valve replacement and median sternotomy wires and skin staples are\n noted. A SG catheter has been placed via right IJ access and the tip is well\n positioned in the distal pulmonary trunk.\n\n There is redemonstration of cardiomegaly which is stable. The mediastinal and\n hilar contours are unremarkable. Blunting of the right costophrenic angle,\n consistent with small effusion. Fluid is again seen in the major fissure,\n giving the appearance of geographic opacifications on the frontal film.\n Additionally, fluid is tracking in the minor fissure. There is overall slight\n increase in fluid in the major fissure. The lungs are otherwise, clear. There\n is no pulmonary vascular congestion.\n\n IMPRESSION:\n 1) S/P aortic valve replacement.\n\n 2) Well positioned SG catheter with no pneumothorax.\n\n 3) Right pleural effusion tracking in the major fissure, minor fissure and in\n the right costophrenic angle, which is slightly increased since the prior\n study.\n\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2160-09-25 00:00:00.000", "description": "Report", "row_id": 211959, "text": "Sinus tachycardia. Delayed R wave transition. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterim change.\n\n" }, { "category": "ECG", "chartdate": "2160-09-24 00:00:00.000", "description": "Report", "row_id": 211960, "text": "Sinus tachycardia\nRightward axis\nLate precordial QRS transition - is nonspecific\nlateral T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nNo previous tracing for comparison\n\n" }, { "category": "Radiology", "chartdate": "2160-09-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882177, "text": " 3:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p emergent intubation\n Admitting Diagnosis: TRACHEAL MALASIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p emergent intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with emergent intubation.\n\n CHEST X-RAY, AP PORTABLE VIEW\n\n COMPARISON: None.\n\n FINDINGS: Heart size is normal. The mediastinal contours are normal. The ET\n tube is about 7 cm from the carina. At the thoracic inlet, there are no\n pleural effusions. There is no pneumothorax. An opacity is seen in the left\n lower lobe, likely pneumonia. There is bilateral diffuse emphysema. There is\n asymmetric pulmonary edema, more on the right. More evident at the lung bases\n due to emphysema.\n\n IMPRESSION:\n 1. Patchy opacity in the left lower lobe, likely pneumonia.\n\n 2. Diffuse bilateral emphysema.\n\n 3. Asymmetric pulmonary edema, more on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-09-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 882324, "text": " 1:55 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval PTX, placement\n Admitting Diagnosis: TRACHEAL MALASIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with COPD, hypercarbic respiratory failure, increased wbc\n count, ?PNA, now s/p Subclav line.\n REASON FOR THIS EXAMINATION:\n eval PTX, placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate subclavian line.\n\n COMPARISON: Chest x-ray dated .\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There has been interval\n placement of a left subclavian central venous line with its tip terminating at\n the junction of the brachiocephalic vein and the superior vena cava. There is\n no evidence of pneumothorax. The endotracheal tube is approximately 4.6 cm\n above the carina. Previously seen bilateral lower lobe opacities, unchanged\n in appearance. Cardiac and mediastinal contours are unchanged in appearance.\n\n IMPRESSION: Appropriately placed left subclavian central venous line. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2160-09-19 00:00:00.000", "description": "CT TRACHEA W/O C W/RECONS", "row_id": 881552, "text": " 3:56 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: COPD,DOE\n Admitting Diagnosis: TRACHEAL MALASIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with copd doe\n REASON FOR THIS EXAMINATION:\n eval stenosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TRACHEA DATED \n\n INDICATION: Chronic obstructive pulmonary disease and dyspnea on exertion.\n\n CT of the central airways was performed according to the CT trachea protocol.\n Initially, at end inspiration, images were acquired using a standard-dose\n technique without intravenous or oral contrast administration. Per the CT\n trachea protocol, imaging extended a few centimeters below the carina but did\n not include the entirety of the lung bases. Subsequently, using a low-dose\n technique, an acquisition was performed over a similar area during dynamic\n expiratory phase of respiration. Additionally, using cine mode, images were\n acquired from the level of the aortic arch to the carina during a coughing\n sequence.\n\n At end inspiration, the trachea and main stem bronchi are normal in caliber\n and demonstrate no significant wall thickening. There is evidence of severe\n tracheobronchomalacia, best demonstrated on the coughing sequence images,\n where there is near complete collapse of the trachea, and complete collapse of\n the main stem bronchi and bronchus intermedius during the coughing procedure.\n The tracheomalacia begins at approximately the level of the aortic arch.\n\n Assessment of the imaged portions of the lungs demonstrates severe emphysema\n with centrilobular features. A noncalcified nodule is observed in the right\n middle lobe just below the minor fissure, best visualized on image 191 of\n series 4, and measuring approximately 5 mm in greatest diameter. A\n nonspecific area of ground glass opacity is seen in the right upper lobe\n posteriorly adjacent to the major and minor fissures. Two tiny micronodules\n are seen in the lung apices, and note is also made of small calcified pleural\n plaques bilaterally.\n\n The imaged portions of the soft tissue structures of the thorax reveal no\n significantly enlarged mediastinal or hilar lymph nodes. Within the imaged\n portion of the heart, diffuse coronary artery calcifications are observed.\n\n Skeletal structures reveal degenerative changes within the spine.\n\n MULTIPLANAR AND 3D RECONSTRUCTION IMAGES: These images confirm the absence of\n tracheal or bronchial stenosis as well as the absence of endoluminal lesions\n within the trachea or main stem bronchi. They also confirm the presence of\n airway malacia.\n\n (Over)\n\n 3:56 PM\n CT TRACHEA W/O C W/RECONS Clip # \n Reason: COPD,DOE\n Admitting Diagnosis: TRACHEAL MALASIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Severe tracheobronchomalacia.\n 2. Severe emphysema.\n 3. 5-mm diameter right middle lobe lung nodule and tiny bilateral apical\n micronodules. Recommend a followup chest CT in three months to document\n stability of these small nodules in order to exclude the possibility of early\n lung neoplasm.\n\n" }, { "category": "Radiology", "chartdate": "2160-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882427, "text": " 9:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates\n Admitting Diagnosis: TRACHEAL MALASIA;CHRONIC PULM DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with COPD, hypercarbic respiratory failure, increased wbc\n count, ?PNA.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old woman with COPD, hypercarbic respiratory failure, to\n evaluate for pneumonia.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: The heart size is normal. The cardiomediastinal contours are\n unchanged in appearance. There is bilateral diffuse emphysema. Note is again\n made of asymmetric pulmonary edema. Continued left lower lobe opacity which\n may represent consolidation.\n\n There has been interval removal of the endotracheal tube. The left subclavian\n catheter appears alive at the junction of the left brachiocephalic vein and\n SVC.\n\n IMPRESSION:\n 1. Continued asymmetric pulmonary edema.\n 2. Bilateral diffuse emphysema.\n 3. Left lower lobe consolidation/atelectasis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-09-25 00:00:00.000", "description": "Report", "row_id": 1432690, "text": "Nursing NOte (1700-1900hrs)\n\nPt is a 51yr old female adm with COPD flare; received steroids. Dx with severe tracheal malacia; stabilized for OR--Y stent placed. While in , pt extubated and initial pH 7.09; reintubated . Hypercarbic issues, oliguria, hypotension. Received short period of neo and IVF boluses (total 4L), decided to briefly paralyze with verconium to obtain better control of resp status. Post verconium, oliguria/hypotension/resp status dramatically improved. Pt was extubated at 1530hrs. Thought is pt may have been hypoventilated during OR/bronch and suffered an acute hypoxic event.\n\nPmhx: <chol, smoker, COPD with home )2 /3L with BIPAP during sleep periods, sleep apnea, IDDM, steoporosis d/t steroids, anemia, depression, anxiety, obesity.\n\nReview of systems:\nNeuro: Extremely talkative upon arrival; anxiety. Increased agitation with delayed appearance of family. Family arrived and spirits improved. Pt cont to speak loudly and fast. Portuguese is primary language however speaks good English. Awaiting arrival of Dr. for further assessment of baseline mental status.\n\nCV: Tachy into 120's at times prob d/t anxiety/mental state. BP 147/72 via a-line. Multiple old bruises to abdomen and upper arms--chronic steroids. Has R SC TLCL, confirmed placement with LR at 10cc/hr. PIV RAC. A-line site unremarkable. Labs due in am. Set of blood cx sent. P-boots.\n\nResp: LS clear, diminished to bases. o2 sats >95% with 3L nc/and face tent at 15L for humidification. Awaiting arrival of BIPAP from F11. Inhalers at bedside. Using yankeur independently to clear sputum expectorated.\n\nGi/GU: NPO. SSI. Abd large, obese with hypoactive BS. Good u/o via foley cath. ?LBM, ordered for lactulose/senna/colace.\n\niD: Presumed PNA--vanco/levo. Steroids. Afebrile on arrival.\n\nSocial: Husband is HCP. Pt is Jehovah Witness but will take blood \"or else my husband will be so made at me.\" Full code.\n\nPlan: Iv antibx. steroids. Inhalers, BIPAP at noc. Labs am. Emotional support. Titrate oxygen. SSi.Closely monitor resp stauts.\n" }, { "category": "Nursing/other", "chartdate": "2160-09-25 00:00:00.000", "description": "Report", "row_id": 1432691, "text": "Transfered to MICU from post recovery from Y stent placement.Patient sleeps on BIPAP 14/6 with 4 liter 02 blends in.Has her on machine in room.\n" }, { "category": "Nursing/other", "chartdate": "2160-09-26 00:00:00.000", "description": "Report", "row_id": 1432692, "text": "Shift Note 1900-0700\nPt 51YO female with significant hx for COPD requiring multiple admissions to . Last admit for COPD exacerbation when she underwent bronch reporting tracheomalacia. Pt refered to for further eval by IP team for possible intervention. Pt admitted to 11 and taken to OR for placement of Y stent. Post procedure failed extubation with pH 7.09 and PaCo2 >100...reintubated. Pt then hypotensive with drop in UO. Started on neo, given IVF bolus and paralyzed with improvement in oxygenation, BP and urine output. Successfully extubated and transferred to MICU for further monitoring. Started on abx for presumed pna.\n\nCV: HR 110-120's, ST with no ectopy. ABP via left radial art line 100-130/60-70's. HR 130-140's with increase in SBP 170's with agitation. Pt on verapamil, lisinopril at home. Started on verapamil last evening. Pt able to be calmed with verbal support and reassurance mostly, but has required prn doses of ativan. LSC triple lumen intact with slight oozing of blood noted at insertion site.\n\nResp: Pt initially on 3L NC and Face tent. Pt agitated and pulling off face mask with acute drop in sats to 79%. Face tent increased to 70%FiO2 with 3L NC. Pt on 3L O2 at home with use of Bipap at night. Pt placed on Bipap with 4L maintaining sats 94-96%. When pulling at mask and anxious, sats will decrease to 88%. Pt agitated and SOB....ABG 7.44/49/59/34. Given 1mg ativan with good response. BBS clear-coarse and diminished in lower lobes.\n\nNeuro: Pt alert/oriented x3. Answering questions appropriately, but occasionally making comments such as \"Is there medicine in this\" referring to suction tubing. Very anxious and angry about hospitalization and \"everything I been through\". Gets very worked up and yelling at times. Responds well to verbal support. Pt has baseline anxiety and per patient takes ativan 0.5mg at home.\n\nGI/GU: Abdomen obese, BS present. On clear liquid diet, taking meds and clear well. Pt very concerned about chocking and afraid to have much more than sips of water. Foley cath draining adequate amounts of UO, clear/yellow. Last BM tuesday. Pt started on bowel regimen.\n\nID: Pt on levofloxacin and vanco. Afebrile. Pan cx yesterday...sputum cx showing gram + cocci in pairs/clusters, cx still pending. WBC 24.4 from 31.8.\n\nEndo: Receiving methylprednisolone....BS AC/HS with sliding scale coverage. Should be started on NPH when diet initiated.\n\nSocial: Family to visit last night, husband called this am. Full code.\n\nPlan: Wean O2\n Control HR, BP\n Continue abx\n Treat anxiety\n" }, { "category": "Nursing/other", "chartdate": "2160-09-26 00:00:00.000", "description": "Report", "row_id": 1432693, "text": "resp care\nPt placed on her own bipap with settings of 14/6 with 4l O2. sats generally 94-96 but to 85 with talking and moving. BS coarse bil. Alb/atro neb given as ordered with improvement in aeration. Cough prod of sml amts of loose white sput. Will cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2160-09-26 00:00:00.000", "description": "Report", "row_id": 1432694, "text": "7a-7p\nsee transfer note\n" } ]

[ { "category": "Radiology", "chartdate": "2138-04-09 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1009356, "text": " 10:19 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: ? tumor\n Admitting Diagnosis: BRAIN MASS\n Field of view: 36 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with brain mass & hx of renal cell CA s/p nephrectomy\n REASON FOR THIS EXAMINATION:\n ? tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with brain mass. History of renal cell carcinoma\n status post nephrectomy.\n\n COMPARISON: Chest radiographs from one day earlier.\n\n TECHNIQUE: Multidetector CT scanning of the chest, abdomen and pelvis was\n performed with oral and intravenous contrast. Non-contrast images through the\n abdomen and delayed images through the kidneys as well as coronal and sagittal\n reformations were obtained.\n\n CT OF THE CHEST: The heart size is within normal limits. There are coronary\n calcifications noted. There is a small amount of pericardial fluid. The\n caliber of the thoracic aorta is within normal limits. There is a 2.9 x 1.9\n cm hilar lymph node with low density centrally consistent with necrosis. Small\n paratracheal lymph nodes are noted which do not meet criteria for pathologic\n enlargement. The central airways are patent without endoluminal lesion.\n\n In the left upper lobe, there is a 2.6 x 2.8 cm poorly defined mass (3:14).\n More inferiorly, there is an 11-mm nodule, also in the left upper lobe (3:20).\n The lower lobes demonstrate bilateral atelectatic changes. There are mild\n subpleural bullous changes bilaterally, more prominent the apices. There are\n no pleural effusions. No axillary lymphadenopathy is appreciated.\n\n CT OF THE ABDOMEN: There are several hypodensities within the liver, which\n demonstrate peripheral contrast enhancement on the portal venous phase, and\n those visualized on the delayed phase demonstrate centripetal filling. These\n are consistent with hepatic hemangiomas. The largest in the left lobe\n measures 10.4 x 6.0, and the second largest in the right lobe dome measures\n 6.9 x 4.7 cm. In addition, there are smaller hypodensities, particularly in\n the right lobe anteriorly, measuring up to 13 mm which are probably also\n hemangiomas but are too small to effectively characterize. These include\n lesions seen on series 3, image 40 and 38.\n\n The gallbladder is normal in size with small amounts of high-density material\n layering within it which may represent sludge. The right adrenal gland is\n normal. The spleen and pancreas appear normal. There has been a left-sided\n nephrectomy. Small bowel has fallen into the nephrectomy bed. In addition,\n there is a small amount of soft tissue measuring no more 23 x 12 mm (3:57). In\n the right kidney, there are multiple cysts. The largest in the upper pole\n (Over)\n\n 10:19 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: ? tumor\n Admitting Diagnosis: BRAIN MASS\n Field of view: 36 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n measures 7.1 x 5.4 cm axially and contains both a septation as well as a\n peripheral calcification. Along the posterior interpolar region, there is a\n 2.2-cm cyst, which has a rather thick wall. Several other cysts are noted\n which are incompletely characterized.\n\n There is no retroperitoneal or mesenteric lymphadenopathy, ascites, free\n intraperitoneal air, and no aneurysmal dilation of the abdominal aorta, though\n there is atherosclerotic calcification infrarenally. Loops of small and large\n bowel are normal in caliber and contour.\n\n CT OF THE PELVIS: The bladder, seminal vesicles, and rectum are unremarkable.\n The prostate is enlarged, measuring 5.9 cm in diameter. There is no free\n fluid in the pelvis. There is no pelvic lymphadenopathy.\n\n OSSEOUS STRUCTURES: There is a lytic lesion involving the T5 vertebral body,\n right pedicle, transverse process, and extending into the spinous process.\n There is destruction of the central cortex, and invasion of the enhancing mass\n into the epidural space, with displacement of the spinal cord towards the\n left. A second lytic lesion which does not demonstrate any cortical break as\n of yet is noted within the L3 vertebral body.\n\n IMPRESSION:\n\n 1. Lesions consistent with metastases from renal cell carcinoma demonstrated\n within the lungs, left hilum, and spine as detailed above. The lesion within\n the T5 vertebral body and posterior elements erodes the cortex, involves the\n epidural space, and causes mass effect in the spinal cord. This was discussed\n with Dr. of the primary service.\n\n 2. Multiple hepatic lesions consistent with hemangiomas. Two smaller hepatic\n lesions are not fully characterized, but are still more likely to be\n hemangiomas than foci of metastatic disease.\n\n 2. Multiple right kidney cysts, some of which appear complex. Contralateral\n renal cell carcinoma cannot be excluded. Small amount of soft tissue in the\n left nephrectomy bed. Attention on followup recommended.\n\n\n\n (Over)\n\n 10:19 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST\n Reason: ? tumor\n Admitting Diagnosis: BRAIN MASS\n Field of view: 36 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2138-04-11 00:00:00.000", "description": "MR HEAD W/ CONTRAST", "row_id": 1009639, "text": " 7:20 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Please do for pre-op planning**Please do at 8 am**\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with brain mass\n REASON FOR THIS EXAMINATION:\n Please do for pre-op planning**Please do at 8 am**\n CONTRAINDICATIONS for IV CONTRAST:\n Has 1 kidney.\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with brain mass, now for pre-op planning.\n\n COMPARISON: MR head of and CT head of .\n\n TECHNIQUE: Limited axial T1-weighted imaging was performed through the brain\n after administration of 20 mL of IV Magnevist for preoperative planning.\n\n FINDINGS: Post-contrast axial T1 and MP-RAGE images of the brain re-\n demonstrate a large heterogeneous mass in the right temporoparietal lobe with\n possible involvement of the right lateral ventricle. The large solid\n enhancing component measures 4.9 x 4.8 cm. There are also areas of\n hemorrhage, cystic change and necrosis. There is surrounding vasogenic edema\n with compression of the right lateral ventricle and 9-mm leftward shift of\n normally midline structures. A 2.0 x 1.7 cm lesion is unchanged in the left\n parapharyngeal space, and again may represent a lymph node. No other lesions\n are seen. The remainder of the exam is unchanged.\n\n IMPRESSION: Large heterogeneous mass in the right parietotemporal lobe with\n possible involvement of right lateral ventricle. 2-cm left parapharyngeal\n lesion, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1009090, "text": " 4:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hx of RCC s/p nephrectomy 6 yrs ago in with HA x 2\n wks, constant, no other neuro complaints. Had CT at OSH with 3-4 cm R parietal\n mass with 1-3 cm shift. Poor study. Pt w/o HA currently, neuro exam nonfocal.\n REASON FOR THIS EXAMINATION:\n eval for mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf MON 5:06 PM\n 5 cm right parietal complex mass with hemorrhagic and cystic components, 1 cm\n leftward shift, subfalcine herniation. Extensive surrounding vasogenic edema.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 57-year-old man with history of renal cell carcinoma presenting\n with headaches for two weeks.\n\n COMPARISON: Not available at this institution.\n\n FINDINGS: In the right parietal lobe, there is a complex 5.2 x 5.1 cm mass\n with hemorrhagic, cystic and solid components, as well as foci of\n calcification. There is 1 cm contralateral shift of septum pellucidum. There\n is mass effect on the ipsilateral ventricle and entrapment of the\n contralateral ventricle. There is subfalcine herniation. The suprasellar\n cisterns are patent. There is a significant amount of surrounding vasogenic\n edema. There are no extra-axial collections.\n\n Surrounding osseous structures demonstrate no concerning lytic or sclerotic\n lesions. Visualized paranasal sinuses are well aerated.\n\n IMPRESSION: Large right parietal complex intra-axial mass with hemorrhagic\n and cystic necrotic components and surrounding vasogenic edema, mass effect on\n ipsilateral ventricle and subfalcine herniation. The differential diagnosis\n includes metastasis from known renal cell carcinoma versus primary high-\n grade glial tumor. Gadolinium-enhanced MR is recommended for further\n characterization as well as to assess for other metastatic foci.\n\n Findings were posted to the ED dashboard as well as discussed with Dr. \n (ED) immediately upon completion of the study.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009755, "text": " 10:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with\n REASON FOR THIS EXAMINATION:\n ET tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement.\n\n A single portable radiograph of the chest demonstrates interval placement of\n an endotracheal tube. The ET tip is at the level of the clavicular heads.\n There is a new nasogastric tube with its tip in the stomach. The proximal\n side port of the nasogastric tube is at the level of the GE junction. The\n nasogastric tube should be advanced. The lung volumes are low. There are\n increased ill-defined opacities projecting over the bilateral lung bases. The\n costophrenic angles are sharp. No pneumothorax. Trachea is midline.\n\n IMPRESSION:\n\n Endotracheal tube in place.\n\n Nasogastric tube with its tip in the stomach. The proximal side port of the\n nasogastric tube is at the level of the GE junction. The nasogastric tube\n should be advanced.\n\n Bibasilar opacities. Diagnostic considerations include atelectasis, although\n the morphology could be seen with early pneumonia as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1009125, "text": " 12:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lower saturation\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57M p/w headache with newly diagnosed 5cm right parietal mass with about 9mm of\n leftward shift and surrounding vasogenic edema with lower oxygen saturation.\n REASON FOR THIS EXAMINATION:\n eval lower saturation\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Headache, newly diagnosed 5-cm right parietal mass with about\n 9-mm of leftward shift and surrounding vasogenic edema with low oxygen\n saturation. Evaluate causes of low oxygen saturation.\n\n FINDINGS: The heart size is within normal limits. No typical configurational\n abnormalities identified. The thoracic aorta is moderately widened and\n elongated but not excessive for age. The pulmonary vasculature is normal. No\n signs of acute infiltrates and the lateral pleural sinuses are free. No\n evidence of pneumothorax in the apical area. Skeletal structures grossly\n within normal limits.\n\n There exists no prior chest examination or records available for comparison.\n\n IMPRESSION: Single view portable chest examination does not disclose any\n cause for patient's question low oxygen saturation.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-08 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1009236, "text": " 2:03 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: **** PLS DO CTA AND CTV of head***** eval new diagnosis mas\n Admitting Diagnosis: BRAIN MASS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with h/o RCC s/p L nephrectomy , with newly diagnosed 5cm R\n parietal mass, left shift\n REASON FOR THIS EXAMINATION:\n **** PLS DO CTA AND CTV of head***** eval new diagnosis mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with brain tumor, for evaluation of arterial\n and vascular supply.\n\n TECHNIQUE: Using departmental protocol, CT angiography and CT venography of\n the head were acquired. Reformatted images were obtained.\n\n FINDINGS: There is a large right basal ganglia mass identified which involves\n the medial temporal lobe and extending to the periatrial region. There is\n enhancement seen in the periatrial region. There is surrounding edema\n identified.\n\n The CT angiography demonstrates no evidence of significantly enlarged vascular\n structures extending to the mass. There is mass effect on the right lateral\n ventricle with displacement. The mass has cystic and solid components.\n\n The CT venography phase of the study demonstrates displacement of the basal\n vein of medially. There is also deviation of the internal cerebral\n veins identified. No vascular occlusion seen. There is no evidence of\n enlarged draining veins identified.\n\n IMPRESSION: Right temporal mass extending to periatrial region with mass\n effect on the right lateral ventricle and midline shift as seen on the recent\n MRI. No abnormal arterial or venous structures are identified.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-13 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1009927, "text": " 2:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: residual mass?\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with parietal mass s/p resection\n REASON FOR THIS EXAMINATION:\n residual mass?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n GADOLINIUM-ENHANCED MR SCAN OF THE BRAIN\n\n HISTORY: Status post resection of right parietal mass. Assess for residual\n tumor.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was obtained pre-\n and post-gadolinium administration.\n\n COMPARISON STUDY: MR scan of the brain from .\n\n FINDINGS: There is a lace-like pattern of enhancement along the anteromedial\n aspect of the right temporal lobe, apparently surrounding the right temporal\n body. There is persistent mild dilatation of the right temporal \n tip, but substantially reduced in extent compared to the prior preoperative\n study. Additionally, there is presumed hemorrhage along the operative tract,\n more peripherally situated within the posterior aspect of the right temporal\n lobe.\n\n The extensive edema surrounding the formerly very large tumor appears\n unaltered in extent. However, overall, there is somewhat less mass effect,\n though there is still leftward subfalcine herniation present. Numerous tiny\n areas of elevated T2 signal are seen within the white matter of both cerebral\n hemispheres, presumably representing chronic small vessel infarctions or post-\n inflammatory residua.\n\n There is soft tissue swelling, subgaleal in locale at the craniotomy site and\n there is a possible fluid collection or surgical material within the crescent-\n shaped space between the dura spanning the craniotomy flap and the inner table\n of the flap itself.\n\n There is redemonstration of the well- defined, rounded 21 mm area of contrast\n enhancement in the left parapharyngeal fat area. Its sharp margination seems\n most consistent with a benign neoplastic process (question neurogenic tumor).\n This location would be very unusual for a lymph node or metastatic disease, as\n was suggested on the previous report.\n\n CONCLUSION: Findings suggest that there is residual tumor in the region of\n the right temporal lobe surrounding the right temporal , with mild\n residual entrapment of this portion of the right lateral ventricle, as\n described above.\n (Over)\n\n 2:41 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: residual mass?\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1009747, "text": " 8:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess post-op head CT, eval for hemorrhage\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p tumor removal from R lateral ventricle\n REASON FOR THIS EXAMINATION:\n Please assess post-op head CT, eval for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post tumor removal from the right lateral ventricle.\n\n COMPARISON: .\n\n TECHNIQUE: Noncontrast head CT.\n\n CT OF THE HEAD WITHOUT CONTRAST: The patient is status post right\n parietotemporal lobe mass resection. Post surgical changes including right\n parietal craniectomy, pneumocephalus, and small area of hematoma in the\n surgical bed. Vasogenic edema is seen. Seven millimeter leftward midline\n shift. Effacement of the right cerebral hemisphere sulci with compression of\n the right lateral ventricle. Extra-axial fluid collection along the right\n parietal convexity measuring up to 9 mm in thickness. There is no\n hydrocephalus.\n\n IMPRESSION: Status post right parietotemporal lobe mass resection with\n postoperative changes as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2138-04-08 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1009147, "text": " 5:37 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate lesion\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with intracranial mass lesion\n REASON FOR THIS EXAMINATION:\n evaluate lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old mid patient, with endocranial mass lesion, to\n evaluate lesion.\n\n PRIOR STUDIES: CT of the head done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the head was performed\n without and with IV contrast.\n\n FINDINGS:\n\n There is a large heterogeneous mass lesion, in the right temporoparietal\n lobes, with areas of hemorrhage, cystic change, necrosis and large solid\n enhancing component. The solid competent measures 5.0 x 4.3 cm. There is\n entrapment of the right temporal . There is surrounding significant\n vasogenic edema, with a leftward shift of subfalcine herniation; measuring\n approximately 1 cm is unchanged, allowing for technical differences, compared\n to the prior CT. Mass effect on the right lateral ventricle, is unchanged.\n There is a 1.7 x 1.6 cm round focus of increased signal on the FLAIR, with\n enhancement on the post-contrast images in the left parapharyngeal space,\n which corresponds to an abnormally enlarged lymph node, on correlation with\n the CT angiogram performed on the same day (series 9, image 1), however, this\n is not completely included on our present study.\n\n IMPRESSION:\n 1. Large heterogeneous mass lesion in the right parietal and temporal lobes,\n with cystic, necrotic, hemorrhagic and solid components, the solid competent\n measuring 5.0 cm, with significant surrounding edema, mass effect and\n subfalcine herniation, and entrapment of the right temporal without\n significant change since the CT head done the day before.\n\n 2. 1.7-cm enhancing focus in the left parapharyngeal region, representing an\n abnormally enlarged lymph node, representing metastatic involvement. However,\n this is not completely included on our present study.\n\n\n (Over)\n\n 5:37 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate lesion\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2138-04-08 00:00:00.000", "description": "Report", "row_id": 1666984, "text": "NPN (NOC):\n\nPT IS A LOVELY 57 Y/O GENTLEMAN W/ PMHX OF RENAL CELL CA RESECTED IN . HE PRESENTED TO ED AT OSH W/ 10 DAY HX OF H/A. CT SHOWED MASS AND PT TRANS HERE FOR FURTHER CARE. HE IS ASYMPTOMATIC EXCEPT FOR H/A. MED W/ VICODIN 1 TAB PO X1 AT 7AM. MRI DONE AT 6AM. PT HAS BEEN NPO EXCEPT PILLS W/ SIPS H2O SINCE MN. IVF BEGUN. DIALNTIN LOAD BEGUN AT 7AM. NO SZ ACTIVITY NOTED. PARENTHETICALLY, PT'S SATS ARE 89% ON R/A. PT HAS NO PULMONARY HX AND CXR LOOKS OKAY PER DR. . HE IS NOW IN LOW TO MID 90'S ON 4 LITERS NC. HIS LUNGS ARE CLEAR, RR 16-20 AND PT IS NOT SOB. PLAN IS FOR BRAIN BX TODAY. PT SPEAKS VERY LIMITED ENGLISH AND HIS SON WILL BE IN EARLY TODAY TO TRANSLATE.\n" }, { "category": "ECG", "chartdate": "2138-04-08 00:00:00.000", "description": "Report", "row_id": 215084, "text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2119-08-07 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 878169, "text": " 2:08 AM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: eval reduction\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 25 foot fall\n\n REASON FOR THIS EXAMINATION:\n eval reduction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Evaluate reduction. Status post fall.\n\n Left wrist, three views on .\n\n Since , a new fiberglass cast has been placed over the wrist.\n Reidentified is a comminuted slightly impacted fracture of the distal radial\n metaphysis with interval reduction of the dorsal angulation of the distal\n fracture fragment. 4mm posterior displacement of the distal fracture\n fragment is unchanged. There is ulnar- positive variance. Nondisplaced\n fracture of the ulnar styloid is unchanged.\n\n IMPRESSION:\n 1. Interval placement of a fiberglass cast which limits fine bony detail.\n 2. Interval reduction of dorsal angulation of distal fracture fragment.\n Posterior displacement of distal fracture fragment is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "LUMBO-SACRAL SPINE (AP & LAT)", "row_id": 878155, "text": " 11:23 PM\n LUMBO-SACRAL SPINE (AP & LAT); T-SPINE Clip # \n Reason: please eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with 5 ft\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n FINDINGS: These two examinations consist of AP and lateral views of the\n thoracic spine, and AP and lateral views of the lumbar spine. There is\n straightening of thoracic kyphosis and lumbar lordosis on the lateral views.\n No fractures are identified in the thoracic or lumbar spine. Alignment is\n normal. There is a horizontal lucency extending into the left ilium from the\n sacroiliac joint, corresponding to a known left iliac fracture. There is\n radiopaque contrast in the bladder.\n\n IMPRESSION:\n 1. No fracture in the thoracic or lumbar spine.\n 2. Left ilium fracture extending to the sacroiliac joint.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 878151, "text": " 10:47 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 5 feet\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 11:24 PM\n no intracranial hemorrhage or mass effect; fractures of the anterior and\n medial wall of right maxillary sinus; suggest facial bone CT to better\n evaluate the orbit\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, or shift of\n normally midline structures. /white matter differentiation is preserved.\n There is no hydrocephalus.\n\n There are fractures of the anterior, medial, and lateral walls of the right\n maxillary sinus, with likely involvement of the orbital floor. There is blood\n in the right maxillary sinus. There is a right nasal bone fracture. There is\n opacification of the ethmoid air cells, right greater than left. There is\n mucosal thickening in the right frontal sinus.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage or mass effect.\n 2. Fractures of the anterior, medial, and lateral wall of the right maxillary\n sinus with likely involvement of the orbital floor. Further evaluation by\n facial bone CT is suggested.\n 3. Right nasal bone fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 878152, "text": " 10:47 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 5 feet\n REASON FOR THIS EXAMINATION:\n fracture?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 11:29 PM\n no fracture or malalignment; small disk protrusion at C5/6 with mild\n degenerative spurring, but traumatic component cannot be excluded; discussed\n with trauma team\n WET READ VERSION #1 DFDkq SUN 11:24 PM\n no fracture or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial noncontrast multidetector CT images of the cervical spine\n were obtained. Sagittal and coronal reconstructions were performed.\n\n FINDINGS: There is no fracture or malalignment. At C5/6, there is a small\n disc protrusion with associated mild uncovertebral spurring, suggesting that\n this is degenerative in nature. However, a traumatic component cannot be\n excluded. There is no prevertebral soft tissue swelling.\n\n IMPRESSION:\n 1. No fracture or malalignment.\n\n 2. Small disc protrusion at C5/6, which may be degenerative in nature, but a\n traumatic component cannot be excluded.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 878153, "text": " 10:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: bleed?\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 5 feet\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq MON 12:50 AM\n -fractures of left inferior pubic ramus and iliac extending into the SI\n joint; associated hematomas with possible active extravasation\n -no solid organ injury or intraperitoneal free fluid\n\n -delayed images through pelvis do not confirm active extravasation\n WET READ VERSION #1 DFDkq SUN 11:31 PM\n -fractures of left inferior pubic ramus and iliac extending into the SI\n joint; associated hematomas with possible active extravasation\n -no solid organ injury or intraperitoneal free fluid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 25 feet.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial multidetector CT images of the abdomen and pelvis were\n obtained with 150 cc of intravenous Optiray. Sagittal and coronal\n reconstructions were performed. The pelvic portion of the study was then\n reconstructed in bone algorithm. And sagittal and coronal reformatted images\n of these reconstructions were obtained. A 30-minute delayed scan through the\n pelvis was also obtained.\n\n ABDOMEN CT WITH INTRAVENOUS CONTRAST: The lung bases are clear with no\n evidence of pneumothorax. The liver, spleen, pancreas, and kidneys do not\n demonstrate any evidence of contusion, laceration, or other injury. The\n gallbladder and adrenal glands appear unremarkable. Unopacified bowel loops\n appear unremarkable. There is no free air or free fluid.\n\n PELVIS CT WITH INTRAVENOUS CONTRAST: There is a Foley catheter in the\n bladder. The uterus, adnexa, and rectum appear unremarkable. There is no\n free fluid.\n\n BONE ALGORITHM RECONSTRUCTIONS: There is a coronal fracture through the left\n iliac , which extends into the sacroiliac joint. The fracture also\n extends into the anterior tip of the sacrum adjacent to the sacroiliac joint.\n There is a comminuted fracture of the left inferior pubic ramus. There is a\n hematoma within the left obturator muscle, as well as in the muscles\n surrounding the ilium fracture. Linear high-density material noted within\n these hematomas on the initial images does not persist on the delayed images,\n and there is no increase in hematoma density on the delayed images. These\n (Over)\n\n 10:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: bleed?\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n linear densities likely represent vascular structures rather than active\n extravasation.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the findings\n demonstrated on the axial images. They are particularly useful in assessing\n the anatomy of the pelvic fractures. They are also useful in excluding spinal\n fractures. Overall value grade is 4.\n\n IMPRESSION:\n 1. No solid organ injury in the abdomen or pelvis. No free fluid.\n 2. Fracture of the left ilium and sacrum. Comminuted fracture of the left\n inferior pubic ramus. Associated intramuscular hematomas without evidence of\n active extravasation.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 878154, "text": " 11:04 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: please eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with 5 ft\n REASON FOR THIS EXAMINATION:\n please eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq SUN 11:59 PM\n right nasal bone fracture\n fractures of medial and lateral walls of the right maxillary sinus/fracture of\n right orbital floor with a fracture fragment displaced into the orbit;\n questionable right lateral orbit wall fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Axial multidetector CT images of the facial bones were obtained\n without contrast. Sagittal and coronal reconstructions were performed.\n\n FINDINGS: There is a right nasal bone fracture with blood in the right nasal\n cavity. There are fractures of the medial and lateral wall of the right\n maxillary sinus, with blood filling the sinus. There is a comminuted fracture\n of the anterior wall of the right maxillary sinus, contiguous with an\n inferior orbital rim and orbital floor fracture. There is a free fracture\n fragment displaced superiorly into the orbit in its anterior aspect. There is\n associated orbital emphysema. There is moderate opacification of the right\n ethmoid air cells and mild opacification of the left ethmoid air cells. There\n is mild mucosal thickening in the sphenoid sinus and in the right frontal\n sinus. There is some gas and swelling in the soft tissues overlying the right\n maxillary sinus and right orbit.\n\n IMPRESSION:\n 1. Fracture of the anterior wall of the right maxillary sinus/right orbital\n floor with a free bony fragment displaced superiorly into the orbit. Fractures\n of the medial and lateral walls of the right maxillary sinus.\n 2. Right nasal bone fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "B ANKLE (AP, MORTISE & LAT) BILAT", "row_id": 878156, "text": " 11:23 PM\n ANKLE (AP, MORTISE & LAT) BILAT Clip # \n Reason: fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 25 foot fall\n REASON FOR THIS EXAMINATION:\n fracture?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n FINDINGS: These two examinations consist of AP and lateral views of the right\n foot, and AP and lateral views of the left foot. There are comminuted\n fractures of the right and left calcaneus. In the right ankle, there is a\n fracture of the distal fibula with mild lateral displacement of the distal\n fracture fragment. The ankle mortise remains intact. There is soft tissue\n swelling circumferentially. In the left ankle, no additional fractures are\n identified, and the mortise is intact.\n\n IMPRESSION:\n 1) Comminuted fractures of the right and left calcaneus.\n 2) Right distal fibula fracture.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "L WRIST(3 + VIEWS) LEFT", "row_id": 878157, "text": " 11:47 PM\n WRIST(3 + VIEWS) LEFT Clip # \n Reason: fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 25 foot fall\n REASON FOR THIS EXAMINATION:\n fracture?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 20 feet.\n\n COMPARISON: No previous studies.\n\n FINDINGS: AP, oblique and lateral views of the left wrist. There is a\n comminuted fracture of the distal radius with dorsal angulation of the distal\n fracture fragment. There is a nondisplaced fracture through the ulnar\n styloid. Alignment of the radius, lunate and capitate appears normal.\n\n IMPRESSION: Colles fracture.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "CHEST (SINGLE VIEW)", "row_id": 879401, "text": " 9:16 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS:\n\n INDICATION: 20-year-old woman with fever.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed. No\n previous study is available for comparison.\n\n The lungs are clear. The heart and mediastinum are within normal limits.\n\n IMPRESSION: No active lung disease on this single chest x-ray. If clinically\n indicated, please obtain repeat PA and lateral radiographs of the chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-07 00:00:00.000", "description": "PELVIS WITH JUDET VIEWS", "row_id": 878221, "text": " 9:57 AM\n PELVIS WITH JUDET VIEWS; PELVIS (AP, INLET & OUTLET) Clip # \n Reason: assess for fx\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with s/p fall w/ left pubic ramus fx, iliac fx\n REASON FOR THIS EXAMINATION:\n assess for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall.\n\n FOUR VIEWS OF THE PELVIS INCLUDING BILATERAL OBLIQUE AND INLET VIEWS:\n\n Comparison is made to the CT performed one day prior. Again seen is a\n slightly comminuted, but minimally displaced fracture involving the inferior\n pubic ramus on the left. The known slightly comminuted left iliac \n fracture with extension into the inferior sacroiliac joint is again seen.\n There is no diastasis of the left sacroiliac joint. Right sacroiliac and hip\n joints and distal lumbar spine appear normal in the views provided.\n\n IMPRESSION: Left iliac and inferior pubic ramus fractures as above.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-16 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 879455, "text": " 2:21 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: FEVER, MULTIPLE FACIAL FRACTURES, EVAL FOR FOCAL SINUS INFECTION,ABCESS\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with multiple facial fractures, now with fever\n REASON FOR THIS EXAMINATION:\n please eval for focal sinus infection/abcess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 20-year-old woman with multiple facial fractures, now with fever,\n evaluate for sinus infection or abscess.\n\n COMPARISONS: CT sinuses performed on .\n TECHNIQUE: Axial MDCT images through the sinuses and orbits without IV\n contrast.\n\n FINDINGS: Again identified are fractures involving the right nasal bone,\n right maxillary sinus, and right orbital floor. These are not significantly\n changed. There has been dramatic improvement in opacification of the right\n maxillary and ethmoid sinuses. There remains premaxillary soft tissue\n swelling, with several areas of focal soft tissue density, which may represent\n organizing hematoma. These findings, especially without IV contrast, are not\n specific re: potential underlying infection; however, there are no CT signs to\n suggest superimposed infection or abscess. There is no adjacent osseous\n destruction. There are no abnormalities seen within the adjacent brain\n parenchyma.\n\n IMPRESSION:\n 1) Stable appearance of multiple facial fractures.\n 2) Dramatic clearing of the previously seen opacification of the right\n maxillary and ethmoid sinuses.\n 3) Persistent premaxillary soft tissue inflammation, with more focal soft\n tissue components, likely related to prior trauma. Without IV contrast, there\n are no specific CT signs to suggest superimposed infection or abscess- follow-\n up contrast enhanced imaging can be considered, in this regard.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-06 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 878150, "text": " 10:26 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: ptx? fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 25 foot fall\n REASON FOR THIS EXAMINATION:\n ptx? fracture?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall from 25 feet.\n\n COMPARISON: No previous studies.\n\n CHEST: AP portable supine view: Evaluation is limited by the superimposed\n trauma board structures. There is no widening of the mediastinum. The\n cardiac silhouette is normal. The lungs are grossly clear. There is no\n pleural effusion and no evidence of pneumothorax in supine position. No\n fractures are identified.\n\n PELVIS: AP supine portable view. There is a left inferior pubic ramus\n fracture. There is a faint linear horizontal lucency through the left iliac\n . Correlation with the torso CT performed on the same day reveals that\n there is a fracture of the left iliac . Hip joint alignment appears\n normal on the single projection provided. The proximal left femur is obscured\n by a superimposed foreign body.\n\n IMPRESSION:\n 1. No evidence of acute traumatic chest injury.\n 2. Left inferior pubic ramus fracture. Faint horizontal linear lucency\n through the left ilium, which is shown to be a fracture on the torso CT scan\n of the same day.\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-07 00:00:00.000", "description": "R FOREARM (AP & LAT) RIGHT", "row_id": 878176, "text": " 5:05 AM\n FOREARM (AP & LAT) RIGHT Clip # \n Reason: assess for fx\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with s/p fall w/ mult fx\n REASON FOR THIS EXAMINATION:\n assess for fx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Assess for fracture.\n\n LEFT FOREARM AP & LATERAL: The lateral image does not include elbow. Compared\n to prior examination of 2:09 a.m., re-identified is an impacted comminuted\n fracture of the distal radial metaphysis with medial and dorsal displacement\n of the distal radial fracture fragment, unchanged. There is ulnar positive\n variance. Ulnar styloid fracture is re- identified. The forearm is in a\n fiberglass cast which limits fine bony detail.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-07 00:00:00.000", "description": "B CT LOW EXT W/O C BILAT", "row_id": 878198, "text": " 8:07 AM\n CT LOW EXT W/O C BILAT; CT RECONSTRUCTION Clip # \n Reason: assess for fx\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman with s/p fall w/ bilat calcaneus fx\n REASON FOR THIS EXAMINATION:\n assess for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old woman with bilateral calcaneus fractures status post\n fall.\n\n TECHNIQUE: Non-contrast MDCT of the bilateral ankles acquired in the axial\n plane and reconstructed in the sagittal and coronal planes.\n\n COMPARISON: No prior CT. Ankle radiographs dated .\n\n CT BILATERAL FEET:\n\n On the right, a comminuted fracture of the distal fibula extends as far\n superiorly as approximately the tibiotalar joint. There is mild displacement\n of the fracture fragments. Markedly comminuted fracture of the calcaneus\n extends to the subtalar and calcaneocuboid joints. The posterior subtalar\n joint is particularly widened and disrupted. The sustentaculum tali is\n comminuted. There is narrowing of the sinus tarsi. Fragments also project to\n the tarsal tunnel. There is a generalized flattening to the configuration of\n the calcaneal fragments. The ankle mortise remains relatively congruent.\n\n On the left, a tiny osseous fragment projects posterolaterally from the distal\n fibula at the expected level of the superior peroneal retinaculum, likely\n representing an avulsion. A comminuted fracture of the calcaneus extends to\n the subtalar and calcaneocuboid joints. There is widening of the posterior\n subtalar joint, less pronounced than on the contralateral side. The\n sustentaculum tali is separated as primarily one fragment. The sinus tarsi is\n not particularly narrowed. The calcaneal fragments have a generalized\n flattened configuration. The ankle mortise remains relatively congruent.\n\n Limited assessment of tendons crossing the ankle joints is grossly\n unremarkable. Diffuse soft tissue edema is more pronounced on the right than\n the left. Casts have been placed on both lower extremities.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatted images were useful in\n delineating the extent of the severely comminuted bilateral calcaneal\n fractures.\n\n IMPRESSION:\n 1. Comminuted bilateral calcaneal fractures, with disrupted subtalar joints,\n as above.\n 2. Comminuted distal right fibula fracture.\n 3. Calcific adjacent to left distal fibula suggestive fo avulsion\n (Over)\n\n 8:07 AM\n CT LOW EXT W/O C BILAT; CT RECONSTRUCTION Clip # \n Reason: assess for fx\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fracture at the insertion site of the superior peroneal retinaculum.\n\n" }, { "category": "Radiology", "chartdate": "2119-08-18 00:00:00.000", "description": "CT PELVIS ORTHO W/O C", "row_id": 879655, "text": " 10:40 AM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: please check status of pelvic fracture\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old woman s/p 5 feet\n REASON FOR THIS EXAMINATION:\n please check status of pelvic fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma and pelvic fractures.\n\n TECHNIQUE: Multidetector CT images of the bony pelvis were obtained without\n intravenous contrast material. Sagittal and coronal reformations were\n created.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Comparison is made to a prior study\n dated . In the interval, there has been no change in the\n appearance of known pelvic fractures. There is a comminuted, oblique fracture\n involving the left iliac bone with extension into the sacroiliac joint. There\n is no associated diastasis. Mildly comminuted, minimally displaced fracture\n of the left inferior pubic ramus is unchanged as well. Hip joints appear\n normal. No other fractures are identified.\n\n Imaged soft tissues are notable for gas within the urinary bladder, which is\n presumably secondary to recent instrumentation. No free fluid is present\n within the pelvis. Previously described soft tissue hematomas are\n inconspicuous on today's exam. Several small, non-pathologically enlarged\n bilateral inguinal lymph nodes are noted.\n\n IMPRESSION: No significant interval change in pelvic fractures..\n\n\n" }, { "category": "Radiology", "chartdate": "2119-08-07 00:00:00.000", "description": "OL WRIST(3 + VIEWS) IN O.R. LEFT", "row_id": 878305, "text": " 8:22 PM\n WRIST(3 + VIEWS) IN O.R. LEFT Clip # \n Reason: ORIF L WRIST\n Admitting Diagnosis: PELVIC FRACTURE,MULTIPLE TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: ORIF of the left wrist.\n\n COMPARISON: , at 10:15.\n\n FINDINGS: Three fluoroscopic spot views obtained in the operating room\n without a radiologist present are submitted for review. These demonstrate a\n metallic plate with screws transfixing a distal radial fracture. Osseous\n alignment is satisfactory.\n DFDdp\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-09 00:00:00.000", "description": "Report", "row_id": 1299266, "text": "TSICU Nursing Progress Note\nNeuro - Pt alert, oriented. Anxious at times, tearful, does not want to be left alone. Eyes swollen shut. MAE spontaneously and to command. Able to make needs known.\n\nCV - ST most of shift, developing frequent PVCs in AM. Repleting K+, MG+, Ca++ per orders. SBP stable. Peripheral pulses palpable. Edema decreasing through night.\n\nResp - Pt with O2 sats > 96% on RA. Lungs CTA. Snoring when deeply asleep with no drop in O2 sats.\n\nGI - Tolerating sips of clears and ice chips. Asked for salad to eat. Abdomen soft, + BS, + flatus.\n\nGU - Brisk clear yellow urine via foley.\n\nSocial - Boyfriend with pt much of night per her request. Boyfriend is supportive, believes that full impact of injury has not really hit yet.\n\nA - Hemodynamically stable. Not requiring O2, no resp compromise.\n\nP - Consider transfer to floor. Replete electrolytes per order. Encourage f/u with SW.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2119-08-07 00:00:00.000", "description": "Report", "row_id": 1299263, "text": "TSICU Nsg Admit Note\n Pt admitted to TSICU via EW s/p fall from rafters during Rolling Stones concert. Positive LOC at the scene yet A+O enroute to EW. Work up revealed the following injuries: right nasal bone fx, right maxillary sinus fx extending to the right orbital floor w/ free floating bone fragment, left inferior pubic ramus and iliac fx's, mild cervical disc protrusion at C5-6 level ? traumatic vs. degenerative, bilateral calcaneal fx's w/ left slightly open, left distal radius fx, fast scan neg, no solid organ injuries, Hcg negative and pt given tetanus in the EW.\n No PMHx, no allergies,\n Meds- birth control\n\nReview of systems\n\nNeuro- Alert and oriented times 3, c/o pain primarily in heels, then in left arm, denies numbness in LE's yet does c/o them having that feeling as though they were \"asleep\". Pt able to feel when touching toes, sensation intact in left hand as well. Pt able to move all extremities w/in limits of injuries.\n\n pt in Sinus, HR 90-100, no ectopy. BP 110-130/60-70, IVF of LR at 125cc's hr, extremities warm and dry, brisk cap refil in all extremities.\n\n pt on RA w/ RR 14-20 non labored. Breath sounds clear in upper lobes yet diminished at bases. Sats 94-98%.\n\nGI- abd soft, nondistended, hypoactive bowel sounds. Pt NPO, started on famotidine, Pt denies nausea at this time.\n\nGU- foley cath intact, urine yellow, clear, Quantity sufficient.\n\nSkin- back side pink on coccyx, LE's wrapped in splints bilaterally, splint on left forearm, hematoma on inner right forearm, small abrasion on left lateral thigh, large amt swelling and ecchymosis over right eye.\n\n pt lives at home in Conn. w/ and one of her three siblings, works as secretary. Pt was here in to attend the concert w/ her boyfriend. notified and father in this AM.\n\nA/P- plan for pt to go to the OR for repair of calcani this AM, monitor serial hcts as ordered, pulmonary toilet and PT/rehab planning, social support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-07 00:00:00.000", "description": "Report", "row_id": 1299264, "text": "Social Work\nSW met with pt's father, mother, and uncle in pt's room. Family coping fairly well but were wondering if pt could be transferred to CT since they're from there. SW informed them that pt may be able to be transferred to CT when/if she goes to rehab, but that pt would most likely need to be cleared medically before being transferred. SW provided them with a list of hotels in the area and discussed the possibility of a \"Room Away From Home\". SW to follow up with family tomorrow re: this issue.\n" }, { "category": "Nursing/other", "chartdate": "2119-08-08 00:00:00.000", "description": "Report", "row_id": 1299265, "text": "T-SICU Nsg Re-admit note\nPt transferred to T-SICU from PACU due to facial swelling and concerns for airway. Pt alert, uncomfortable with turning. Anxious that she is \"ugly\". boyfriend in and pt comforted by presence. Ox3, follows commands. Wiggles toes, sensation of toes grossly intact. TOes warm, brisk Cap refill. L hand warm, able to move fingers, sensation of fingers intact. Splints/casts intact, no drainage. Facial edema, cannot open eyes on own. Opthamology in and did eye exam, pleased with exam. Pt sitting up, iced gauzes to eyes, drinking water. Using PCA sparingly. mother and siblings in to visit. Continues sinus tachy. on 2 l NC, O2 sats 97-100%. Brisk u/o, Temp up to 101.8. Tylenol given PO.\n" } ]

[ { "category": "Echo", "chartdate": "2179-10-21 00:00:00.000", "description": "Report", "row_id": 87597, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 131/77\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Increased IVC diameter\n(>2.1cm) with 35-50% decrease during respiration (estimated RA pressure\n(10-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV wall\nthickness.\n\nAORTA: Normal aortic diameter at the sinus level. No 2D or Doppler evidence of\ndistal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal mitral valve\nsupporting structures. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThe estimated right atrial pressure is 10-15mmHg. There is mild symmetric left\nventricular hypertrophy with normal cavity size and global systolic function\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened. There is a minimally\nincreased gradient consistent with minimal aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is a trivial/physiologic pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nModerate pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038777, "text": ", H. NMED SICU-A 4:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p dobhoff placement to eval the position.\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n s/p dobhoff placement to eval the position.\n ______________________________________________________________________________\n PFI REPORT\n Feeding tube terminates at gastroduodenal junction.\n\n" }, { "category": "Radiology", "chartdate": "2179-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038377, "text": " 10:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Extension of bleed? - please repeat at 7pm on \n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right thalamic hemorrhage\n REASON FOR THIS EXAMINATION:\n Extension of bleed? - please repeat at 7pm on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl TUE 12:27 PM\n The blood in the fourth ventricle is less dense. Otherwise, stable\n intraparenchymal hemorrhage with intraventricular extension. Stable leftward\n subfalcine herniation of approximately 4 to 5 mm.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT\n\n HISTORY: 73-year-old man with right thalamic hemorrhage. Evaluate for\n extension of bleed.\n\n COMPARISON: Head CTs from yesterday () at 2033 hours, 1449 hours,\n and 1209 hours.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS:\n Intraparenchymal hemorrhage with associated vasogenic edema, centered in the\n right thalamus and extending into the temporal and parietal lobes is\n unchanged, measuring 4.2 x 3.3 cm. Hemorrhage extends into the lateral\n ventricles bilaterally, right greater than left. Blood within the fourth\n ventricle is less dense. There is shift of midline structures to the left of\n approximately 4 mm. The caliber of the ventricular system is stable. No new\n focus of hemorrhage is identified. -white matter differentiation is\n normally preserved.\n\n Mucosal thickening within the right sphenoid sinus is unchanged.\n\n IMPRESSION:\n 1. Blood within the fourth ventricle is less dense. Otherwise, unchanged\n intraparenchymal hemorrhage centered in the right thalamus, with\n intraventricular extension.\n 2. Stable leftward subfalcine herniation of approximately 4 to 5 mm.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038378, "text": ", H. NMED SICU-A 10:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Extension of bleed? - please repeat at 7pm on \n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right thalamic hemorrhage\n REASON FOR THIS EXAMINATION:\n Extension of bleed? - please repeat at 7pm on \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The blood in the fourth ventricle is less dense. Otherwise, stable\n intraparenchymal hemorrhage with intraventricular extension. Stable leftward\n subfalcine herniation of approximately 4 to 5 mm.\n\n" }, { "category": "Radiology", "chartdate": "2179-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038291, "text": " 7:59 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluation of intraventricular bleed\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with change in mental status\n REASON FOR THIS EXAMINATION:\n Evaluation of intraventricular bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc MON 10:53 PM\n 1. Stable right intraparenchymal hemorrhage, centered around the right\n thalamus, with hemorrhage seen within the lateral, third, and fourth\n ventricles, unchanged. Stable left worse subfalcine herniation. No new focus\n of hemorrhage identified.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with change of mental status, evaluate for\n intraventricular bleeding.\n\n COMPARISON: at 2:49 p.m. and 12:09 p.m.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: Intraparenchymal hemorrhage with associated vasogenic edema,\n centered in the region of the right thalamus and extending into the temporal\n and parietal lobes, measures 3.4 cm x 3.9 cm and is unchanged in size from\n 2:49 p.m. Hemorrhage extends into the ventricular system, with hemorrhage seen\n in the lateral ventricles bilaterally, as well as in the third and fourth\n ventricles, unchanged. There is shift of midline structures to the left, of\n approximately 5 mm, unchanged. The caliber of the ventricular system is\n stable. There is no evidence of an acute major vascular territorial\n infarction. No new focus of hemorrhage is identified.\n\n There is mucosal thickening in the right sphenoid sinus. Osseous structures\n are unremarkable.\n\n IMPRESSION:\n\n Stable intraparenchymal hemorrhage centered in the right thalamus. Stable\n intraventricular hemorrhage.\n\n 2. Stable leftward subfalcine herniation of approximately 5 mm.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038292, "text": ", H. NMED SICU-A 7:59 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluation of intraventricular bleed\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with change in mental status\n REASON FOR THIS EXAMINATION:\n Evaluation of intraventricular bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable right intraparenchymal hemorrhage, centered around the right\n thalamus, with hemorrhage seen within the lateral, third, and fourth\n ventricles, unchanged. Stable left worse subfalcine herniation. No new focus\n of hemorrhage identified.\n\n" }, { "category": "Radiology", "chartdate": "2179-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038201, "text": " 12:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for hemorrhage, evidence of CVA.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with L sided weakness\n REASON FOR THIS EXAMINATION:\n eval for hemorrhage, evidence of CVA.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw MON 12:26 PM\n acute right thalamic hemorrhage 2.3 x 4 cm with intraventricular extension. no\n hydrochephalus, no shift\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT: Contiguous axial images were obtained through the brain. No IV\n contrast was administered.\n\n HISTORY: Left sided weakness\n\n COMPARISONS: None.\n\n FINDINGS: There is a 4 x 2.3 cm focus of parenchymal hyperdensity centered in\n the right thalamic region compatible with acute hemorrhage. There is\n intraventricular extension of this hemorrhage with blood noted in both lateral\n ventricles and third ventricle. There is a small amount of edema surrounding\n the parenchymal hemorrhage without significant mass effect of shift of\n midline. There is no hydrocephalus. There is preservation of - white\n matter differentiation.\n\n There are no fractures identified. Soft tissues are unremarkable.\n\n IMPRESSION:\n 4 x 2.3 cm parenchymal hemorrhage centered in the right thalamus with\n intraventricular extension. No hydrocephalus or evidence of herniation.\n\n The results of the study were communicated with Dr. at\n 12:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2179-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1039902, "text": " 9:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infection ?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right thalamic hemorrhage presenting with change in mental\n satus\n REASON FOR THIS EXAMINATION:\n infection ?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 10:49 AM\n PFI: No acute infection.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right thalamic hemorrhage presenting with change in mental\n status. Evaluate for possible infection.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position does not demonstrate any acute parenchymal infiltrate.\n Heart appears moderately enlarged with some suspected calcifications in the\n mitral ring area. The pulmonary vasculature is not congested.\n\n There exists a preceding chest examination of . View at that\n time noted improved less congested pulmonary vasculature persists.\n\n IMPRESSION: No evidence of acute infection on portable chest examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1039903, "text": ", H. NMED FA11 9:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infection ?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right thalamic hemorrhage presenting with change in mental\n satus\n REASON FOR THIS EXAMINATION:\n infection ?\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute infection.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038776, "text": " 4:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p dobhoff placement to eval the position.\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n s/p dobhoff placement to eval the position.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 6:56 PM\n Feeding tube terminates at gastroduodenal junction.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Dobbhoff tube placement.\n\n Dobbhoff tube tip terminates in region of gastroduodenal junction.\n Endotracheal tube and nasogastric tube have been removed. Slight improved\n aeration in left retrocardiac region as well as overall increase in lung\n volumes and improvement in previously described pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2179-10-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1039914, "text": " 9:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: signs of new hemorrhage/stroke\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right thalamic hemorrhage presenting with mental status\n change\n REASON FOR THIS EXAMINATION:\n signs of new hemorrhage/stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl TUE 3:54 PM\n no significant change in right thalamic hemorrhage w/ intraventricular\n extension.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT\n\n HISTORY: 73-year-old man with right thalamic hemorrhage, presenting with\n mental status changes. Evaluate for new hemorrhage or stroke.\n\n COMPARISON: Multiple prior head CTs, most recently yesterday () and\n dating back to .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: The right thalamic hemorrhage, with intraventricular extension is\n unchanged in comparison to yesterday's CT. Associated edema and compression\n of the right lateral ventricle are stable.\n\n No areas of new hemorrhage are identified. Small focus of high attenuation\n within the sulcus within the left parietal lobe is stable.\n\n Opacification of the left sphenoid sinus and probable mucosal retention cysts\n are not significantly changed.\n\n IMPRESSION:\n 1. Unchanged right thalamic hemorrhage, with intraventricular extension and\n surrounding edema, and compression of the right lateral ventricle.\n 2. Stable small focus of subarachnoid blood within the left parietal lobe,\n likely representing redistribution of blood.\n 3. No new hemorrhage identified. MRI is more sensitive for the detection of\n acute stroke.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1038231, "text": " 2:28 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: r/o extension of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with known thalamic bleed worsening mental status\n REASON FOR THIS EXAMINATION:\n r/o extension of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw MON 3:18 PM\n increased size of right thalamic bleed with increased intraventricular\n extension. 4mm leftward midline shift. increased size right temporal\n ventricular .\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT: Contiguous axial images were obtained through the brain. No IV\n contrast was administered.\n\n HISTORY: 73-year-old man with known thymic bleed and worsening mental status.\n Please evaluate extension of the bleed.\n\n COMPARISON: Head CT from at 12:09 p.m.\n\n FINDINGS: Again noted is a parenchymal hemorrhage in the region of the right\n thalamus. There is interval increas in the size, now measuring 4.2 x 3.4 cm.\n In addition, there is increased intraventricular hemorrhage with hyperdense\n material layering in the right and left occipital horns. There is increased\n size of the right temporal compared to prior examination. There is blood\n present now within the fourth ventricle. There is 4 mm leftward shift of\n normally midline structures. There is no evidence for downward transtentorial\n herniation. There are no fractures seen. The sinus airspaces are well\n pneumatized.\n\n IMPRESSION:\n 1. Increased size of right thalamic hemorrhage.\n 2. Increased amount of intraventricular hemorrhage with extension into the\n bilateral occipital horns and the fourth ventricle.\n 4. 4 mm leftward shift of normally midline structures.\n 5. No evidence for transtentorial herniation.\n\n The results of the study were communicated with Dr. at\n approximately 3:10 p.m. on .\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2179-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1038232, "text": " 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ETT\n REASON FOR THIS EXAMINATION:\n evaluate for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 73-year-old male with intracranial hemorrhage. ET tube\n placed. Check position.\n\n FINDINGS: Portable supine AP chest radiograph is obtained. Evaluation is\n somewhat limited by low lung volumes. The ET tube is seen with its tip\n approximately 3.4 cm above the carina. NG tube courses into the left upper\n quadrant. There is central hilar prominence with mild engorgement, likely on\n the basis of mild pulmonary congestion. There is likely bibasilar\n atelectasis, slightly greater on the left. No large pleural effusions or\n pneumothorax is seen. Heart size is grossly unremarkable. Osseous structures\n appear intact.\n\n IMPRESSION:\n\n Adequate positioning of ET and NG tubes.\n\n Mild central congestion.\n SESHa\n\n" }, { "category": "Radiology", "chartdate": "2179-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1039827, "text": " 6:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: To look for extension of the intraventricular hemorrhage\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with a R thalamic hemorrhage and w extension into the\n ventricles.\n REASON FOR THIS EXAMINATION:\n To look for extension of the intraventricular hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXKc MON 8:19 PM\n No significant change in the right thalamic hemorrhage, with intraventricular\n extension.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with right thalamic hemorrhage, with extension into\n the ventricles, look for extension of the intraventricular hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is a 4.2 cm x 3.1 cm right thalamic hemorrhage, with\n associated vasogenic edema, not significantly changed in size from . There is extension of the hemorrhage into the ventricular system, with\n a small amount of hemorrhage seen within the right and left lateral\n ventricles, involving the frontal of the right lateral ventricle, as well\n as layering dependently in both ventricles. The overall caliber of the\n ventricular system is unchanged from the prior study. Additionally, there is\n associated mild mass effect, with a leftward shift of normally midline\n structures of 2.5 mm, slightly improved from the prior study. Hemorrhage\n within the fourth ventricle is slightly less apparent, likely reflecting\n evolving blood products. There is a small focus of high attenuation within a\n sulcus within the left parietal lobe (2B:38), which may reflect a small amount\n of subarachnoid hemorrhage likely from redistribution. There is no new foci\n or hemorrhage.\n\n There is no acute major vascular territorial infarction. There is near\n complete opacification of the left sphenoid sinus, as well as mucosal\n thickening of the right sphenoid sinus. Osseous structures are unremarkable.\n\n IMPRESSION:\n 1. No significant change in size of a right thalamic hemorrhage, with\n extension into the ventricular system.\n\n 2. No change in caliber of the ventricular systems.\n\n 3. Small focus of subarachnoid blood seen within a sulcus in the left\n parietal lobe, likely reflects redistribution.\n\n (Over)\n\n 6:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: To look for extension of the intraventricular hemorrhage\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n" }, { "category": "Radiology", "chartdate": "2179-10-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1039828, "text": ", H. NMED FA11 6:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: To look for extension of the intraventricular hemorrhage\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with a R thalamic hemorrhage and w extension into the\n ventricles.\n REASON FOR THIS EXAMINATION:\n To look for extension of the intraventricular hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant change in the right thalamic hemorrhage, with intraventricular\n extension.\n\n" }, { "category": "ECG", "chartdate": "2179-10-26 00:00:00.000", "description": "Report", "row_id": 222671, "text": "Normal sinus rhythm with occasional premature atrial contractions. Compared to\nthe previous tracing of no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2179-10-23 00:00:00.000", "description": "Report", "row_id": 222672, "text": "Sinus rhythm with short P-R interval\nConsider inferior infarct - age undetermined\nLateral infarct - age undetermined\nAnterior T wave changes are nonspecific\nSince previous tracing of , atrial fibrillation not seen, Q wave in\nlead aVF now seen\n\n" }, { "category": "ECG", "chartdate": "2179-10-21 00:00:00.000", "description": "Report", "row_id": 222673, "text": "Atrial fibrillation\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , atrial fibrillation and ST-T wave\nabnormalities are now present\n\n" }, { "category": "ECG", "chartdate": "2179-10-18 00:00:00.000", "description": "Report", "row_id": 222674, "text": "Sinus bradycardia. Tracing is normal except for rate. No previous tracing\navailable for comparison.\n\n" }, { "category": "Physician ", "chartdate": "2179-10-18 00:00:00.000", "description": "Physician Surgical Admission Note", "row_id": 638457, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Coumadin\n ASA 81\n Norvasc\n atenolol\n Lescol\n Protonix\n MVI\n glucosamine\n ? Ambien vs lunesta\n Past medical history:\n Family / Social history:\n HTN / controlled per wife\n / controlled per wife\n DVT x 3 (one after surgery, other two after plane flights) - last\n one in of 08)\n OA - knees and hip\n \"knee surgery\" ? side\n \"disc surgery\" / posterior approach / ? reason\n GERD\n kidney stones\n \"kidney stone surgery\"\n Social HX:\n Retired from bank of , lives with wife at home / full\n flight of stairs / no tobacco / glass of wine daily\n Family HX:No known stroke\n Flowsheet Data as of 04:06 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 34.9\nC (94.8\n Tcurrent: 34.9\nC (94.8\n HR: 55 (55 - 58) bpm\n BP: 141/73(90) {141/73(90) - 141/73(90)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 100%\n Total In:\n 58 mL\n PO:\n TF:\n IVF:\n 8 mL\n Blood products:\n 50 mL\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 58 mL\n Respiratory support\n SpO2: 100%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Oriented (to): , Movement:\n Non -purposeful, Sedated, Tone: Decreased, left side\n Labs / Radiology\n [image002.jpg]\n Imaging: Ct: on arrival with Right thalamic bleed with\n intraventricular\n extension. No hydro at present\n Assessment and Plan\n Assessment And Plan: 73 year old male with extensive PHX / on Coumadin\n for DVT with\n INR 2.9. Found off bed and aware of surroundings this am\n Neurologic: Ct at 7 pm, neuro checks q 1, sedation of propofol.\n Neurosurgery to evaluate this PM. ventriculostomy at bedsire\n Cardiovascular: SBP 130 - 160. Check EKG, and cardiac enzymes.\n Pulmonary: Pulmonary toilet\n Gastrointestinal: famotodine\n Renal: will check lytes. frugual Hydration secondary to\n Intraventricular bleed\n Hematology: History of DVT. Held coumadin, will reverse INR down to\n 1.5, 4 units FFP. need 2 more and 5 mg vitamin K if INR does not\n correct. Vit K / Proplex given down in the E.R\n Infectious Disease: none\n Endocrine: Will maintain normoglycemia and normothermia\n Fluids:\n Electrolytes:\n Nutrition:\n General:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2179-10-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 638472, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Repeat CT, monitor neuro status.\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n 73yr male on Coumadin presents with extending thalamic bleed. Intubated\n for airway protection. DNR.\n" }, { "category": "Respiratory ", "chartdate": "2179-10-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 638473, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n ABG pending.\n" }, { "category": "Respiratory ", "chartdate": "2179-10-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 638694, "text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position25cm @lip\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 9 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Triggering synchronously\n Pt remains on CMV 500/16/.4/5 PEEP\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM RSBI-18 . Plan is to ?extubate this am.\n" }, { "category": "Nursing", "chartdate": "2179-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638836, "text": ".H/O dysphagia\n Assessment:\n Pt failed speech and swallow evaluation.\n Action:\n Dobhoff placed and confirmed by XRay.\n Response:\n Will start tube feeds Replete with Fiber as ordered.\n Plan:\n Re-eval in days.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt mostly sleepy during shift. Safely extubated. PERRL 2mm. No facial\n droop. Not responding verbally, occasionally will whisper\n but does\n not answer questions except to nod yes/no. Left sided weakness\n improving. Follows commands consistently.\n Action:\n Neuro checks q 1-2 hours.\n Response:\n Neuro status continues to improve.\n Plan:\n Continue neuro checks q 1-2 hours, repeat speech and swallow eval when\n pt more alert, ?repeat head CT tomorrow, transfer to SDU tomorrow if\n pt remains stable.\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639124, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638667, "text": "73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911.\n .H/O CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n When off Ppf gtt, pt opens eyes when name is called. Pt lifts and holds\n RUE. Strong grasp with right hand. Pt able to squeeze and let go to\n command. +posturing noted at times with LUE, but mostly no movement\n noted. Pt kicks BLE in bed; able to lift/fall BLE. +gag/cough/corneal\n reflex. Strong cough. Pupils are 2mm bilaterally; sluggishly reactive\n in the morning, but brisk this afternoon.\n Action:\n Neuro exam q1hr. Ppf gtt titrated for sedation. Head CT done this\n morning.\n Response:\n Pt comfortable with Ppf gtt (currently at 30mcg/kg/min). No change in\n neuro exam.\n Plan:\n Q1hr neuro; notify SICU HO and neurology team with any changes. Titrate\n Ppf gtt for comfort. Follow up result of head CT. Keep SBP 130-170.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sat >/= 96% on current vent setting. CMV 40%, Vt 500 x 16, PEEP 5.\n Pt with strong cough.\n Action:\n No change in vent setting. Mouth care performed per VAP prevention\n protocol. Suctioned for small amount thick white secretions.\n Response:\n No respiratory distress. O2 sat >/= 96%; no episodes of desat.\n Plan:\n Wean vent setting as tolerated. ?extubate tomorrow. Mouth care per VAP\n prevention protocol.\n" }, { "category": "Nursing", "chartdate": "2179-10-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638467, "text": "HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n .H/O CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n s/p hemorrhagic stroke today, found down by wife @home, transferred to\n ED. On neurology service with neurosurg. Consult for possible EVD\n placement.\n Action:\n Received from ED via CT around 1600.\n Total 4u FFP given to correct INR.\n Ventilated for airway protection.\n Aline placed for blood pressure management with sbp goal <140\n Q1 hr neuro assessments done, one off propofol at 1600 with neurosurg.\n Present\n Support given to family (wife, 2 sons). into see patient.\n Equipment at bedside for possible drain placement\n Keep intubated for airway protection\n Propofol as needed for sedation, take off q 2 hrs. for better neuro\n exam\n Response:\n Blood pressure within parameters without any intervention\n Continue with q 1 hr. neuro checks\n Plan:\n Neuro checks as above.\n Labs as ordered\n Repeat head ct @ \n ?Possible EVD placement to be determined by neurosurg\n Call icu/neurology team with any changes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n s/p hemorrhagic stroke\n Action:\n Intubated for airway protection.\n Response:\n Abgs pending, on propofol for sedation as needed.\n Plan:\n Intubated over night, will evaluate ability to extubated in am.\n Call sicu/neurology team w/any changes.\n" }, { "category": "Nursing", "chartdate": "2179-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638520, "text": ".H/O CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Pt remains on propofol for sedation. Dose titrated 40-60 mcg/kg/min.\n Propofol off for neuro exam and then restarted. Pupils are 2 react\n slightly and sluggishly. Pt opens eyes off propofol and follows\n commands inconsistently on the right side. He needs to be asked\n multiple times to perform a task but he eventually is able to complete\n task. He wiggles toes and squeezes hand to command. He is able to stop\n squeezing hand when asked. Able to lift and hold right arm. Right leg\n will lift and fall. Left leg will withdraw to painful stimuli and left\n arm with posture to painful stimuli. Repeat head ct done at 20:30 and\n unchanged per neurology resident and sicu resident updated family. Goal\n sbp less than 180 per stroke fellow. Sbp been between 130-160 on and\n off propofol.\n Action:\n Titrate propofol. Continue with neuro exam q1hr. ?repeat head ct\n today.\n Response:\n No change in neuro exam. Propofol effective in keeping pt comfortable.\n Plan:\n Continue to monitor neuro exam. Answer questions for family and provide\n emotional support.\n" }, { "category": "Nursing", "chartdate": "2179-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638521, "text": ".H/O CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Pt remains on propofol for sedation. Dose titrated 40-60 mcg/kg/min.\n Propofol off for neuro exam and then restarted. Pupils are 2 react\n slightly and sluggishly. Pt opens eyes off propofol and follows\n commands inconsistently on the right side. He needs to be asked\n multiple times to perform a task but he eventually is able to complete\n task. He wiggles toes and squeezes hand to command. He is able to stop\n squeezing hand when asked. Able to lift and hold right arm. Right leg\n will lift and fall. Left leg will withdraw to painful stimuli and left\n arm with posture to painful stimuli. Repeat head ct done at 20:30 and\n unchanged per neurology resident and sicu resident updated family. Goal\n sbp less than 180 per stroke fellow. Sbp been between 130-160 on and\n off propofol.\n Action:\n Titrate propofol. Continue with neuro exam q1hr. ?repeat head ct\n today.\n Response:\n No change in neuro exam. Propofol effective in keeping pt comfortable.\n Plan:\n Continue to monitor neuro exam. Answer questions for family and provide\n emotional support.\n Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n" }, { "category": "Nursing", "chartdate": "2179-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638519, "text": ".H/O CVA (Stroke, Cerebral infarction), Hemorrhagic\n Assessment:\n Pt remains on propofol for sedation. Dose titrated 40-60 mcg/kg/min.\n Propofol off for neuro exam and then restarted. Pupils are 2 react\n slightly and sluggishly. Pt opens eyes off propofol and follows\n commands inconsistently on the right side. He needs to be asked\n multiple times to perform a task but he eventually is able to complete\n task. He wiggles toes and squeezes hand to command. He is able to stop\n squeezing hand when asked. Able to lift and hold right arm. Right leg\n will lift and fall. Left leg will withdraw to painful stimuli and left\n arm with posture to painful stimuli. Repeat head ct done at 20:30 and\n unchanged per neurology resident and sicu resident updated family. Goal\n sbp less than 180 per stroke fellow. Sbp been between 130-160 on and\n off propofol.\n Action:\n Titrate propofol. Continue with neuro exam q1hr. ?repeat head ct today.\n Response:\n No change in neuro exam. Propofol effective in keeping pt comfortable.\n Plan:\n Continue to monitor neuro exam. Answer questions for family and provide\n emotional support.\n" }, { "category": "Physician ", "chartdate": "2179-10-19 00:00:00.000", "description": "Intensivist Note", "row_id": 638575, "text": "SICU\n HPI:\n 73 year-old left-handed man with a history of hypertension,\n recurrent DVT on warfarin (also on daily baby aspirin),\n dyslipidemia who presents today with onset of left-sided weakness\n and language difficulties since ~10:30 am.\n Chief complaint:\n left-sided weakness\n and language difficulties since ~10:30 am.\n PMHx:\n HTN\n -Recurrent lower extremity DVT on anti-coagulation, last\n reportedly (others in , )\n -Dyslipidemia\n -GERD\n -Arthritis\n -Gout\n -Cervical disc disease, s/p surgery\n -Knee surgery, unclear laterality\n -Nephrolithiasis\n -Glaucoma\n Current medications:\n 1. 2. 1000 mL NS 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Docusate Sodium (Liquid) 5. Fentanyl Citrate\n 6. HydrALAzine 7. Insulin 8. Influenza Virus Vaccine 9. Pantoprazole\n 10. Pneumococcal Vac Polyvalent\n 11. Potassium Chloride 12. Propofol 13. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 03:00 PM\n intubated in ED\n ARTERIAL LINE - START 05:10 PM\n Stable right intraparenchymal hemorrhage, centered around the\n right thalamus. NS to decide if going to the O.R for ventriculostomy.\n INR corrected\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:30 PM\n Pantoprazole (Protonix) - 08:20 PM\n Other medications:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 48 (44 - 66) bpm\n BP: 138/52(76) {104/43(59) - 180/74(110)} mmHg\n RR: 17 (12 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 980 mL\n 462 mL\n PO:\n Tube feeding:\n IV Fluid:\n 425 mL\n 462 mL\n Blood products:\n 555 mL\n Total out:\n 970 mL\n 647 mL\n Urine:\n 970 mL\n 347 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 10 mL\n -185 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 36\n PIP: 15 cmH2O\n Plateau: 11 cmH2O\n Compliance: 83.3 cmH2O/mL\n SPO2: 99%\n ABG: 7.43/37/112/26/0\n Ve: 8.6 L/min\n PaO2 / FiO2: 280\n Physical Examination\n General Appearance: Intubated sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Bilateral)\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Neurologic: (Responds to: Noxious stimuli)\n Labs / Radiology\n 180 K/uL\n 11.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 106 mEq/L\n 139 mEq/L\n 32.0 %\n 8.3 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n WBC\n 8.3\n Hct\n 32.0\n Plt\n 180\n Creatinine\n 0.7\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n Other labs: PT / PTT / INR:15.3/30.0/1.4, CK / CK-MB / Troponin\n T:73//<0.01, Ca:8.5 mg/dL, Mg:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 73 y/o left handed man with acute left hemiparesis\n /\n confusion / dysphasia found to have right thalamic IPH w/\n intraventricular extension\n Neurologic: Neuro checks Q: 2 hr, Awaiting Neurosurgery decisaion\n Cardiovascular: BP control BP Between 130 and 160 systolic\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: INR CRRECVTED, vIT k, FFP\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds:\n Imaging:\n Fluids: D5NS\n Consults: Neuro surgery\n Billing Diagnosis: Other: Intraparenchyma bleed\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2179-10-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 638655, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 9 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n BS: decreased. To CT today for repeat of head CT; no extension of bleed\n and possible small improvement. Pt\ns mental status improving. Continue\n to monitor neuro status and consider beginning to wean vent in AM.\n" }, { "category": "Nutrition", "chartdate": "2179-10-21 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 638986, "text": "Subjective: Per pt\ns daughter, pt had good appetite, stable wt PTA.\n Reports that pt is talking more today than yesterday.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 180 cm\n 90 kg\n 92.2 kg ( 06:00 AM)\n 27.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 112\n 90.9\n 100\n Diagnosis: Stroke\n PMH : HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Food allergies and intolerances:\n Pertinent medications: Diltiazem, NS @ 40cc/hr, RISS, Colace, Protonix,\n others noted\n Labs:\n Value\n Date\n Glucose\n 127 mg/dL\n 01:47 AM\n Glucose Finger Stick\n 134\n 10:00 AM\n BUN\n 15 mg/dL\n 01:47 AM\n Creatinine\n 0.7 mg/dL\n 01:47 AM\n Sodium\n 140 mEq/L\n 01:47 AM\n Potassium\n 3.7 mEq/L\n 01:47 AM\n Chloride\n 107 mEq/L\n 01:47 AM\n Calcium non-ionized\n 8.6 mg/dL\n 01:47 AM\n Phosphorus\n 2.6 mg/dL\n 01:47 AM\n Magnesium\n 2.1 mg/dL\n 01:47 AM\n Current diet order / nutrition support: Replete with Fiber @ 80cc/hr\n ordered (1920kcal, 119g protein)\n GI: softly distended, +BS\n Assessment of Nutritional Status\n Adequately nourished\n Estimated Nutritional Needs\n Calories: 2070-2430 (BEE x or / 23-27 cal/kg)\n Protein: 99-117 (1.1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake:\n Specifics: 73 y.o. M adm s/p R-sided thalamic ICH with IVH, likely \n HTN and coagulopathy. Pt was extubated yesterday (), but failed a\n S/S evaluation due to fatigue and confusion. A feeding tube was placed\n for initiation of tube feeding. Current TF rx likely underfeeds\n kcals. Rec change TF so that adequate kcals can be given without\n providing excess protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec change TF rx to Fibersource @ 70cc/hr + 15g Beneprotein, which\n will provide 2070kcals & 104g protein.\n 2) Repeat S/S eval if pt\ns MS continues to clear.\n 3) Check residuals q4hrs, hold if >150cc.\n 4) Check chemistry 10 panel daily.\n Please page if ?\ns \n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639097, "text": "Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib with frequent PAC\ns. Continues on Dilt gtt. SBP\n transiently 120\n Action:\n Dilt weaned to 10/hr.\n Response:\n HR 80\ns. SBP 130\ns-150\n Plan:\n Continue wean Dilt as tolerated. ?restart anticoagulation.\n Intracerebral hemorrhage (ICH)\n Assessment:\n More alert, unable to assess orientation secondary to expressive\n aphasia. Pt becoming more frustrated by speech problems. side\n weakness unchanged.\n Action:\n Neuro exams q 2 hours.\n Response:\n Neuro exam unchanged from previous assessment.\n Plan:\n Continue neuro checks q 2, repeat speech consult, physical therapy/OT\n consults, continue provide support to pt and family.\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639211, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n Atrial fibrillation (Afib)\n Assessment:\n Hr continues to be 100-140\ns, Diltazem gtt at 5mg/hr\n Action:\n Pt started on po diltazem effect, hr continued at times\n continues to be in 120\n Pt was to transfer to step down unit\n Response:\n Diltazem gtt increased to 10mg/hr,\n Plan:\n Diltazem po to be increased to 60mg\n Monitor vs\n Pt to keep in icu tonight\n Attempt to wean diltazem iv\n .H/O dysphagia\n Assessment:\n Pt has failed speech and swallow study yesterday\n Action:\n Speech and swallow into assess patient today\n Response:\n pt passed speech and swallow\n Plan:\n to have supervision with po intake\n pills to be crushed or puree or via dobhoff\n 1:1 supervision for all po intake only when pt is alert\n Aspiration precautions\n To continue to tubefeedings until adquete po intake\n Hypertension, benign\n Assessment:\n Sbp > 160, dr called and aware\n Action:\n Pt received 20mg of hyralazine\n Response:\n Sbp less than 160\n Plan:\n Continue to monitor\n Keep bp less than 160\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2179-10-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 639213, "text": "Pertinent medications: NeutraPhos, Protonix, RISS, Colace, others noted\n Labs:\n Value\n Date\n Glucose\n 163 mg/dL\n 02:15 AM\n Glucose Finger Stick\n 139\n 10:00 AM\n BUN\n 19 mg/dL\n 02:15 AM\n Creatinine\n 0.6 mg/dL\n 02:15 AM\n Sodium\n 140 mEq/L\n 02:15 AM\n Potassium\n 3.8 mEq/L\n 02:15 AM\n Chloride\n 108 mEq/L\n 02:15 AM\n TCO2\n 26 mEq/L\n 02:15 AM\n PO2 (arterial)\n 112 mm Hg\n 02:49 AM\n PCO2 (arterial)\n 37 mm Hg\n 02:49 AM\n pH (arterial)\n 7.43 units\n 02:49 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 02:49 AM\n Calcium non-ionized\n 8.3 mg/dL\n 02:15 AM\n Phosphorus\n 2.6 mg/dL\n 02:15 AM\n Magnesium\n 1.8 mg/dL\n 02:15 AM\n Current diet order / nutrition support: TF: REplete with Fiber @\n 80cc/hr (1920kcals, 119g protein)\n Diet: Pureed solids/Heart Healthy/Constant carbohydrate with thin\n liquids\n GI: soft, + BS\n Assessment of Nutritional Status\n 73 y.o. M adm with thalamic bleed. Pt receiving TF, however pt also\n passed a speech/swallow evaluation today and diet was advanced to\n pureed foods with thin liquids. Team consulted re: ? recs for TF with\n po\ns. Per pt\ns RN, pt has not taken po\ns yet, and she was going to try\n to give pt liquids soon. Pt\ns mental status is waxing & , thus\n making is occasionally unsafe for pt to take po\ns. Thus, rec continue\n with continuous TF until pt starts eating, then TF can be changed to\n cycled o/n. Current TF likely underfeeds kcals & overfeeds protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec continue with continuous TF.\n 2) Rec change TF goal to FIBERSOURCE @ 70cc/hr +15g beneprotein\n (2070kcal, 104g protein).\n 3) Encourage po\ns as tolerated with supervision and assistance.\n 4) Will follow and adj TF rx as needed.\n Please page if ?\ns \n" }, { "category": "Physician ", "chartdate": "2179-10-20 00:00:00.000", "description": "Intensivist Note", "row_id": 638791, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n R thalamic bleed\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n 1. 2. 1000 mL NS 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Docusate Sodium (Liquid) 5. Fentanyl Citrate\n 6. HydrALAzine 7. Insulin 8. Influenza Virus Vaccine 9. Magnesium\n Sulfate 10. Pantoprazole 11. Pneumococcal Vac Polyvalent\n 12. Potassium Chloride 13. Propofol 14. Sodium Chloride 0.9% Flush 15.\n Timolol Maleate 0.5%\n 24 Hour Events:\n Repeat CT head stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Hydralazine - 08:28 AM\n Other medications:\n Flowsheet Data as of 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 78 (43 - 80) bpm\n BP: 144/58(84) {116/50(70) - 181/74(100)} mmHg\n RR: 12 (12 - 21) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 2,009 mL\n 804 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,899 mL\n 774 mL\n Blood products:\n Total out:\n 2,502 mL\n 925 mL\n Urine:\n 1,852 mL\n 325 mL\n NG:\n 650 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n -493 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 646 (646 - 857) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 6 cmH2O\n SPO2: 95%\n ABG: ///25/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness), (LLE: Weakness), No(t) Sedated, No(t) Chemically paralyzed\n Labs / Radiology\n 194 K/uL\n 12.0 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.1 %\n 9.2 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n 12:46 AM\n WBC\n 8.3\n 9.2\n Hct\n 32.0\n 35.1\n Plt\n 180\n 194\n Creatinine\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n 117\n Other labs: PT / PTT / INR:14.1/29.1/1.2, CK / CK-MB / Troponin\n T:73//<0.01, Ca:8.4 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with R thalamic bleed.\n Neurologic: Neuro checks Q: 2 hr\n Cardiovascular: Stable. Keep SBP<180 with prn hydral.\n Pulmonary: Extubate today\n Gastrointestinal / Abdomen: Place Dobhoff if fails speech & swallow\n eval.\n Nutrition: Tube feeding, Start TF.\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS, Goal fs<150.\n Infectious Disease: No issues.\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 34 minutes\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639206, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639208, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639209, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n" }, { "category": "Physician ", "chartdate": "2179-10-20 00:00:00.000", "description": "Intensivist Note", "row_id": 638771, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n R thalamic bleed\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n 1. 2. 1000 mL NS 3. Chlorhexidine Gluconate 0.12% Oral Rinse 4.\n Docusate Sodium (Liquid) 5. Fentanyl Citrate\n 6. HydrALAzine 7. Insulin 8. Influenza Virus Vaccine 9. Magnesium\n Sulfate 10. Pantoprazole 11. Pneumococcal Vac Polyvalent\n 12. Potassium Chloride 13. Propofol 14. Sodium Chloride 0.9% Flush 15.\n Timolol Maleate 0.5%\n 24 Hour Events:\n Repeat CT head stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Hydralazine - 08:28 AM\n Other medications:\n Flowsheet Data as of 10:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 36.3\nC (97.3\n HR: 78 (43 - 80) bpm\n BP: 144/58(84) {116/50(70) - 181/74(100)} mmHg\n RR: 12 (12 - 21) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 2,009 mL\n 804 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,899 mL\n 774 mL\n Blood products:\n Total out:\n 2,502 mL\n 925 mL\n Urine:\n 1,852 mL\n 325 mL\n NG:\n 650 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n -493 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 646 (646 - 857) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 18\n PIP: 6 cmH2O\n SPO2: 95%\n ABG: ///25/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness), (LLE: Weakness), No(t) Sedated, No(t) Chemically paralyzed\n Labs / Radiology\n 194 K/uL\n 12.0 g/dL\n 117 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 11 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.1 %\n 9.2 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n 12:46 AM\n WBC\n 8.3\n 9.2\n Hct\n 32.0\n 35.1\n Plt\n 180\n 194\n Creatinine\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n 117\n Other labs: PT / PTT / INR:14.1/29.1/1.2, CK / CK-MB / Troponin\n T:73//<0.01, Ca:8.4 mg/dL, Mg:2.2 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with R thalamic bleed.\n Neurologic: Neuro checks Q: 2 hr\n Cardiovascular: Stable. Keep SBP<180 with prn hydral.\n Pulmonary: Extubate today\n Gastrointestinal / Abdomen: Place Dobhoff if fails speech & swallow\n eval.\n Nutrition: Tube feeding, Start TF.\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS, Goal fs<150.\n Infectious Disease: No issues.\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 34 minutes\n" }, { "category": "Physician ", "chartdate": "2179-10-21 00:00:00.000", "description": "Intensivist Note", "row_id": 638945, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n Weakness, aphasia\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n IV access: Peripheral line Order date: @ 1507 12. Metoprolol\n Tartrate 5 mg IV X3 Order date: @ 0507\n 2. 1000 mL NS\n Continuous at 40 ml/hr Order date: @ 1507 13. Metoprolol Tartrate\n 5 mg IV ONCE Duration: 1 Doses Order date: @ 0528\n 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1750 14. Pantoprazole 40 mg IV Q24H Order date: @ 1521\n 4. Diltiazem 25 mg IV BOLUS ONCE Duration: 1 Doses Order date: @\n 0635 15. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: \n @ 1505\n 5. Diltiazem 5 mg/hr IV DRIP INFUSION Start: After completion of bolus\n dose Order date: @ 0635 16. Potassium Chloride IV Sliding Scale\n Order date: @ 0703\n 6. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1521 17.\n Potassium Phosphate 30 mmol / 500 ml D5W IV ONCE Duration: 1 Doses\n Infuse over 6 hours Order date: @ 1115\n 7. Fentanyl Citrate 25-50 mcg IV Q4H:PRN Order date: @ 1819 18.\n Potassium Chloride 20 mEq PO ONCE Duration: 1 Doses\n Hold for K > Order date: @ 0439\n 8. HydrALAzine 20 mg IV Q4H:PRN SBP>180 Order date: @ 0913 19.\n Propofol 20-100 mcg/kg/min IV DRIP INFUSION\n to be used for sedation as needed Order date: @ 1801\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1521 20. Sodium Chloride 0.9%\n Flush 3 mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1507\n 10. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1504 21. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY glaucaoma\n Order date: @ 1219\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 0749\n 24 Hour Events:\n EXTUBATION - At 09:42 AM\n INVASIVE VENTILATION - STOP 09:45 AM\n intubated in ED\n EKG - At 04:00 AM\n Pt in rapid A.fib.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 5 mg/hour\n Other ICU medications:\n Hydralazine - 08:28 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36\nC (96.8\n HR: 111 (50 - 150) bpm\n BP: 141/72(93) {93/50(73) - 208/158(257)} mmHg\n RR: 19 (12 - 23) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 1,687 mL\n 818 mL\n PO:\n Tube feeding:\n 56 mL\n 267 mL\n IV Fluid:\n 1,540 mL\n 311 mL\n Blood products:\n Total out:\n 1,625 mL\n 815 mL\n Urine:\n 1,025 mL\n 815 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 62 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 646 (646 - 696) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SPO2: 95%\n ABG: ///26/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Tactile\n stimuli), No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 198 K/uL\n 12.6 g/dL\n 127 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 140 mEq/L\n 36.3 %\n 9.2 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n 12:46 AM\n 01:47 AM\n 06:32 AM\n WBC\n 8.3\n 9.2\n 9.2\n Hct\n 32.0\n 35.1\n 36.3\n Plt\n 180\n 194\n 198\n Creatinine\n 0.7\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n 117\n 127\n Other labs: PT / PTT / INR:14.3/28.6/1.2, CK / CK-MB / Troponin\n T:73//<0.01, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with L weakness & language difficulties -> R\n thalamic bleed\n Neurologic: Neuro checks Q: 2 hr, Pain controlled\n Cardiovascular: blood pressure control, with hydralazine, metoprolol\n PRN\n Pulmonary: pulmonary toliet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: Blood within the fourth ventricle is less dense.\n Otherwise, unchanged\n intraparenchymal hemorrhage centered in the right thalamus, with\n intraventricular extension.\n 2. Stable leftward subfalcine herniation of approximately 4 to 5 mm.\n Fluids:\n Consults:\n Billing Diagnosis: CVA, (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:22 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n" }, { "category": "Nursing", "chartdate": "2179-10-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639266, "text": "Atrial fibrillation (Afib)\n Assessment:\n HR mostly 100-110, brief self-limiting bursts to 120s.\n Action:\n Dilt. 60mg given, newly increased dose.\n Response:\n HR improving through night.\n Plan:\n Continue PO meds, monitor HR.\n" }, { "category": "Nursing", "chartdate": "2179-10-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638678, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient sedated on propofol, off every 2 hours (for 5-10 minutes) for\n full neuro exam. Patient opens eyes to voice, inconsistently follows\n simple commands. Moving right side frequently. Left lower extremitiy\n moves on bed slightly and left arm postures. Occasionally able to nod\n in response to questions, nods\n when questioned about pain. Pupils\n approx 2 mm and brisk. Patient has strong cough, minimal secretions.\n Action:\n Continued with neuro checks every 1-2 hours.\n Response:\n Neuro exam unchanged.\n Plan:\n ? extubate today. Continue to follow neuro exam closely.\n Hypertension, benign\n Assessment:\n Patient\n s SBP ranging 150-180\ns. More hypertensive with any\n stimulation and when PPF off for exam. Heart rate mostly 50\ns with\n occasional PVC\n Action:\n Goal SBP 130-170 per neuro. Given hydralazine as needed for\n hypertension. Patient otherwise comfortable on Propofol gtt, minimized\n stimulation. Currently repleting KCL (? Ectopy related to\n hypokalemia).\n Response:\n All vitals stable see flowsheet for details.\n Plan:\n Continue with current bp parameters, until otherwise notified.\n" }, { "category": "Nursing", "chartdate": "2179-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 638949, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt in rapid A.fib at 0400 after turning/repositioning to right side. HR\n 120-150s. SBP increased to 180-210s.\n Action:\n Dr. and neurology team notified. EKG done. Pt\n repositioned to left side. Metoprolol 5mg IV x4 given without effect.\n Diltiazem 25mg IV bolus given and diltiazem gtt @ 5mg/hr started.\n Response:\n Pt continues to be in A.fib. After diltiazem IV bolus given HR\n decreased to 90s, but currently HR 100-120s on diltiazem gtt. SBP\n within goal of 130-170.\n Plan:\n Monitor HR and BP closely. Goal SBP 130-170. ?cycle enzymes. Notify\n SICU HO if pt continues to be in rapid A.fib. Needs cardiology consult.\n .H/O dysphagia\n Assessment:\n TF infusing via DHT.\n Action:\n TFincreased slowly as ordered. Replete with fiber currently at 50cc/hr.\n Response:\n No c/o nausea; no emesis. Abdomen soflty distended with +bowel sound.\n No bowel movement overnight.\n Plan:\n Increase TF by 20cc q6hr; goal rate: 80cc/hr. Monitor for nausea.\n Intracerebral hemorrhage (ICH)\n Assessment:\n PERRLA. Pt very strong on right side. Lifts/holds RUE and RLE. Postures\n and at times minimally withdraws LUE. Pt lifts/falls LLE in bed.\n Follows commands consistently. Pt\ns speech very garbled; very difficult\n to understand pt. Pt gets agitated d/t difficulty finding words.\n Nods/shakes head to questions. +gag/cough/corneal reflex.\n Action:\n Neuro exam q2hr. Emotional support provided when pt upset.\n Response:\n No change in neuro exam.\n Plan:\n Neuro exam q2hr; notify SICU HO and neurology team with any changes.\n ?transfer to neuro stepdown if able to wean off diltiazem gtt. Provide\n emotional support. Update pt and family on plan of care.\n" }, { "category": "Physician ", "chartdate": "2179-10-21 00:00:00.000", "description": "Intensivist Note", "row_id": 638953, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n Weakness, aphasia\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n IV access: Peripheral line Order date: @ 1507 12. Metoprolol\n Tartrate 5 mg IV X3 Order date: @ 0507\n 2. 1000 mL NS\n Continuous at 40 ml/hr Order date: @ 1507 13. Metoprolol Tartrate\n 5 mg IV ONCE Duration: 1 Doses Order date: @ 0528\n 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1750 14. Pantoprazole 40 mg IV Q24H Order date: @ 1521\n 4. Diltiazem 25 mg IV BOLUS ONCE Duration: 1 Doses Order date: @\n 0635 15. Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: \n @ 1505\n 5. Diltiazem 5 mg/hr IV DRIP INFUSION Start: After completion of bolus\n dose Order date: @ 0635 16. Potassium Chloride IV Sliding Scale\n Order date: @ 0703\n 6. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1521 17.\n Potassium Phosphate 30 mmol / 500 ml D5W IV ONCE Duration: 1 Doses\n Infuse over 6 hours Order date: @ 1115\n 7. Fentanyl Citrate 25-50 mcg IV Q4H:PRN Order date: @ 1819 18.\n Potassium Chloride 20 mEq PO ONCE Duration: 1 Doses\n Hold for K > Order date: @ 0439\n 8. HydrALAzine 20 mg IV Q4H:PRN SBP>180 Order date: @ 0913 19.\n Propofol 20-100 mcg/kg/min IV DRIP INFUSION\n to be used for sedation as needed Order date: @ 1801\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1521 20. Sodium Chloride 0.9%\n Flush 3 mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1507\n 10. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1504 21. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY glaucaoma\n Order date: @ 1219\n 11. Magnesium Sulfate IV Sliding Scale Order date: @ 0749\n 24 Hour Events:\n EXTUBATION - At 09:42 AM\n INVASIVE VENTILATION - STOP 09:45 AM\n intubated in ED\n EKG - At 04:00 AM\n Pt in rapid A.fib.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 5 mg/hour\n Other ICU medications:\n Hydralazine - 08:28 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36\nC (96.8\n HR: 111 (50 - 150) bpm\n BP: 141/72(93) {93/50(73) - 208/158(257)} mmHg\n RR: 19 (12 - 23) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 1,687 mL\n 818 mL\n PO:\n Tube feeding:\n 56 mL\n 267 mL\n IV Fluid:\n 1,540 mL\n 311 mL\n Blood products:\n Total out:\n 1,625 mL\n 815 mL\n Urine:\n 1,025 mL\n 815 mL\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n 62 mL\n 3 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 646 (646 - 696) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 6 cmH2O\n SPO2: 95%\n ABG: ///26/\n Ve: 8.8 L/min\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: (Awake / Alert / Oriented: x 1), (Responds to: Tactile\n stimuli), No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 198 K/uL\n 12.6 g/dL\n 127 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 15 mg/dL\n 107 mEq/L\n 140 mEq/L\n 36.3 %\n 9.2 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n 12:46 AM\n 01:47 AM\n 06:32 AM\n WBC\n 8.3\n 9.2\n 9.2\n Hct\n 32.0\n 35.1\n 36.3\n Plt\n 180\n 194\n 198\n Creatinine\n 0.7\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n 117\n 127\n Other labs: PT / PTT / INR:14.3/28.6/1.2, CK / CK-MB / Troponin\n T:73//<0.01, Ca:8.6 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with L weakness & language difficulties -> R\n thalamic bleed\n Neurologic: Neuro checks Q: 2 hr, Pain controlled\n Cardiovascular: blood pressure control, with hydralazine, metoprolol\n PRN went into a fib on diltizem gtt\n Pulmonary: pulmonary toliet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: Blood within the fourth ventricle is less dense.\n Otherwise, unchanged\n intraparenchymal hemorrhage centered in the right thalamus, with\n intraventricular extension.\n 2. Stable leftward subfalcine herniation of approximately 4 to 5 mm.\n Fluids:\n Consults:\n Billing Diagnosis: CVA, (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:22 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n" }, { "category": "Nursing", "chartdate": "2179-10-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639341, "text": "73 year old white male on Coumadin for DVT since ,\n found down (20 minute alone time). Pt was at neighbors house\n for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. Pt with very dysarthric speech, worsening left sided weakness.\n Ct scan revealed large right thalamic bleed into ventricles very close\n to brainstem.\n PMHx:\n HTN\n -Recurrent lower extremity DVT on anti-coagulation, last\n reportedly (others in , )\n -Dyslipidemia\n -GERD\n -Arthritis\n -Gout\n -Cervical disc disease, s/p surgery\n -Knee surgery, unclear laterality\n -Nephrolithiasis\n -Glaucoma\n Intracerebral hemorrhage (ICH)\n Assessment:\n Alert, able to answer yes/no but speech very dysarthric. Expressive\n aphasia. Slight left facial droop. PERRL 3 mm bil. Right side able to\n lift and hold extremities. LUE withdraws to pain, pt will\n intermittently wiggles toes of left foot. LLE pPatchy sensation on left\n side. Pt had repeat speech and swallow study done yesterday, pt able\n to have puree foods when alert with supervison and sitting upright in\n bed.\n Action:\n Neuro checks q 2\n Response:\n Neuro exam unchanged.\n Plan:\n Continue closely monitor for neuro changes, hemodynamic monitoring, ,\n PT/OT consults, OOB, continue provide support to pt and family, keep\n informed of plan.\n Atrial fibrillation (Afib)\n Assessment:\n Hr 90-120\ns rapid afib, pt was on diltazem gtt yesterday, pt started\n on po diltzem yesterday 60mg qid\n Action:\n Iv diltazem d/c\nd yesterday, pt continues on po diltazem\n Response:\n Pt converted back to sr this am, ekg done, dr. assessed ekg\n Plan:\n Continue to monitor\n Add: this morning pt sitting upright in chair, pt ate\n bowl of cream\n of wheat and also tolerating 180cc of juice. Pt family concerned\n about left foot edema pt left foot warm to touch, good capillary refill\n of toes ,dr. assessed left foot edema\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Code status:\n DNR (do not resuscitate)\n Height:\n 72 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 92.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: 74 y/old left handed man with histor of HTN and\n recurrent LE DVTs presents to ED after his wife found him awake but\n collapsed on bed with left sided weakness. On coumadin @ home, INR 2.9\n upon admission. CT done upon admission to ED. Had left facial droop,\n slow to answer questions. Mental status deteriorated in ED, intubated\n for airway protection, 2nd head CT done before transferring to SICU.\n Repeat CT done, transferred from there to SICU.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:80\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None,\n O2 saturation:\n 94% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,130 mL\n 24h total out:\n 1,140 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:04 AM\n Potassium:\n 4.5 mEq/L\n 02:04 AM\n Chloride:\n 106 mEq/L\n 02:04 AM\n CO2:\n 23 mEq/L\n 02:04 AM\n BUN:\n 23 mg/dL\n 02:04 AM\n Creatinine:\n 0.7 mg/dL\n 02:04 AM\n Glucose:\n 139 mg/dL\n 10:00 AM finger stick\n Hematocrit:\n 37.0 %\n 02:04 AM\n Finger Stick Glucose:\n 139\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu\n Transferred to: neuro stepdown unit\n Date & time of Transfer: 12:33\n" }, { "category": "Nursing", "chartdate": "2179-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639053, "text": "Atrial fibrillation (Afib)\n Assessment:\n Dilt gtt running at 15mg/hr. HR remains AF 80-110\ns with rare bursts\n to 130s.\n Action:\n Dilt increased from 5-> 15mg/hr this AM. TTE done to r/o PFO/clot.\n Response:\n HR decreased to 80s-110s on increased Dilt. AF remains moderately\n controlled.\n Plan:\n Awaiting read from echo. ?Start Amio vs continued dilt for better rate\n control if pt does not have clot visible on TTE.\n Intracerebral hemorrhage (ICH)\n Assessment:\n PERRLA at 2mm. Pt very strong on right side. Lifts/holds RUE and RLE.\n Withdraws LUE. Pt moving LLE in bed. Follows commands consistently but\n delayed. Pt\ns speech slurred; very difficult to understand pt. Pt gets\n agitated d/t difficulty finding words. Nods/shakes head to questions.\n +gag/cough/corneal reflex.\n Action:\n Neuro check q2hr. Emotional support provided when pt upset.\n Response:\n Unchanged neuro exam.\n Plan:\n Neuro exam q2hr; notify SICU HO and neurology team with any changes.\n ?transfer to neuro stepdown if able to wean off diltiazem gtt. Provide\n emotional support. Update pt and family on plan of care.\n" }, { "category": "Nursing", "chartdate": "2179-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639064, "text": "Atrial fibrillation (Afib)\n Assessment:\n Dilt gtt running at 15mg/hr. HR remains AF 80-110\ns with rare bursts\n to 130s.\n Action:\n Dilt increased from 5-> 15mg/hr this AM. TTE done to r/o PFO/clot.\n Response:\n HR decreased to 80s-110s on increased Dilt. AF remains moderately\n controlled.\n Plan:\n Awaiting read from echo. ?Start Amio vs continued dilt for better rate\n control if pt does not have clot visible on TTE.\n Intracerebral hemorrhage (ICH)\n Assessment:\n PERRLA at 2mm. Pt very strong on right side. Lifts/holds RUE and RLE.\n Withdraws LUE. Pt moving LLE in bed. Follows commands consistently but\n delayed. Pt\ns speech slurred; very difficult to understand pt. Pt gets\n agitated d/t difficulty finding words. Nods/shakes head to questions.\n +gag/cough/corneal reflex.\n Action:\n Neuro check q2hr. Emotional support provided when pt upset.\n Response:\n Unchanged neuro exam.\n Plan:\n Neuro exam q2hr; notify SICU HO and neurology team with any changes.\n ?transfer to neuro stepdown if able to wean off diltiazem gtt. Provide\n emotional support. Update pt and family on plan of care.\n ------ Protected Section ------\n Following cardiac enzymes d/t RAF to 160s early AM . First two labs\n sent negative for cardiac event. Last lab due to be sent @ .\n ------ Protected Section Addendum Entered By: , RN\n on: 17:57 ------\n" }, { "category": "Physician ", "chartdate": "2179-10-23 00:00:00.000", "description": "Intensivist Note", "row_id": 639321, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n Aspirin 3. Atorvastatin 4. Diltiazem 5. Diltiazem 6. Docusate Sodium\n (Liquid) 7. Heparin\n 8. Insulin 9. Influenza Virus Vaccine 10. Magnesium Sulfate 11.\n Pantoprazole 12. Pneumococcal Vac Polyvalent\n 13. Potassium Chloride 14. Potassium Chloride 15. Senna 16. Sodium\n Chloride 0.9% Flush 17. Timolol Maleate 0.5%\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:37 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 12:36 PM\n Pantoprazole (Protonix) - 08:13 PM\n Other medications:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37\nC (98.6\n HR: 116 (80 - 121) bpm\n BP: 157/73(107) {155/73(98) - 160/95(108)} mmHg\n RR: 21 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 2,651 mL\n 716 mL\n PO:\n Tube feeding:\n 2,006 mL\n 636 mL\n IV Fluid:\n 406 mL\n 80 mL\n Blood products:\n Total out:\n 1,870 mL\n 1,000 mL\n Urine:\n 1,870 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 781 mL\n -284 mL\n Respiratory support\n O2 Delivery Device: None, Face tent\n SPO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 247 K/uL\n 13.1 g/dL\n 155 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 23 mg/dL\n 106 mEq/L\n 140 mEq/L\n 37.0 %\n 9.4 K/uL\n [image002.jpg]\n 02:49 AM\n 12:46 AM\n 01:47 AM\n 06:32 AM\n 11:00 AM\n 02:02 PM\n 02:15 AM\n 03:57 PM\n 10:00 PM\n 02:04 AM\n WBC\n 9.2\n 9.2\n 9.4\n Hct\n 35.1\n 36.3\n 37.0\n Plt\n 194\n 198\n 247\n Creatinine\n 0.7\n 0.7\n 0.6\n 0.6\n 0.7\n Troponin T\n <0.01\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 117\n 127\n 163\n 173\n 132\n 155\n Other labs: PT / PTT / INR:14.3/28.6/1.2, CK / CK-MB / Troponin\n T:43//<0.01, Ca:8.8 mg/dL, Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with L weakness & language difficulties -> R\n thalamic bleed.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable, still with L\n sided weakness\n Cardiovascular: 60 QID, converted spontaneously to SR, will check EKG,\n stable on Dilt PO\n Pulmonary: pulm toilet\n Gastrointestinal / Abdomen: sips ok\n Nutrition: Tube feeding, replete Mag\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley\n Wounds: stable\n Imaging: none\n Fluids: KVO\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:11 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 07:03 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker, PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2179-10-23 00:00:00.000", "description": "Intensivist Note", "row_id": 639322, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n Aspirin 3. Atorvastatin 4. Diltiazem 5. Diltiazem 6. Docusate Sodium\n (Liquid) 7. Heparin\n 8. Insulin 9. Influenza Virus Vaccine 10. Magnesium Sulfate 11.\n Pantoprazole 12. Pneumococcal Vac Polyvalent\n 13. Potassium Chloride 14. Potassium Chloride 15. Senna 16. Sodium\n Chloride 0.9% Flush 17. Timolol Maleate 0.5%\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:37 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 12:36 PM\n Pantoprazole (Protonix) - 08:13 PM\n Other medications:\n Flowsheet Data as of 08:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37\nC (98.6\n HR: 116 (80 - 121) bpm\n BP: 157/73(107) {155/73(98) - 160/95(108)} mmHg\n RR: 21 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 2,651 mL\n 716 mL\n PO:\n Tube feeding:\n 2,006 mL\n 636 mL\n IV Fluid:\n 406 mL\n 80 mL\n Blood products:\n Total out:\n 1,870 mL\n 1,000 mL\n Urine:\n 1,870 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n 781 mL\n -284 mL\n Respiratory support\n O2 Delivery Device: None, Face tent\n SPO2: 94%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (LUE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 247 K/uL\n 13.1 g/dL\n 155 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 23 mg/dL\n 106 mEq/L\n 140 mEq/L\n 37.0 %\n 9.4 K/uL\n [image002.jpg]\n 02:49 AM\n 12:46 AM\n 01:47 AM\n 06:32 AM\n 11:00 AM\n 02:02 PM\n 02:15 AM\n 03:57 PM\n 10:00 PM\n 02:04 AM\n WBC\n 9.2\n 9.2\n 9.4\n Hct\n 35.1\n 36.3\n 37.0\n Plt\n 194\n 198\n 247\n Creatinine\n 0.7\n 0.7\n 0.6\n 0.6\n 0.7\n Troponin T\n <0.01\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 117\n 127\n 163\n 173\n 132\n 155\n Other labs: PT / PTT / INR:14.3/28.6/1.2, CK / CK-MB / Troponin\n T:43//<0.01, Ca:8.8 mg/dL, Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with L weakness & language difficulties -> R\n thalamic bleed.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, stable, still with L\n sided weakness\n Cardiovascular: 60 QID, converted spontaneously to SR, will check EKG,\n stable on Dilt PO\n Pulmonary: pulm toilet\n Gastrointestinal / Abdomen: sips ok\n Nutrition: Tube feeding, replete Mag\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley\n Wounds: stable\n Imaging: none\n Fluids: KVO\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:11 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 07:03 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker, PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2179-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639049, "text": "Atrial fibrillation (Afib)\n Assessment:\n Dilt gtt running at 15mg/hr. HR remains AF 80-110\ns with rare bursts\n to 130s.\n Action:\n Dilt increased from 5-> 15mg/hr this AM. TTE done to r/o PFO/clot.\n Response:\n HR decreased to 80s-110s on increased Dilt. AF remains moderately\n controlled.\n Plan:\n Awaiting read from echo. ?Start Amio vs continued dilt for better rate\n control.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-10-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639050, "text": "Atrial fibrillation (Afib)\n Assessment:\n Dilt gtt running at 15mg/hr. HR remains AF 80-110\ns with rare bursts\n to 130s.\n Action:\n Dilt increased from 5-> 15mg/hr this AM. TTE done to r/o PFO/clot.\n Response:\n HR decreased to 80s-110s on increased Dilt. AF remains moderately\n controlled.\n Plan:\n Awaiting read from echo. ?Start Amio vs continued dilt for better rate\n control.\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 639236, "text": "Chief Complaint: Left sided weakness\n HPI:\n 73 year old white male on Coumadin for DVT since ,\n found down this am (20 minute alone time). Wife reports pt found\n at 11:20 this am off bed. Pt was at neighbors house for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. She called 911. Currently pt with garbled speech. While in the\n ED worsening muscle strength left sided to 0/5\n Atrial fibrillation (Afib)\n Assessment:\n Hr continues to be 100-140\ns, Diltazem gtt at 5mg/hr\n Action:\n Pt started on po diltazem effect, hr continued at times\n continues to be in 120\n Pt was to transfer to step down unit\n Response:\n Diltazem gtt increased to 10mg/hr,\n Plan:\n Diltazem po to be increased to 60mg\n Monitor vs\n Pt to keep in icu tonight\n Attempt to wean diltazem iv\n .H/O dysphagia\n Assessment:\n Pt has failed speech and swallow study yesterday\n Action:\n Speech and swallow into assess patient today\n Response:\n pt passed speech and swallow\n Plan:\n to have supervision with po intake\n pills to be crushed or puree or via dobhoff\n 1:1 supervision for all po intake only when pt is alert\n Aspiration precautions\n To continue to tubefeedings until adquete po intake\n Hypertension, benign\n Assessment:\n Sbp > 160, dr called and aware\n Action:\n Pt received 20mg of hyralazine\n Response:\n Sbp less than 160\n Plan:\n Continue to monitor\n Keep bp less than 160\n Add: left hand edemous and finger edemous, let hand warm to tough,pt\n has good capillary refill in left finger, dr. into assess hand\n and spoke with family.\n" }, { "category": "Physician ", "chartdate": "2179-10-22 00:00:00.000", "description": "Intensivist Note", "row_id": 639147, "text": "SICU\n HPI:\n 73M with L weakness & language difficulties -> R thalamic bleed.\n Chief complaint:\n Right Thalmic bledd\n PMHx:\n HTN, recurrent LE DVT (, , ), dyslipidemia, GERD,\n arthritis, gout, cervical disc dz s/p surgery, knee surgery,\n nephrolithiasis, glaucoma\n Current medications:\n 1000 mL NS 3. Aspirin 4. Atorvastatin 5. Chlorhexidine Gluconate 0.12%\n Oral Rinse 6. Diltiazem\n 7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9. Heparin 10.\n HydrALAzine 11. Insulin 12. Influenza Virus Vaccine\n 13. Magnesium Sulfate 14. Neutra-Phos 15. Neutra-Phos 16. Pantoprazole\n 17. Pneumococcal Vac Polyvalent\n 18. Potassium Chloride 19. Propofol 20. Sodium Chloride 0.9% Flush 21.\n Timolol Maleate 0.5%\n 24 Hour Events:\n TRANS ESOPHAGEAL ECHO - At 01:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Diltiazem - 5 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:32 PM\n Other medications:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 37.2\nC (98.9\n HR: 85 (73 - 118) bpm\n BP: 162/72(98) {134/60(71) - 166/90(112)} mmHg\n RR: 18 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 92.2 kg (admission): 90 kg\n Height: 72 Inch\n Total In:\n 2,633 mL\n 856 mL\n PO:\n Tube feeding:\n 1,338 mL\n 694 mL\n IV Fluid:\n 935 mL\n 162 mL\n Blood products:\n Total out:\n 2,065 mL\n 620 mL\n Urine:\n 2,065 mL\n 620 mL\n NG:\n Stool:\n Drains:\n Balance:\n 568 mL\n 236 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), rate controlled\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (LUE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 198 K/uL\n 12.6 g/dL\n 163 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 108 mEq/L\n 140 mEq/L\n 36.3 %\n 9.2 K/uL\n [image002.jpg]\n 05:30 PM\n 08:26 PM\n 02:15 AM\n 02:49 AM\n 12:46 AM\n 01:47 AM\n 06:32 AM\n 11:00 AM\n 02:02 PM\n 02:15 AM\n WBC\n 8.3\n 9.2\n 9.2\n Hct\n 32.0\n 35.1\n 36.3\n Plt\n 180\n 194\n 198\n Creatinine\n 0.7\n 0.7\n 0.7\n 0.6\n Troponin T\n <0.01\n <0.01\n <0.01\n <0.01\n <0.01\n TCO2\n 28\n 25\n Glucose\n 109\n 117\n 127\n 163\n Other labs: PT / PTT / INR:14.3/28.6/1.2, CK / CK-MB / Troponin\n T:43//<0.01, Ca:8.3 mg/dL, Mg:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M with L weakness & language difficulties -> R\n thalamic bleed.\n Neurologic: Neuro checks Q: 2 hr, fentanyl prn, stable\n Cardiovascular: Aspirin, Statins, rate controlled on 5 of diltiazem,\n will wean; enzymes negative x 3\n Pulmonary: pulm ti\\oilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: KVO, plan to hep lock\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 AM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 18 Gauge - 04:00 PM\n Arterial Line - 05:10 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2179-10-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639333, "text": "73 year old white male on Coumadin for DVT since ,\n found down (20 minute alone time). Pt was at neighbors house\n for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. Pt with very dysarthric speech, worsening left sided weakness.\n Ct scan revealed large right thalamic bleed into ventricles very close\n to brainstem.\n PMHx:\n HTN\n -Recurrent lower extremity DVT on anti-coagulation, last\n reportedly (others in , )\n -Dyslipidemia\n -GERD\n -Arthritis\n -Gout\n -Cervical disc disease, s/p surgery\n -Knee surgery, unclear laterality\n -Nephrolithiasis\n -Glaucoma\n Intracerebral hemorrhage (ICH)\n Assessment:\n Alert, able to answer yes/no but speech very dysarthric. Expressive\n aphasia. Slight left facial droop. PERRL 2 mm bil. Right side able to\n lift and hold extremities. LUE withdraws to pain, pt moves on bed.\n Patchy sensation on left side.\n Action:\n Neuro checks q 2\n Response:\n Neuro exam unchanged.\n Plan:\n Continue closely monitor for neuro changes, hemodynamic monitoring,\n repeat speech and swallow consult, PT/OT consults, OOB, continue\n provide support to pt and family, keep informed of plan.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2179-10-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639337, "text": "73 year old white male on Coumadin for DVT since ,\n found down (20 minute alone time). Pt was at neighbors house\n for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. Pt with very dysarthric speech, worsening left sided weakness.\n Ct scan revealed large right thalamic bleed into ventricles very close\n to brainstem.\n PMHx:\n HTN\n -Recurrent lower extremity DVT on anti-coagulation, last\n reportedly (others in , )\n -Dyslipidemia\n -GERD\n -Arthritis\n -Gout\n -Cervical disc disease, s/p surgery\n -Knee surgery, unclear laterality\n -Nephrolithiasis\n -Glaucoma\n Intracerebral hemorrhage (ICH)\n Assessment:\n Alert, able to answer yes/no but speech very dysarthric. Expressive\n aphasia. Slight left facial droop. PERRL 3 mm bil. Right side able to\n lift and hold extremities. LUE withdraws to pain, pt will\n intermittently wiggles toes of left foot. LLE pPatchy sensation on left\n side. Pt had repeat speech and swallow study done yesterday, pt able\n to have puree foods when alert with supervison and sitting upright in\n bed.\n Action:\n Neuro checks q 2\n Response:\n Neuro exam unchanged.\n Plan:\n Continue closely monitor for neuro changes, hemodynamic monitoring, ,\n PT/OT consults, OOB, continue provide support to pt and family, keep\n informed of plan.\n Atrial fibrillation (Afib)\n Assessment:\n Hr 90-120\ns rapid afib, pt was on diltazem gtt yesterday, pt started\n on po diltzem yesterday 60mg qid\n Action:\n Iv diltazem d/c\nd yesterday, pt continues on po diltazem\n Response:\n Pt converted back to sr this am\n Plan:\n Continue to monitor\n" }, { "category": "Nursing", "chartdate": "2179-10-23 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639338, "text": "73 year old white male on Coumadin for DVT since ,\n found down (20 minute alone time). Pt was at neighbors house\n for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. Pt with very dysarthric speech, worsening left sided weakness.\n Ct scan revealed large right thalamic bleed into ventricles very close\n to brainstem.\n PMHx:\n HTN\n -Recurrent lower extremity DVT on anti-coagulation, last\n reportedly (others in , )\n -Dyslipidemia\n -GERD\n -Arthritis\n -Gout\n -Cervical disc disease, s/p surgery\n -Knee surgery, unclear laterality\n -Nephrolithiasis\n -Glaucoma\n Intracerebral hemorrhage (ICH)\n Assessment:\n Alert, able to answer yes/no but speech very dysarthric. Expressive\n aphasia. Slight left facial droop. PERRL 3 mm bil. Right side able to\n lift and hold extremities. LUE withdraws to pain, pt will\n intermittently wiggles toes of left foot. LLE pPatchy sensation on left\n side. Pt had repeat speech and swallow study done yesterday, pt able\n to have puree foods when alert with supervison and sitting upright in\n bed.\n Action:\n Neuro checks q 2\n Response:\n Neuro exam unchanged.\n Plan:\n Continue closely monitor for neuro changes, hemodynamic monitoring, ,\n PT/OT consults, OOB, continue provide support to pt and family, keep\n informed of plan.\n Atrial fibrillation (Afib)\n Assessment:\n Hr 90-120\ns rapid afib, pt was on diltazem gtt yesterday, pt started\n on po diltzem yesterday 60mg qid\n Action:\n Iv diltazem d/c\nd yesterday, pt continues on po diltazem\n Response:\n Pt converted back to sr this am\n Plan:\n Continue to monitor\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Code status:\n DNR (do not resuscitate)\n Height:\n 72 Inch\n Admission weight:\n 90 kg\n Daily weight:\n 92.2 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: 74 y/old left handed man with histor of HTN and\n recurrent LE DVTs presents to ED after his wife found him awake but\n collapsed on bed with left sided weakness. On coumadin @ home, INR 2.9\n upon admission. CT done upon admission to ED. Had left facial droop,\n slow to answer questions. Mental status deteriorated in ED, intubated\n for airway protection, 2nd head CT done before transferring to SICU.\n Repeat CT done, transferred from there to SICU.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:80\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None, Face tent\n O2 saturation:\n 94% %\n O2 flow:\n 70 L/min\n FiO2 set:\n 24h total in:\n 1,130 mL\n 24h total out:\n 1,140 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:04 AM\n Potassium:\n 4.5 mEq/L\n 02:04 AM\n Chloride:\n 106 mEq/L\n 02:04 AM\n CO2:\n 23 mEq/L\n 02:04 AM\n BUN:\n 23 mg/dL\n 02:04 AM\n Creatinine:\n 0.7 mg/dL\n 02:04 AM\n Glucose:\n 155 mg/dL\n 02:04 AM\n Hematocrit:\n 37.0 %\n 02:04 AM\n Finger Stick Glucose:\n 139\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2179-10-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 639133, "text": "73 year old white male on Coumadin for DVT since ,\n found down (20 minute alone time). Pt was at neighbors house\n for\n coffee / returned home around 11 am. Wife returned home at 11:20\n am when she found pt. She states pt called out to her \"you\n better come up here\". She denies witnessing any seizure activity\n or incontinence. At that time pt denied tripping or striking\n head. Pt with very dysarthric speech, worsening left sided weakness.\n Ct scan revealed large right thalamic bleed into ventricles very close\n to brainstem.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Alert, able to answer yes/no but speech very dysarthric. Expressive\n aphasia. Slight left facial droop. PERRL 2 mm bil. Right side able to\n lift and hold extremities. LUE withdraws to pain, pt moves on bed.\n Patchy sensation on left side.\n Action:\n Neuro checks q 2\n Response:\n Neuro exam unchanged.\n Plan:\n Continue closely monitor for neuro changes, hemodynamic monitoring,\n repeat speech and swallow consult, PT/OT consults, OOB, continue\n provide support to pt and family, keep informed of plan.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" } ]

[ { "category": "Nursing/other", "chartdate": "2103-12-25 00:00:00.000", "description": "Report", "row_id": 1274372, "text": "PATIENT ADMITTED S/P CABG X 3 FROM OR. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. IV NEO ^. PACER OFF. CT'S PATENT FOR MODERATE SERO-SANG DRAINAGE. OG IN PLACE, PLACEMENT CHECKED. FOLEY IN PLACE, PATENT FOR COPIOUS AMT CLEAR URINE. DOPPLERABLE PULSES.\n" }, { "category": "Nursing/other", "chartdate": "2103-12-25 00:00:00.000", "description": "Report", "row_id": 1274373, "text": "NEURO: RUSSIAN SPEAKING, FAMILY HERE, DAUGHTER TO STAY THE NIGHT IN WAITING ROOM. APPEARS ORIENTED, MAE, FOLLOWING COMMANDS.\n\nCARDIAC: MP SR-ST, RATE DOWN AFTER IV EPI STOPPED. IV NTG FOR S B/P CONTROL.PACER A DEMAND RATE 60. CT'S PATENT FOR MODERATE SERO-SANG DRAINAGE. DOPPLERABLE PULSES. K REPLEATED.\n\nRESP: EXTUBATED TO PHH AT 1500 WITHOUT PROBLEMS. DOING WELL, C/R SMALL AMT WHITE/TAN.\n\nGI: OG TUBE DC'D WITH EXTUBATION, TOLERATING ICE CHIPS. ^ DIET AS TOLERATED.\n\nGU: FOLEY IN PLACE, PATENT FOR MODERATE CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT ^, FOLLOWING PROTOCOL.\n\nFAMILY AWARE OF EVENTS AND PLEASED WITH PROGRESS.\n\nPLAN: ENCOURAGE PATIENT TO TURN/DEEP BREATH. ^ DIET AS TOLERATED, OOB IN AM, ? DC SWAN, ? TRANSFER.\n" }, { "category": "Nursing/other", "chartdate": "2103-12-26 00:00:00.000", "description": "Report", "row_id": 1274374, "text": "Nursing Progress Note\nCVS: HR sinus to sinus tachy with occ pvcs. SBP maintained within cabg parameters with ntg iv gtt range from 0.4-1.0 mcg/kg. Current cvp is 5, PAd is 13. aplpable pulses x 4 ext, skin warm dry and intact except for surgical incisions. Sternal dressing with scant sero sang drainage, remains occlusive. Mediastinal dressing dry adn intact, tubes draining sero sang fluid with increased amounts during turns and repositioning. r rad a line and r ij pa line recal per unit protocol, transduced. See carevue flow sheet for PIV's and further incision/dressing information.\n\nNeuro: intact per daughter who translates for primarily russian speaking father. MAE, pupils equal, speecch cough and gag intact.\n\nResp: on 3 l nc sats >93, long smoking history. Cough and deep breath on prompt IS up to 750 with assistance of daughter. Lungs clear in uppers dim in lowers, no expectoration.\n\nGI: abd soft flat non tender, bs inaudible at this time.\n\nGU: foley cath draining clear yellow urine > 30 cc hour.\n\nPain: morphine for incisional pain with reported relief.\n\nEndo: insulin gtt per csru protocol.\n\nPlan: attempt to wean and dc insulin by am, wean nt as tol. Pain control. Pulm toilet. Monitor for decerased UOp. Utilize daughter for translation at this time. transfer to floor bed if able to wean pressor.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-12-25 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 890277, "text": " 1:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with chest pain s/p CABG\n\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP single view.\n\n INDICATION: Central venous line placement, evaluate for pneumothorax or\n effusion. Status post bypass surgery.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n supine position. The patient is now intubated, the ETT terminating in the\n trachea some 5 cm above the level of the carina. An NG tube reaches below the\n diaphragm. A right internal jugular approach central venous sheath carries a\n Swan-Ganz catheter, the tip of which reaches the central PA. Two mediastinal\n and one left sided chest tube is in place. The latter directed posteriorly\n and downwards. There is no evidence of pneumothorax or any new parenchymal\n infiltrates. No pulmonary congestion is noted. Mild mediastinal widening\n observed in comparison with the preoperative examination of .\n\n IMPRESSION: Satisfactory findings on first followup examination to bypass\n surgery.\n\n" }, { "category": "Radiology", "chartdate": "2103-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 889715, "text": " 5:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for etiology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n eval for etiology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old with chest pain.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH\n\n No prior studies.\n\n FINDINGS: Cardiac and mediastinal contours are normal. The lungs are clear.\n There is no pneumothorax, and pulmonary vasculature is normal. Osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n No radiographic evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-12-24 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 890080, "text": " 8:48 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP CABG\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with 3VD pre-op for CABG (monday)\n REASON FOR THIS EXAMINATION:\n pls eval for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preoperative evaluation before coronary artery bypass.\n\n COMPARISON: None available.\n\n FINDINGS/TECHNIQUE: scale, color duplex, and spectral Doppler\n interrogation examination of the extracranial carotid arteries was performed.\n\n On the right, peak systolic velocities were 90 cm/second in the internal\n carotid artery (ICA), 86 cm/second in the external carotid artery (ECA), 66\n cm/second in the common carotid artery (CCA). The flow within the right\n vertebral artery was antegrade. The ICA-to-CCA ratio was 1.36 on the right.\n\n On the left, the peak systolic velocity was 93 cm/second in the ICA, 84\n cm/second in the ECA, and 62 cm/second in the CCA. The flow within the left\n vertebral artery was antegrade. The left ICA to CCA ratio was 1.5.\n\n IMPRESSION: Non-hemodynamically significant stenoses of less than 40% were\n demonstrated in the right and left internal carotid arteries.\n\n" }, { "category": "ECG", "chartdate": "2103-12-25 00:00:00.000", "description": "Report", "row_id": 204957, "text": "Sinus rhythm. Increase in rate compared to the previous tracing of .\nThere is prior inferior wall myocardial infarction. The rate has increased and\nthere is continued T wave inversion in leads II, III and aVF and new ST segment\nflattening and slight depression in lead V5 and new T wave inversion in\nlead V6 consistent with lateral ischemic process superimposed on previous\nfindings. Followup and clinical correlation are suggested.\n\n" }, { "category": "ECG", "chartdate": "2103-12-23 00:00:00.000", "description": "Report", "row_id": 204958, "text": "Sinus bradycardia. T wave inversion in leads II, III and aVF. ST-T wave\nflattening in leads V5-V6. Compared to the previous tracing of there\nis continued evidence for prior inferior wall myocardial infarction. Question\nongoing inferior ischemia. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2103-12-21 00:00:00.000", "description": "Report", "row_id": 204959, "text": "Sinus rhythm. There are continued inferolateral ST-T wave abnormalities as\nrecorded on , without diagnostic interim change. Clinical correlation\nis suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2103-12-20 00:00:00.000", "description": "Report", "row_id": 204960, "text": "Sinus rhythm. Prior inferior wall myocardial infarction. ST segments are upward\ncoved in leads III and aVF and the T waves are inverted, raising the question\nof active inferior ischemic process. There is sinus arrhythmia. Followup and\nclinical correlation are suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2103-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 890573, "text": " 7:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post chest tube pull film eval for ptx or mediastinal accumu\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with chest pain s/p CABG\n\n REASON FOR THIS EXAMINATION:\n post chest tube pull film eval for ptx or mediastinal accumulation\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Status post CABG.\n\n CHEST: A single upright AP view is compared to previous examination of . Since the previous exam the ET and NG tubes, Swan-Ganz\n catheter, and chest tube as well as mediastinal drains have been removed.\n There is no evidence of pneumothorax. The heart size remains enlarged. There\n is a probable subsegmental atelectasis in left lower lobe and a small left\n pleural effusion. There is no overt pulmonary edema.\n\n The patient is status post median sternotomy and CABG.\n\n DR. \n" } ]

[ { "category": "Radiology", "chartdate": "2172-06-10 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 959402, "text": " 5:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: hypoxia\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p cabg mv repair\n REASON FOR THIS EXAMINATION:\n hypoxia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FBr WED 7:06 PM\n Moderate bilateral pleural effusion. severe pulmonary edema.Small retro\n strenal fluid collection likely post surgical.No mediastinal hemmorhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old male status post CABG and mitral valve repair with\n hypoxia.\n\n Comparison is made to prior chest radiograph dated .\n\n TECHNIQUE: MDCT acquired axial images were obtained through the chest without\n intravenous contrast. 5-mm, 1.25 mm, and coronal reaffirmations were\n evaluated.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST:\n\n FINDINGS:\n\n There is marked emphysema with scattered, widespread, ground-glass, lobular\n opacification and thickening of the interlobular septae most consistent with\n moderate congestive heart failure. Additionally, heterogeneous opacification\n involves the periphery of the posterior segment of the right upper lobe along\n the major fissure consistent with aspiration or other pneumonia. Bilateral\n lower lobe compression atelectasis (left greater than right) lies adjacent to\n moderate-sized simple pleural effusions. Minimal sectretions are noted distal\n to endotracheal tube which ends 6.5 cm from the carina. The airways are patent\n to the subsegmental level. A vertically- oriented small simple fluid\n collection is noted posterior to the median sternotomy site, a normal\n postoperative finding. Post CABG/MVR clips/leads are noted, and the tip of a\n right- sided central venous line terminates within the distal SVC. There is\n mild probable postoperative thickening of the pericardium with no large\n pericardial effusion noted. Likely reactive medistinal lymphadenopathy is\n present, the largest node measuring up to 1.2 cm in the right paratracheal\n chain. Linear streaks of subcutaneous air are noted along the left anterior\n chest wall.\n\n Limited examination of the upper abdomen displays a nasogastric tube to\n terminate within the gastric fundus and a small nonobstructive right\n interpolar renal calculi along with a posterior left upper pole simple cyst.\n No malignant appearing osseous lesions are identified and median sternotomy\n site appears well apposed.\n\n (Over)\n\n 5:30 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: hypoxia\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Moderate interstitial pulmonary edema with small to moderate bilateral\n simple pleural effusions and adjacent lower lobe compression atelectasis.\n\n 2. Heterogeneous posterior right upper lobe opacity, likely pneumonia,\n could be due to aspiration.\n\n 3. Simple postoperative posterior sternal fluid collection.\n\n 4. Emphysema.\n\n 5. Nonobstructive right renal calculi.\n\n Updated findings regarding possible right upper lobe pneumonia were discussed\n with caring PA on at approximately 11:45am.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958746, "text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for hypoxia\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n eval for hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY AT 4:37 A.M.\n\n COMPARISON: at 2100.\n\n INDICATION: Decreasing oxygenation.\n\n Nasogastric tube has been inserted with resolution of gastric distention.\n Other lines and tubes remain in standard position. Pulmonary edema pattern\n has slightly improved and there is improving aeration in the right lower lobe.\n However, left retrocardiac opacity has worsened, most likely due to a\n combination of atelectasis and effusion. There is otherwise no substantial\n change from the recent radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958890, "text": " 10:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion? infiltrate?\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n effusion? infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10:47\n\n INDICATION: CABG and mitral valve repair.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior study, the lines and tubes remain in place\n and there is no PTX. However, there appears to be some coarsening of the\n vascular markings and increased pleural fluid layering out consistent with\n worsening in fluid status. There is no definite evidence for a pneumothorax.\n\n IMPRESSION: Worsening fluid status.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958517, "text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess chf\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD preop\n\n REASON FOR THIS EXAMINATION:\n assess chf\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Preoperative evaluation of the patient with known\n coronary heart disease.\n\n PA and lateral upright chest radiograph compared to .\n\n The heart size is normal. Mediastinal position, contours and width are\n unremarkable. There are widespread areas of interstitial opacities which may\n represent mild congestive heart failure. This finding has improved comparing\n to the previous film. There is no pleural effusion. There are no focal areas\n of infiltrate suggesting infectious process. The lungs are generally slightly\n hyperinflated which may represent COPD.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 958676, "text": " 2:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Please at\n with abnormalities. Pt still in the OR, aprrox. ETA to CSRU 1 hour 20\n minutes.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old male status post CABG and mitral valve repair.\n\n Comparison is made to prior chest radiograph dated and .\n\n SINGLE PORTABLE SUPINE CHEST RADIOGRAPH:\n\n FINDINGS: The patient is now noted to be status post median sternotomy/CABG\n with mitral valve repair. Endotracheal tube is approximately 6 cm from the\n carina and a nasogastric tube ends proximal to the gastroesophageal junction.\n A Swan-Ganz catheter tip appears to be within the RV outflow tract. Multiple\n mediastinal drains and left-sided chest tube along with epicardial wires are\n identified. There is no evidence of pneumothorax or large effusions. There is\n slight progression to interstitial pulmonary edema with mild obscuration of\n the hemidiaphragms bilaterally, likely consistent with bilateral basilar\n atelectasis.\n\n IMPRESSION:\n 1. Status post CABG/MVR. No evidence of pneumothorax or effusion.\n 2. Slight progression to moderate interstitial pulmonary edema.\n 3. OGT terminates within the esophagus. Advancement recommended.\n 4. Swan-Ganz tip appears to terminate within the RV outflow tract.\n\n Findings discussed with the caring nurse on date of\n exam at 3:00 p.m.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958036, "text": " 4:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n THIS IS A PORTABLE SEMI-UPRIGHT CHEST STATED .\n\n INDICATION: Coronary artery disease.\n\n Endotracheal tube terminates 5.0 cm above the carina with the cuff of tube\n slightly over inflated. Nasogastric tube is coiled in proximal stomach with\n tip directed towards the GE junction. Heart size is normal. Pulmonary\n vascularity is engorged and indistinct, with diffuse hazy and reticular\n opacities throughout the mid and lower lung zones consistent with pulmonary\n edema. Small partially layering pleural effusions are present bilaterally on\n the semi-upright projection.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-02 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 958138, "text": " 10:11 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: CAD\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD, intubated\n REASON FOR THIS EXAMINATION:\n portable, r/o stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old man with coronary artery disease and suspected carotid\n stenosis.\n\n RADIOLOGIST: The study was read by Dr. .\n\n TECHNIQUE: Evaluation of the extracranial carotid arteries was performed with\n B-mode, color and spectral Doppler ultrasound.\n\n FINDINGS: A small amount of plaque was seen in the bilateral internal carotid\n arteries, with B-mode ultrasound.\n\n On the right side, peak systolic velocities were 53 cm/sec for the internal\n carotid artery, 47 cm/sec for the common carotid artery and 251 cm/sec for the\n external carotid artery. The right ICA/CCA ratio was 1.12.\n\n On the left side, peak systolic velocities were 106 cm/sec for the ICA, 91\n cm/sec for the CCA and 338 cm/sec for the ECA. The left ICA/CCA ratio was\n 1.16.\n\n Both vertebral arteries presented antegrade flow.\n\n COMPARISON: None available.\n\n IMPRESSION: Less than 40% stenosis of the bilateral internal carotid\n arteries.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959282, "text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG/MV repair w/worsening hypoxia-r/o PTX/effusin\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n s/p CABG/MV repair w/worsening hypoxia-r/o PTX/effusin\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, 5:44 a.m.\n\n INDICATION: Status post CABG and mitral valve repair. Worsening hypoxia.\n\n FINDINGS: Compared with , there is now prominent diffuse interstitial\n opacity, most suggestive of pulmonary edema. Swan-Ganz catheter has been\n removed with the right IJ sheath remaining in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 959356, "text": " 1:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p line placement - xray done\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n s/p line placement - xray done\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreasing oxygenation and increasing requirement for ventilation\n support in a patient who is status post recent CABG and mitral valve repair.\n Also, evaluate after line placement.\n\n COMPARISON: Prior chest radiograph obtained earlier today at 5:30 a.m.\n\n TECHNIQUE AND FINDINGS: A portable frontal chest radiograph was obtained in\n upright position at noon.\n\n Heart size appears slightly increased as compared to earlier today. Left\n retrocardiac opacity and small left basilar effusion are now more prominent as\n well, obscuring the left hemidiaphragm. There remains diffuse bilateral\n pulmonary edema.\n\n There has been interval placement of a nasogastric tube and a new right\n internal jugular central venous line, with removal of the prior, wider bore\n sheath. The tip of the endotracheal tube appears now in a more cranial\n position than before, currently located at the level of the medial ends of the\n clavicles, approximately 7.7 mm above the carina.\n\n CONCLUSION:\n 1. Mild interval worsening in heart size, left retrocardiac opacity and left\n basilar pleural effusion. Persistence of diffuse pulmonary edema.\n 2. Line and tubes as described above, with interval partial pull-back of the\n endotracheal tube and interval placement of a new nasogastric tube.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958283, "text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with history of cad awaiting CABG\n REASON FOR THIS EXAMINATION:\n preop evaluation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative evaluation before CABG. History of coronary artery\n disease.\n\n COMPARISON: Prior chest radiograph obtained 2 days ago.\n\n TECHNIQUE AND FINDINGS: A portable chest radiograph was obtained in supine\n position.\n\n There has been interval removal of the endotracheal tube and of the\n nasogastric tube. Heart size remains normal and lung hila are again\n symmetric. Pulmonary vascular flow cephalization and bilateral perihilar\n haziness and reticular opacities are again consistent with pulmonary edema.\n The appearance of the left lung base is now improved as compared to two days\n ago, with the left hemidiaphragm distinctly seen. The lateral right\n costophrenic angle is not included in the image.\n\n CONCLUSION: Interval removal of the endotracheal and nasogastric tubes.\n Persistence of pulmonary edema. Improved visibility of the left lung base.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 958715, "text": " 8:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval following reintubation\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Pt failed extubation attempt\n and was reintubated emergently.\n REASON FOR THIS EXAMINATION:\n eval following reintubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY, AT 21:01.\n\n COMPARISON: at 14:29.\n\n INDICATION: Emergent reintubation.\n\n Endotracheal tube terminates about 3.5 cm above the carina. Other lines and\n tubes are unchanged in position. Removal of nasogastric tube, accompanied by\n development of moderate to marked gastric distention. Pulmonary edema pattern\n has progressed with increasing perihilar haziness. More confluent basilar\n opacities likely represent a combination of atelectasis and dependent edema.\n Small pleural effusions, right greater than left are noted. Dependent edema\n and atelectasis. Small pleural effusions have slightly increased in size.\n Nasogastric tube has been removed, and there is development of moderate to\n marked gastric distention.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959007, "text": " 11:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct d/c, r/o ptx\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n s/p ct d/c, r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Chest tube removal.\n\n Endotracheal tube, Swan-Ganz catheter, and nasogastric tube remain in place.\n Mediastinal drain and left chest tube have been removed, with no evidence of\n pneumothorax. Cardiac and mediastinal contours are stable. Interstitial\n edema has decreased, and bilateral pleural effusions also appear improved.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 961297, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion - page with concerns\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with history of cad awaiting CABG\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion - page with concerns\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:27 A.M. ON \n\n HISTORY: Awaiting CABG.\n\n IMPRESSION: AP chest compared to through 14:\n\n Moderately severe pulmonary edema which improved on has recurred\n accompanied by small bilateral pleural effusions. Heart size is normal and\n unchanged. No pneumothorax. Tracheostomy tube in standard placement.\n Findings were discussed by telephone with Dr. at the time of\n dictation.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959892, "text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrate\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Decreased oxygenation.\n\n Lines and tubes are in standard position. Cardiac and mediastinal contours\n are stable. Worsening perihilar and basilar pulmonary edema are present.\n Left retrocardiac opacity is probably due to atelectasis with adjacent pleural\n effusion. Small right pleural effusion is unchanged.\n\n IMPRESSION: Worsening pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960244, "text": " 6:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval trach placement\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. now s/p trach / peg\n REASON FOR THIS EXAMINATION:\n please eval trach placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old male status post CABG and mitral valve repair, status\n post tracheostomy. Evaluate tracheostomy tube placement.\n\n COMPARISON: .\n\n SINGLE FRONTAL VIEW OF THE CHEST: A tracheostomy tube has been placed and\n endotracheal tube removed. The tracheostomy tube tip is at the thoracic\n inlet, approximately 6.5 cm from the carina. A right internal jugular\n catheter tip terminates at the cavoatrial junction. There is stable bibasilar\n and perihilar pulmonary edema. There is stable retrocardiac opacity\n consistent with left lower lobe collapse.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-20 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 960750, "text": " 12:05 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: GI contrast only, no IV contrast.\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n Field of view: 38\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: The presence of 4.6 cm abdominal aortic aneurysm was discussed with\n APN on and follow-up recommended.\n\n\n 12:05 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: GI contrast only, no IV contrast.\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with abdominal distension and tenderness after PEG.\n REASON FOR THIS EXAMINATION:\n GI contrast only, no IV contrast.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 69-year-old man with abdominal distention after PEG tube\n placement.\n\n COMPARISONS: Limited comparison to a prior chest CT dated .\n\n TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with oral\n and intravenous contrast, and sagittal and coronal reconstructions were also\n performed.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is interval progression of mixed\n consolidative and ground-glass opacity in the visualized portion of the right\n lower lobe. There is also similar persistent opacity in the right middle lobe.\n Bibasilar pleural effusions and adjacent atelectases are also present.\n\n Within the limitations of a non-contrast study, the liver appears normal. The\n gallbladder contains a large high-density material which could represent\n either sludge, tiny stones or perhaps vicarious excretion of contrast if there\n has been recent contrast administration. However, the gallbladder is not\n distended.\n\n The spleen, pancreas and adrenal glands are unremarkable. There is a low-\n density hypoattenuating focus in the upper pole of the left kidney compatible\n with a 13-mm simple renal cyst. There are bilateral renal vascular\n calcifications. An additional small 3 mm calcification within the right mid\n pole may be vascular or represent a tiny non-obstructing stone.\n\n A new gastrostomy tube terminates within the stomach. The site of entry\n appears normal. There is a small amount of free intraperitoneal air, but this\n is not unanticipated after gastrostomy tube placement in the immediate post-\n procedure course. The post-operative stomach, small and large bowel are\n unremarkable. The appendix appears normal.\n\n An infrarenal abdominal aortic aneurysm measuring up to 4.6 cm in AP dimension\n is noted with thin mural calcifications.\n\n CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is present within the\n bladder. There is sigmoid diverticulosis. The prostate and seminal vesicles\n appear normal. There is a trace amount of the ascites within the pelvis.\n There is no lymphadenopathy.\n\n (Over)\n\n 12:05 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: GI contrast only, no IV contrast.\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: There are no suspicious lytic or blastic lesions. Degenerative\n changes are present with osteophytes at the thoracolumbar junction.\n\n IMPRESSION:\n 1. Worsening right lower lobe opacity consistent with pneumonia or\n aspiration.\n\n 2. Unremarkable appearance of gastrostomy tube. A small amount of free air\n can be seen shortly after tube placement.\n\n 3. Dense material in the gallbladder, consistent with either sludge, stones\n or vicarious excretion of contrast, if there is recent intravenous contrast\n administration.\n\n 4. 4.6 cm infrarenal abdominal aortic aneurysm. Clinical evaluation and\n imaging follow-up are recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960964, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. now s/p trach / peg\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Evaluate for pleural effusion in postoperative patient.\n\n Vascular catheter has been removed with no evidence of pneumothorax.\n Tracheostomy tube is unchanged in position. Cardiac and mediastinal contours\n are stable in appearance. Worsening vascular engorgement and increasing\n perihilar haziness are present in conjunction with a worsening bilateral\n interstitial pattern. Small bilateral pleural effusions are unchanged.\n\n IMPRESSION: Worsening pulmonary edema. Persistent small bilateral pleural\n effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960985, "text": " 10:34 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p bronch\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. now s/p trach / peg\n\n REASON FOR THIS EXAMINATION:\n s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:55 a.m. \n\n HISTORY: Coronary artery disease, MR, status post tracheostomy and\n bronchoscopy.\n\n IMPRESSION: AP chest compared to through :\n\n Mild pulmonary edema and small bilateral pleural effusions have improved since\n 8:42 a.m. Heart size is normal. No pneumothorax. Tracheostomy tube in\n standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-13 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 959802, "text": " 11:25 AM\n RENAL U.S. PORT Clip # \n Reason: RISING CREATINE EVAL FOR OBSTRUCTION, SIZE\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with rising cr intubated in CSRU.Portable exam\n REASON FOR THIS EXAMINATION:\n size of kidneys. obstruction?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69-year-old man with rising creatinine, intubated. Evaluate the\n size of kidneys. Evaluate for obstruction.\n\n No comparison studies.\n\n RENAL ULTRASOUND: The right kidney measures 11.5 cm. The left kidney\n measures 11.6 cm. There is no hydronephrosis, stones, or masses. There are\n bilateral moderate-sized pleural effusions, left greater than right.\n\n IMPRESSION:\n\n 1. No evidence for hydronephrosis.\n\n 2. Bilateral moderate pleural effusions, left greater than right.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 959627, "text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. Decreasing oxygenation\n requiring increasing vent support\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Followup evaluation status post CABG/MVR.\n\n Comparison is made to prior chest radiograph dated and prior CT\n from same date.\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH.\n\n FINDINGS:\n\n Since most recent radiograph, there has been improvement to moderate\n interstitial pulmonary edema and size of small bilateral pleural effusions.\n The right lower lobe atelectasis appears improved with decreased left lower\n lobe atelectasis but persistent retrocardiac opacity. A patchy density\n projecting over the right mid hemithorax, likely corresponding to posterior\n right upper lobe opacity identified on CT examination is slightly more\n appreciable on today's examination. There is no evidence of pneumothorax and\n right-sided central line, endotracheal tube, and nasogastric tube remain in\n unchanged position.\n\n IMPRESSION:\n\n Improvement to moderate interstitial pulmonary edema and bilateral pleural\n effusions.\n\n Persistent left lower lobe atelectasis. Right upper lobe patchy density,\n likely corresponding to pneumonia, possibly aspiration related.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-19 00:00:00.000", "description": "ABDOMEN U.S. (PORTABLE)", "row_id": 960684, "text": " 12:49 PM\n ABDOMEN U.S. (PORTABLE) Clip # \n Reason: RUQ PAIN R/O CHOLELITHIASIS\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man s/p CABG/MVR c/b resp failure. now s/p trach/peg w/abdm\n distention and RUQ pain\n REASON FOR THIS EXAMINATION:\n r/o cholelithiasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69 y/o man status post CABG and MVR, with right upper quadrant\n pain, evaluate for cholelithiasis.\n\n COMPARISON: .\n\n ABDOMINAL ULTRASOUND: Liver demonstrates normal echogenicity with no focal\n abnormalities. The gallbladder is sludge filled, without any evidence of\n gallbladder wall edema. There is no intra or extrahepatic biliary ductal\n dilatation. The right kidney measures 10.2 cm, the left kidney measures 9.9\n cm. There is no hydronephrosis or stones. Limited assessment of the pancreas\n because of overlying bandages. The spleen is normal in size measuring 11.7\n cm. There are bilateral pleural effusions, greater on the left.\n\n IMPRESSION:\n 1) Sludge filled gallbladder, without evidence of gallbladder wall edema.\n 2) Again seen are bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960702, "text": " 2:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: f/u to assess free air\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. now s/p trach / peg\n\n REASON FOR THIS EXAMINATION:\n f/u to assess free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old man status post CABG and mitral valve repair along with\n tracheostomy and PEG placement. Followup to assess intra-abdominal free air.\n\n Comparison is made to most recent radiograph taken approximately at 12:30 a.m.\n on .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH.\n\n FINDINGS:\n\n Small amount of pneumoperitoneum appears resolved. Mild-to-moderate\n interstitial pulmonary edema persists, however, previously identified medial\n right lower lobe opacity is not as appreciable on current radiograph and may\n have represented atelectasis. Small left effusion is stable. Tracheostomy,\n right- sided central venous catheter, aortic valve replacement, and\n mediastinotomy wires are unchanged. No evidence of pneumothorax.\n IMPRESSION:\n\n 1. No evidence of residual intraperitoneal air.\n\n 2. Unchanged mild-to-moderate interstitial edema and small left effusion.\n\n" }, { "category": "Radiology", "chartdate": "2172-06-19 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 960603, "text": " 12:10 AM\n PORTABLE ABDOMEN Clip # \n Reason: s/p PEG w/increased abdominal distention and pain-please \n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with\n REASON FOR THIS EXAMINATION:\n s/p PEG w/increased abdominal distention and pain-please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PEG tube placement, with increasing abdominal\n distention and pain.\n\n FINDINGS: Single portable abdominal radiograph is reviewed. No comparisons.\n There is no free intraperitoneal air. No dilated loops of bowel are seen. A\n few small foci of air are seen within the colon and rectum. PEG tube is seen\n overlying the left abdomen.\n\n IMPRESSION: Unremarkable abdominal radiograph.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 960604, "text": " 12:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p PEG w/increased abdiminal distention and pain-r/o free a\n Admitting Diagnosis: ATRIAL FIBRILLATION;CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with CAD/MR s/p CABG/MV Repair. now s/p trach / peg\n\n REASON FOR THIS EXAMINATION:\n s/p PEG w/increased abdiminal distention and pain-r/o free air ***please do\n upright film***\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old man status post CABG and mitral valve repair, now with\n recent tracheostomy and PEG placement. Increasing abdominal distention.\n Evaluate for free air.\n\n Comparison is made to prior radiograph dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n There has been interval placement of a PEG tube and a small amount of\n pneumoperitoneum is identified underneath the right hemidiaphragm.\n Additionally, there is a questionable opacity developing within the right\n lower lobe _____ behind the right heart border. Mild-to-moderate interstitial\n pulmonary edema persists as does a mild atelectasis within the left lower lobe\n and bilateral small pleural effusions. A tracheostomy tube and right-sided\n central venous catheter are unchanged in position. Post-surgical changes from\n CABG and MVR are identified.\n\n IMPRESSION:\n\n 1. Mild pneumoperitoneum status post PEG placement.\n\n 2. Questionable developing right lower lobe air bronchogram containing\n opacity. be aspiration related.\n\n 3. Persistent mild-to-moderate pulmonary edema.\n\n Nurse was paged at approximately 11:00 a.m. to discuss\n these findings.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-10 00:00:00.000", "description": "Report", "row_id": 1356047, "text": "7p-7a\nNeuro: Received pt alert and oriented to self only. Perrla. MAE. Follows commands. Denied pain. As noc progressed, pt increasingly more confused and restless, picking at iv's, pt pulled out , taking high flow mask off, despite telling pt to leave on for oxygenation issues. See carevue. Pt sedated on propofol after extubation.\n\nCV: HR 80-120s. Afib, converted to NSR at 0400. received a total of 35mg iv lopressor between 0030-0430, see med sheets for details. Amio bolus given as ordered at 0130. At 0400, hypertensive SBP 150-170s,PA at bedside, see carevue, ntg to 5mcg/kg/, nicardipine gtt started and increased to 3mcg as ordered, SBP continuing to 150-160s. Hydralazine 20mg ivp given w/ no results. Weaned all gtts after pt was re-intubated. Heparin gtt increased to 1000units/hr per PA . Amio gtt at 0.5mg/ since pt NPO. Lopressot changed to iv while pt npo. +palpable pedal pulses.\n\nResp: LS diminished. Sats 92-94% at beginning of shift. At 0300, sats decreased to 90%, bipap(see carevue) on for approx. 1 hour, pt unable to tolerate, despite haldol 5mg ivp given, pt agitation increased, off for approx 1 hour w/ sats 90-92%, pt desat to 88% on high flow mask FiO2 95% see carevue for abgs, PA aware, bipap placed back on pt, SBP 170s, PA at bedside, pt intubated at 0530, uneventful. Orally intubated 7.5 tube, presently on CMV mode, see carevue for details. Peep decreased from 15 to 10, see carevue.\n\nGI/GU: NPO. Abd soft round, +BS. OGT placed after intubation, +placement, draining bilious secretions. Foley draining 30-280cc/hr of clear yellow urine, urine cx sent as ordered. Lasix 40mg ivp q8 hours.\n\nEndo: No coverage needed.\n\nSocial: Daughter called and updated.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropropiate. Bronch today. ? CT of chest.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-10 00:00:00.000", "description": "Report", "row_id": 1356048, "text": "resp care\nreceived intubated/vented in ac mode. settings titrated to lung protective settings however pt with consistent spontaneous efforts exceeding preset Vt. bronched in am for bloody secretions,bal obtained,since then has had yellowish sputum. transporting imminently to ct scan. bs diminished bilaterally. refer to flow sheet for full data.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-23 00:00:00.000", "description": "Report", "row_id": 1356104, "text": "respiratory Care\nPt trached on vent support. At hour sleep pt is noted to have substantial prolonged desaturation peep increased to adjust for desaturation with good results, peep decreased gradually starting at 0400 with the goal to be back at 5 of peep by 0700. AM RSBI 24. Sx for thick brown secretions, good aeration. Pt noted to have continued large minute ventilation 12-15 LPM. ADG with continued respiratory alkalosis and normoxia. Goal is to wean to trach collar trials today.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-23 00:00:00.000", "description": "Report", "row_id": 1356105, "text": "Respiratory Care Note\nPt received on PSV 5/5 as noted. Pt suctioned for moderate amts thick, bloody-brown secretions. Pt placed on 100% trach mask. Speech evaluated pt for swallow and PMV when placed on trach mask. Pt did well with swallow eval and will able to eat a regular diet when on PMV and trach mask. Fio2 weaned to 70% according to sats. ABG reveals mild respiratory alkalosis with a PaO2 of 68. Pt tolerating trach mask and PMV trial well. Plan to continue with trach mask trials as tolerated as long as sats are greater than 90% - may rest overnight on PSV.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-23 00:00:00.000", "description": "Report", "row_id": 1356106, "text": "PROB: REHAB SCREENING\n\nCV: SR, VSS. CHEST DRESSINGS CLEAN AND DRY. J-P X2 DRAINING S/S.\n\nRESP: LUNGS CLEAR, DIM IN BASES. C/R THICK BROWN SPUTUM. O2 SATS ADEQUATE, ON TRACH COLLAR WITH PASSEY MUIR VALVE MOST OF DAY. PT C/O FATIQUE AND RESTING ON VENT SINCE :30. SEE FLOW SHEET FOR ABGS.\n\nGU: LASIX WITH RESPONSE.\n\nGI: NA HIGH, STARTED ON FREE WATER BOLUSES. TOLERATING TUBE FEEDS. SWALLOW EVAL TODAY, DID WELL WELL. TOLERATING SOFT/PUREED FOODS. CONTINUES ON TFEEDS. STOOL X1.\n\nNEURO: AND ORIENTED X3. MAE. PERL. APPROPRIATE. AMBULATES WITH 2 PERSON ASSIST. SEEN BY PT.\n\nENDO: BS PER FLOW SHEET S/S INSULIN.\n\nASSESSMENT: DOING BETTER, READY FOR REHAB.\n\nPLAN: CONT. PUREED FOODS WITH ASSIST.\nPULMONARY HYGIENE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-24 00:00:00.000", "description": "Report", "row_id": 1356107, "text": "REspiratory Care\nPt trached on vent support. No vent setting changes made this shift. Maintained adequate oximetry values (mid to high 90's all shift). BS occ coarse, sx for mod amounts of thick brown secretions, occ raising plugs of brown secretions by mouth. AM RSBI 14. Continue with trach collar trials during day. Plan is to DC to rehab setting later today.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-24 00:00:00.000", "description": "Report", "row_id": 1356108, "text": "NEURO: , oriented x3, responds , , turns by self in bed\n\nRESP: Tolerated PEEP 5/PS 5/50% on vent, Sats 96%, lung sounds clear at apices/dim at bases, Pt able to expectorate own secretions, plan for trach collar/PMV\n\nCV: NSR with HR in 70s, a-line was accidentally removed by Pt, SBP by cuff are 110-120s, pedal pulses palpable.\n\nGI/GU: Continues on TF at goal, abd firm, +BS, no BM, advance diet as tolerated; Foley in place draining yellow/sediment urine, creat 1.3, repleted K\n\nENDO: On SSRI\n\nSOCIAL: Daughter called overnight.\n\nPLAN: Trach collar, PMV, advance diet, ?rehab discharge\n" }, { "category": "Nursing/other", "chartdate": "2172-06-24 00:00:00.000", "description": "Report", "row_id": 1356109, "text": "Respiratory Care Note\nPt received on PSV 5/5 - pt placed on trach mask as noted. BS clear bilaterally with good aeration. Pt suctioned for small to moderate amts thick, bloody to brown secretions. Cuff deflated and PMV in place. Pt has a strong voice and is tolerating trach mask and PMV well. Plan to continue with trach mask trial as tolerated. Plan to transfer to rehab tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-10 00:00:00.000", "description": "Report", "row_id": 1356049, "text": "7am-7pm update\nneuro: pt sedated on propofol gtt. propofol gtt off breifly this afternoon for neuro check. pt woke, MAE and followed commands. pt resedated per team. PERRL\n\nCV: pt in and out of afib. pt continues on amio gtt at 0.5mg/. pt given 150 mg amio bolus x1 this afternoon and converted into NSR. pt has stayed in NSR since. pt also recieving lopressor IV 10 mg q4h. pt remains on heparin gtt (for afib). heparin gtt off breifly this am for line change. heparin gtt increased to 1100 u/hr this am per team. repeat PTT pending. BP 110-140's/50-60's. MAP 70-80's. trending NP. hct stable. lytes replaced. pp by doppler\n\nresp: LS dim with ronchi. pt suctioned for thick tan blood tinged sputum. pt bronched this am -> bloody plugs noted on right lobe during bronch. bronchial washing sent for culture. pt weaned to AC 40% 420 x 24 with 10 PEEP. see flowsheet for vent adjustments and abg's. CT of Chest done this afternoon.\n\ngi: pt with + bs. pt restarted on replete with fiber TF this afternoon. TF at 10 cc/hr (goal 80 cc/hr) no residuals.\n\ngu: foley draining clear yellow urine. old foley dc'd and new foley placed this am. after new foley placed -> UA and CX sent.\npt continues on lasix TID -> diuresing well. BUN/Creatinine 41 and 1.5 this am\n\nAccess: right IJ introducer changed to multi lumen using guidewire. placement confirmed by CXR\n\nskin: skin intact. sternum covered with steri strips. sternum washed with betadine and covered with DSD - as ordered. warts noted on bil hands and feet.\n\nsocial: daughter updated by NP via phone this afternoon\n\nplan: pulm toleit, monitor abg's/oxygeantion, monitor rhythm, continue amio gtt, continue heparin gtt -> goal PTT 50-70 (per team), advance TF as tolarated, skin care\n" }, { "category": "Nursing/other", "chartdate": "2172-06-11 00:00:00.000", "description": "Report", "row_id": 1356050, "text": "7p-7a\nNeuro: Pt sedated on propofol gtt. Propofol turned off at 0215 for neuro check, pt mae, bilat hand grasps on command and wiggled toes on command, re-sedated on propofol after neuro check. Perrla. No indication of pain by facial grimace or vital signs.\n\nCV: HR 60-70s SR rare PVC noted, lytes repleted prn. SBP 110-130s. Tolerating lopressor 10mg ivp q4 hours. Amio gtt at 0.5mg/. Heparin gtt increased to 1300units/hr. CVP 9-13. Hydralazine ivp q6 hours started. +dopplerable pedal pulses.\n\nResp: LS diminished. Sats 94-96%. Orally intubated w/ 7.5 tube 21 at lip. CMV mode FiO2 40%, rate 24, pt breathing over vent rate, Peep of 10, TV 420. Acceptable abgs on present settings. See carevue for details.\n\nGI/GU: Abd soft, round, +BS. +placement of ogt. TF presently at 50cc/hr w/ no residual, goal rate for 80cc/hr, to be increased at 0700 to 70cc/hr. Foley draining adequate amts of clear yellow urine, lasix increased to 60mg ivp q8 hours.\n\nEndo: No coverage needed.\n\nSocial: Daughter called and updated w/ POC.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. Increased TF to goal as pt tolerates. ? start to wean vent as pt tolerates in am. ? Echo in am.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-24 00:00:00.000", "description": "Report", "row_id": 1356110, "text": "PROB: REHAB\n\nCV: SR NO ECTOPY NOTED, VSS. CHEST DRESSINGS CLEAN AND DRY.\n\nRESP: C/R THICK TAN SPUTUM. ON TRACH COLLAR MOST OF DAY.\n\nGU: LASIX WITH GOOD RESPONSE.\n\nGI: TOLERATING SOFT SOLIDS. BOWEL SOUNDS PRESENT. STOOL X1.\n\nNEURO: APPROPRIATE, ORIENTED X3. DISAPPOINTED HE'S NOT GOING TO REHAB TODAY. PT REQUESTING , GIVEN 2MG ATIVAN WITH GOOD EFFECT.\n\nENDO: TREATED WITH S/S INSULIN.\n\nASSESSMENT: READY FOR REHAB.\n\nPLAN: DISCHARGE PLANNING DONE, REFERRAL DONE.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-25 00:00:00.000", "description": "Report", "row_id": 1356111, "text": "Resp Care\nMr. became restless last evening, pulling on his lines and aattempting to get out of bed. Had been put back on the vent to rest overnight but taken off after less than an hour due to agitation and disconnecting himself. Initially on 50% trach collar, sats down at times to 80s. ABGs drawn at this time with Po2 71. Changed to a hi-flow neb with sats back up to 95-98, FIO2 at 60. He also received ativan with some success. Breathsounds are coarse, suctioned for very thick brown sputum. ? transfer to rehab later today.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-25 00:00:00.000", "description": "Report", "row_id": 1356112, "text": " 7p-7a\nneuro: a+o x3, mae, following commands this am; became agitated at beginning of shift and was pulling at lines/tubes/attempted to pull trach/attempted to crawl out of bed->ativan 2mg gt and bilateral arm restraints->pt slept until ~midnight and then pt again became agitated and would not listen to reason/attempting to crawl out of bed->roxicet through gt->pt slept until 0300 when he woke and was pleasant and following commands; ambulated x1 to sink and back-pt unsteady on feet, requiring support from RN to maintain balance\n\ncv: sr 68-92, to afib for ~2hrs did not resolve with po diltiazem, but returned to sr with 2.5 mg iv lopressor, hydralazine po held x1 for sbp 92, sbp 92-125, afeb\n\nresp: lungs cta, diminished to bases, attempted to put pt on vent to rest, but pt did not tolerate/became very agitated and attempted to pull trach out; pt left on trach collar overnight-02 sats 89-92% on fi02 100%-> high flow 02-> 02 sats >95%; suctionned occasionally for thick bloody secretions\n\ngi: tolerating tube feeds at goal 35ml/hr, able to drink water safely with supervision/cuff down/passy muir valve in place, fingersticks ssri\n\ngu: foley to gravity draining clear yellow urine, good reaction to iv lasix\n\nlabs: repleted K+\n\nassess: stable\n\nplan: transfer to rehab, downsize trach?, restart antidepressant, increase activity\n" }, { "category": "Nursing/other", "chartdate": "2172-06-25 00:00:00.000", "description": "Report", "row_id": 1356113, "text": "csru nursing update\ntransferred to rehab at 1100am with paramedics, pt ao x3, calm and cooperative, pleasant with no signs of confusion/violent behavior. pt verbalized not being able to remember being uncooperative and pulling lines out the night before. saturating up to 99% on hiflow 60%, not in respiratory distress, able to cough up and out thick secretions, nebs per RT. NSR, stable bp, afebrile, distal pulses palpable. foely dc'd, on lasix, to start diamox. daughter phoned and updated, will wait pt in rehab\n\nA/P: stable -> transferred to NE with paramedics\n" }, { "category": "Echo", "chartdate": "2172-06-13 00:00:00.000", "description": "Report", "row_id": 84249, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease.\nHeight: (in) 70\nWeight (lb): 186\nBSA (m2): 2.03 m2\nBP (mm Hg): 124/46\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 13:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Trivial MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction with inferior hypokinesis.\nOverall left ventricular systolic function is mildly depressed. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nA mitral valve annuloplasty ring is present with only mild inflow gradient.\nTrivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.] There is a\ntrivial/physiologic pericardial effusion. There is at least borderline\npulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function appears similar to slightly more vigorous.\n\n\n" }, { "category": "Echo", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 84250, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 70\nWeight (lb): 186\nBSA (m2): 2.03 m2\nBP (mm Hg): 149/61\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 14:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - akinetic; basal inferior - akinetic;\n\nRIGHT VENTRICLE: Small RV cavity. Paradoxic septal motion consistent with\nprior cardiac surgery.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor subcostal views.\n\nConclusions:\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is mildly depressed. The right ventricular cavity is unusually small.\nThe aortic valve is not well seen. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nA mitral valve annuloplasty ring is present. No mitral regurgitation is seen.\nThe pulmonary artery systolic pressure could not be determined. There is a\nvery small pericardial effusion detected (however no subcostal views\nobtained).\n\nCompared with the prior study (images reviewed) of , inferior wall\nmotion abnormality was present previously. Overall left ventricular function\nnow appears less vigorous; views are technically suboptimal for comparison.\n\n\n" }, { "category": "Echo", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 84251, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Hypertension. Left ventricular function. Mitral valve disease. Murmur. Myocardial infarction. Shortness of breath. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 08:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. No\nthrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in ascending aorta. Complex (mobile) atheroma in the\nascending aorta. Simple atheroma in aortic arch. Normal descending aorta\ndiameter. Complex (>4mm) atheroma in the descending thoracic aorta. Complex\n(mobile) atheroma in the descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPrebypass:\n1. The left atrium is normal in size. No thrombus is seen in the left atrial\nappendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Overall left ventricular systolic function is normal\n(LVEF>55%).\n4. Right ventricular chamber size and free wall motion are normal.\n5. There are simple atheroma in the aortic arch. There are complex (>4mm),\nmobile atheroma in the descending thoracic aorta. Given degree of descending\ndisease an epiaortic scan was performed. There are simple atheroma in the\nascending aorta. There is a single complex (mobile) atheroma 0.5 cm on the\nposterior surface of the prox ascending aorta on epiaortic scan. There are\nsimple atheroma in the aortic arch. There are complex (>4mm), mobile atheroma\nin the descending thoracic aorta. Aortic canullation and cross clamping were\nguided by the epiaortic scan\n6. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 7. The mitral valve leaflets are mildly\nthickened. Moderate (2+) mitral regurgitation is seen. (3+) was evoked with\nprovacative maneuvers (fluid, elevated BP, Trendelenberg) Vena contracta\nmeasured as 0.6 cm.\n8. There is no pericardial effusion.\n\nPostbypass (on Phenylphrine ggt):\n1. Preserved biventricular systolic function\n2. There is a ring prosthesis in the mitral position. MR is now trace/mild\neccentric valvular MR.\n3. Study otherwise unchanged from prebypass.\n\n\n" }, { "category": "Echo", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 84252, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment.\nHeight: (in) 68\nWeight (lb): 170\nBSA (m2): 1.91 m2\nBP (mm Hg): 143/55\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 16:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal/small IVC diameter\nwith respiratory collapse (estimated RAP 0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. [Intrinsic LV\nsystolic function likely depressed given the severity of valvular\nregurgitation.] No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Moderate (2+)\nMR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mild PA systolic hypertension. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\nPhysiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is\n0-5mmHg. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and systolic function (LVEF>55%). Regional left ventricular wall\nmotion is normal. [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.] There is a very small\n(0.4 cm) focal area of ventricular thinning in the basal inferior wall with\npreserved left ventricular function around this region. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There\nis mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved\nregional/global biventricular function. Very small focal area of thinning in\nthe basal inferior wall with preserved overall contraction. This is of unclear\nsignificance. Moderate mitral regurgitation. Mild pulmonary artery systolic\nhypertension.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 1356030, "text": "Patient re-intubated post resp failure and hypoxemia.Now on PSV with acceptable Blood Gas.Pao2 however questionable on 70%.BS coarse,suctioned for moderate amount of thick yellow sputum.Treated with a/a with vent check,will be on guard on how we wean his FIo2 since oxygen transport is poor.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 1356031, "text": "Nursing Progress Note:\nNeuro: Propofol off for 15 minutes: Pt followed commands by squeezing hands and moving toes on commands. MAE. Opened eyes to voice. Perl 3mm brisk.\n\nResp: LCTA decreased bases. Minimal ETT secretions. Sats 95% on current vent settings. Placed on cpap this am and abg's are improving. Able to wean fio2 from 90% to 70%. Vent set at cpap 12/12/70% SVO2 60's.\n\nCV: SR w/o ectopy. HR 80-90's. MAP 70's on NTG gtt. CI >via fick and SVO2 60's. Pt on dobutamine at 2.5/mcg/k/. PAD 20, CVP 10-12. Febrile. Pulses dopplerable. Sternal and mediastinal dressings cdi. Minimal serosanguinous drainage. CT to 20cm wall suction. A and V wires intact. Sense and capture appropriately. Ademand at 60.\n\nGI/GU: Abdomen soft, nondistended. NGT to LCS. Bilious drainage. NPO. Foley cath. UO good.\n\nEndoc: Insulin gtt\n\nPain: Morphine\n\nPlan: Monitor resp status. Wean peep and fio2 if able. Monitor abg's. Pain management. Monitor for bleeding and follow hct.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 1356012, "text": "Neuro: received pt sedated on prop gtt.-pt lightened for neuro assessment then resedated: maes to command, nods approp. shakes head \"no\" to pain. grimaces w/nailbed stimulation & mouth care. +perrl.\n\nCv: sr 90s, no ectopy. lytes repleted. sbp 80s-110s. ntg continues. goal <140. sbp 120s-150s after moving/turning, returns to baseline within 10 minutes. ivp lopressor for spontaneous increase in sbp to 150s w/good effect. dopplerable pulses. lower extrems cool/dry. afebrile. heparin gtt started @ 900units/hr. AM ptt 58, PA aware. next ptt due 0800. q8h cpk's-next due 0800. plan for pt to go to OR end of week.\n\nResp: received intubated on cmv @ 60%, peep 12, rate 12. pa02 99 initially. pt overbreathes to 20s. repeat abg reflects pa02 209. peep now @ 10 w/pao2 118. ls clr bilaterally. o2sats >98%. sxn'd for nothing. MDI's via RT.\n\nGi/Gu: npo except meds; ogt to lcs, sm amt brown-bilious drainage this shift. +bs. no bm. abd soft, nt, nd. huo clr yellow, 25-50cc/hr-very marginal diureses after iv lasix. creatinine 1.5, PA aware.\n\nEndo: bs monitored per protocol.\n\nSocial: no telephone calls from family this shift.\n\nPlan: continue monitoring cardioresp status, labs. ?wean vent. prepare for OR end of week. update family re: status & plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 1356013, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on SIMV/PS settings as of this time. Weaning Peep and FiO2 through night. ABG shows adequate ventilation and oxygenation. Sxn for small amount bloody secretions. Combivent inhaler given x2 during the noc. BLBS are expiratory wheezes and rhonchi apices. RSBI completed on PS 5=68. Plan for extubation this AM.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 1356014, "text": "RESPIRATORY CARE NOTE\nADDENDUM: Patient on AC ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 1356015, "text": "Resp Care\n\nPt was weaned and extubated this shift without incident. Cuff leak present prior and no stridor noted after.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-07 00:00:00.000", "description": "Report", "row_id": 1356032, "text": "csru nursing update\ncvs: went into RAF up to 150s with significant drop in svo2, co/ci, magsulfate/lopressor iv/amiod bolus and gtt done without success, cardioverted x4 initially with minimal result. on/off neo gtt also done during cardioversion as sbp dropped to 60s. svo2 further dropped to mid 40s with co 2s and ci 1.5, extra amiod bolus given and cardioverted once more -> reverted to SB 30s then Apaced at 90s with better effect, svo2 to 60. fluid bolus 250cc also given which also help to improve co/ci, present ci>2. ntg gtt restarted after Apacing as sbp >150mmhg. presently on ntg 1/amiod o.5/dobu 5/prop 70/ ins 4. tylenol x1 given for hyperthermia, cooling measures also done. pedal pulses palpable/weak.\n\nresp: tolerating slow vent wean, sao2 98-100% with adequate abg (pls refer to carevue for present vent settings.) suctioned for thick tan secretions, lungs coarse->clear with diminished bases. ct's draining minimal serous fluid, no airleak\n\nneuro: kept sedated, mae's to command when lightened. PEARL 3+, morphine for pain control.\n\ngi: reglan given, ogt draining dark bilious fluid, about 200cc during entire shift. very hypoactive bowel sounds\n\ngu: creat 1.6 (pt's baseline), uop trending down, yellow with sediment. no bowel movement, colace given \n\nskin: pressure areas intact. left small toe (5th digit) cyanotic but blanching\n\nsocial: daughter phoned and updated\n\nplan: ? commence anticoagulation\n wean vent as tolerated, monitor resp/hemodynamic status\n ?protonix than zantac\n cont plan of care\n" }, { "category": "Nursing/other", "chartdate": "2172-06-07 00:00:00.000", "description": "Report", "row_id": 1356033, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on spontaneous ventilation. We weaned on settings conservatively, See Careview. He lost A line and an ABG was drawned from Rt radial site. Good results. We are sxtn for scant secretions. Plan: Wean as tolerated & Continue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356092, "text": "7a-7a\nNeuro: Pt and cooperative, nodding, and writing on paper for communication. Perrla. MAE. Denies pain, C/O \"being anxious\" treated w/ ativan 0.5mg ivp w/ relief.\n\nCV: HR 60-80s rare pvc. K repleted. SBP 110s-130, hydralazine increased to 20mg via gtube q6 hour. Also additional 10mg hydralazine prn as ordered for SBP>130, see carevue. Heparin gtt decreased to 1400units/hr MD , next PTT due at 1600. + palpable pedal pulses.\n\nResp: LS coarse. Suctioned for small to moderate amts of thick blood tinged. Sats >92%. RR WNL. Pt trach #8.0, CPAP 10 peep, 5 PS- ABG = 7.53/33/76, MD aware, no further changes at that time. Ok to decrease peep MD at 1400. See carevue for futher details.\n\nGI/GU: Abd softly distended, denies abd pain when asked. +BS. OK to restart TF MD . TF restarted at 15cc/hr Nutren Pulmonary, increase 10cc/hr q 6 hours to goal 35cc/hr as pt tolerates. Incontinent of loose paste-like stool. Foley draining adequate amts of clear- sediment yellow urine. Lasix on hold at present time, diamox started d/t alkalosis.\n\nEndo: RISS.\n\nSocial: Daughter updated w/ POC.\n\nIV: Will need picc per MDs on am rounds (this am).\n\nActivity: OOB to chair x2 assist, tolerated well, in chair approx. 4 hours.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Increase TF as pt tolerates to the goal of 35cc/hr. Monitor for abd. pain. Keep SBP<130. To get coumadin tonight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-12 00:00:00.000", "description": "Report", "row_id": 1356057, "text": "Neuro: slightly sedated on prop at 30-is able to follow comands and mae, does nod head to questions, getting morphine for pain, puplis are equal and reactive to light.\n\nCardiac: af in the 90-110 range did attempt x 2 amio boluses and x 1 of 5 iv lopressor which only temp slowed down rate-still remains in a/f, no ectopy, continues po bp meds which were slightly weaned up today for htn, dopplerable dp pulses, skin warm dry and intact, low grade temps in the 99 range, +2 edema in extremities, heparin gtt continues and is theraupetic.\n\nResp: lungs dim throughout, changed to cpap with peep of 10 and abgs ok, sxned for small amounts of thick white secretions, per team some left lower lobe atelectisis noted.\n\nSkin: chest with qd chloroseptic swab dsd and site with steristrips is cdi, old ct site healing and dsd over site is cdi, left leg with steri strips is cdi, back and coccyx id intact and no breakdown noted.\n\nGi/Gu: tf goal changed to 70/hr while on prop, residuals all less then 50, abd is soft and slightly distended, patient does have hypoactive bowel sounds no bm today was given lactulose-did have bm yesterday, on riss, continues lasix gtt making good u/o.\n\nId: conts zosyn/vanco, need vanco trough on pre dose, wbc is wnl's no spike in temp.\n\nSocial: daughter in to visit and updated, spokesperson callled and updated and will call back on night shift.\n\nPlan: continues to keep negative with lasix gtt, ? in am about any further wean in vent setting, monitor ptts, monitor blood sugars, continue prop gtt, check vanco trough sat pre dose.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-13 00:00:00.000", "description": "Report", "row_id": 1356058, "text": "Resp Care: Pt continues on mechanical ventilation: PSV 5/10 40%. VE 13-17LPM. Pt appears comfortable on current settings-> NO changes overnight. ABG this am: 7.46/46/94/34/7/96%. LS: occassional rhonchi which clears with suction. Sxn'd small amounts of thick white secretions. MDI's given per . PLAN: continue vent support->wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-13 00:00:00.000", "description": "Report", "row_id": 1356059, "text": "NEURO: ORALLY INTUBATED. OPENING EYES SPONTANEOUSLY AT TIMES, TO VOICE AT ALL TIMES, PEARL AT 2-3MM/, , FOLLOWS COMMANDS. LIGHTLY SEDATED ON PROPOFOL GTT AT 25 MCG.\n\nPAIN: MORPHINE 2MG IV X 2 FOR GRIMACING AND SLIGHT INCREASE IN BP.\n\nPULM: CPAP MODE 40%, PS 5, PEEP 10 ALL NOC. SATS 94-96%. NO WEANING. LAST ABG 7.46/46/94/96%. LUNGS CLEAR AFTER SUCTIONED, SLIGHTLY DIMINISHED RUL. SX'D ~ Q2H FOR SMALL AMTS THICK WHITE SECRETIONS. WBC 9.6K, AFEBRILE.\n\nCV: ATRIAL FIB-FLUTTER WITH VR 90'S-120 UNTIL 0510 WHEN CONVERTED TO NSR 70'S. HEPARIN GTT AT 1500 UNITS/HR, PTT 65.0 AT 0300. CVP 10-16. + PERIPHERAL EDEMA. K 3.1, REPLETED WITH KCL POWDER DOWN OGT.\n\nRENAL: BUN 65/CREATININE 2.3. LASIX GTT DECREASED TO 5MG/HR AT 2400 FOR INCREASING CREATININE. UO 120-250/HR.\n\nGI: ABDOMEN SOFTLY DISTENED, + BS, SCANT AMT STOOL STAINING WITH REPOSITIONING. REGLAN AND COLACE GIVEN. TOLERATING TF AT 70CC/HR, 5-20CC RESIDUALS.\n\nENDO: BS 113-145, QID BS WITH SSRI COVERAGE.\n\nSOCIAL: DAUGHTER CALLED IN FOR UPDATE ~ 2100.\n\nPLAN: CONTINUE CPAP MODE, ? DECREASE PEEP TO 5 TODAY, FOLLOW ABGS. CHECK PTT IN 6-8H, GOAL PTT 50-70. ? CHANGE LASIX GTT TO IVP TODAY. CHECK LYTES Q4H D/T LASIX. TROUGH VANCO LEVEL AT TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-02 00:00:00.000", "description": "Report", "row_id": 1356016, "text": "npn 0700-1900\n\nevents;carotid ultrasound done surface echo done\nweaned and extubated with satisfactory sats\n\nneuro; initially sedated with propofol to 50 mcgs /kg/min wild when lightened given 1 mg haldol i.v with good effect. pt aoox2-3 says hosp to place following command consistently .initally alille confused on extubation voice quiet difficult to hear at times but appears quieter and less agitated at present.\n\nresp; lungs coarse rhonchi suctioned for mod amounts of thick yellow secretions productive cough of thick clear secretions needs encouraged to cough and deep breath. on 40% face mask rr 16-20 po2 70's.\n\ncvs; tmax 100.1 po nsr with isolated pvc's lytes repleated. bp difficult to control on nitro 1.4 mcg/kg. started on ppo lopressor 25 mgs tid amd hydralazine added with fair effect appears anxious .\n\ngu; excellent response to lasix 20 mgs i.v. draining clear yellow urine vai foley.\n\ngi; npo ogt removed with extubation. belly soft distended pos bs in all 4 quads.\nbs miin requirements on riss.\nheme heparin at 900units /hr with ptt from 5pm pending. cks sent.\n\na/p continue to orientate as necessary.\nmaintain sbp @ 140. may increase po lopressor and hydralazine i.v dilt d/'c\nprepare pt for cardiac surgery in near future no definate date decided as yet.\n\nstill with groin aline. in rt groin. peripph ivs tempremental\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1356076, "text": "NEURO: Sedated on 50mcg of Propofol, Pt responds approp to commands when sedation is weaned (+hand grasps/+moves toes), non-verbal communicated that he was in pain, given IV morphine with some relief\n\nRESP: Continues on CPAP with 5 PEEP, 10 PS, Sats 95-96%, PaO2s 80s, weaning fiO2 down to 50%, lung sounds clear, coarse when needing suction, suctioned for small blood tinged secretions, trach site small serosanguinous drainage\n\nCV: NSR without ectopy, HR 70s, SBP 120-140s (keep <140) on 3.0mcg Nitro drip, plan to start Nicardipine drip, pedal pulses palpable, Hct was 25.8\n\nGI/GU: PEG tube to gravity (initially bloody drainage; currently bilious), BS hypoactive, ?restart of TF/use for meds of tube today; Foley in place draining yellow/clear urine at >60cc/hr, creatinine 2.0\n\nENDO: on SSRI\n\nSOCIAL: Daughter visited and updated on Pt's status.\n\nPLAN: Monitor trach site/resp status, manage BP, ?restart TF, continue with plan of care\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1356077, "text": "Resp Care\nPt remains trached with #8.0 portex with DIC. no vent changes made this shift, abg WNL. BLBS course and wheezey at times, improved with suctioning and combivnet puff. suctioning thick blood tinged secretions. cuff pressure 25. plan to remains on PSV and wean fio2 and peep slowly as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356093, "text": "respiratory care\npt remains on PSV, PEEP redeuced to 8 with acceptable ABG's.BS clear.Suctioned for moderate amount of yellow thick secretions.combivent x3 and Qvar x1 given as ordered.per attending, its to maintain Pao2> 60.\nPlan:monitor respiratory status closely,wean Peep as tolerated,follow ABg's.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-01 00:00:00.000", "description": "Report", "row_id": 1356010, "text": "69yr male with ACS, admitted from OSH - 8.0 ET, 22 @ lip. Cath at OSH reveals multi-vessel blockage (RCA, LAD). Admitted here for OR tomorrow (). Hx - AAA (not repaired), OSA, fem- stent. BS diminished with a few fine crackles.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1356078, "text": "7am-7pm update\nneuro: propofol gtt weaned to off at 9 am. pt , and able to follow commands. PERRL.\n\nCv: pt remains in afib, HR 100-130's. pt given 5 mg iv lopressor x 1. carvedilol doses increased to 25 mg PO BID. SBP 100-150's. MAP 70-80's. nicardipine gtt at 3.0 mcg/kg/. hct stable. pp by doppler. pt restarted on heparin gtt this am for afib. currently running at 600 u/hr. pt given 3 mg coumadin this evening\n\nresp: LS coarse, clear with suctioned. suctioned for moderate amount of blood tindged sputum. trach care done x2. trach site with moderate amount of serouanginous draiange. pt remains on CPAP 60% with 5 PS and 10 peep. sponaneous TV in the 600's. RR WNL. see flowsheet for abg's.\n\ngi/gu: pt with + hypoactive bs. G tube remains to gravity. g tube draining billious fluid. pt remains NPO except for meds. foley draining yellow urine with sediment. pt given 40 mg IV lasix x 1 -> diuresing well. creatinine 2.0 this am (down from yesterday)\n\nendo: elvated bs treated with ss reg insulin per protocol\n\nid: pt afebrile. wbc's 12.0 this am (up from yesterday). vanco and zoysn dc'd this am\n\nactivity: pt OOb to chiar this am with 2 assist -> full assist. pt backed to bed\n\nplan: pulm toleit, monitor abg's. trach care, keep SBP < 140, BP control, ?? restart TF, continue heparin gtt -> goal PTT 40-60, continue coumadin, skin care, advance activity as tolerated, monitor creatinine\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1356079, "text": "Resp Care\nPt remains trached on PSV. FiO2 weaned this shift and tolerating with adequate PaO2 values. BS mostly clear bilaterally, suctioning for moderate amounts of thick yellow secretions via tracheal and oral suctioning. See CareVue for RSBI results, details and specifics.\nPlan: Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 1356025, "text": "Resp. care Note\nPt received from OR intubated and vented on settings as charted on resp flowsheet. Problems with oxygenation in the OR so placed on peep 12 on arrival to CSRU. Initial ABG with Pao2 81. Peep increased to 15,maintained on 100% and repeat ABG with PaO2 423. FiO2 weaned to 50% and peep weaned to 10. Combivent as ordered. Cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 1356026, "text": "addendum nursing\nVent weaned to CPAP 5/8/50% Sats 96% SVO2 57.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 1356027, "text": "7p-7a\nNeuro: At beginning of shift pt alert,sleepy, following all commands,mae,perrla, nodded yes when asked if wants \"breathing tube out\" able to move head forward. Pt resedated after re-intubation, on propofol,perrla, mae to painful stimuli. No indictions of pain.\n\nCV: HR 70-100s. >100 during episode of re-intubation. SR/ST. SBP labile on and off neo and ntg. Currently off of neo and ntg. SBP 110s. /15-20s. CVP 7-16. SVO2 52-64, MD Bridges aware. CI>2 by fick, see carevue. Low SVO2 treated w/ fluid bolus x3 and 2 units of PRBCs,no adverse reactions, see carevue. Epicardial wires attached and on Ademand backup, see carevue for settings. +palpable pedal pulses, verified w/ doppler.\n\n\nResp: At beginning of shift, pt following commands, acceptable abgs on CPAP 5/5, MD Bridges at bedside before extubation and aware of SVO2 57-60 before extubation. Ok to extubate, extubated at , pt sats to 55, pt in resp. distress, pt oxygenation w/ ambu and oral airway w/ improved sats to 90%, anesthesia called stat and at bedside re-intubated 7.5 tube, see carevue for vent settings and changes. ABG after re-intubation 7.21/62/108, MD Bridges aware, rate on vent increased to 18, w/ improved abg 7.32/48/106, MD Bridges aware. Presently on CMV rate 18 TV 700, fiO2 70% w/ acceptable abgs, see carevue for details. LS clear diminished at bases. Sats 94-100% at present time. Suctioned for scant amts of thick white.\n\nGI/GU: Abd soft, abesent BS. NGT replaced after extubation draining bilious to brownish drainage. Foley draining 40-60cc/hr of clear yellow urine, see carevue.\n\nEndo: Gtt per protocol.\n\nSocial: Daughter updated w/ POC.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. Once pt stabilizes, wean vent as pt tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 1356028, "text": "Respiratory Care Note:\n\nPt recived on minimal spontaneous ventilation. After elective extubation, sats dropped into 40's, require extensive mouth-bag mask with oral airway to increased Sats, Anesthesia called for re-intubation, uneventful. We still had difficult to oxygenate & ventilate /n, See Careview for multiple changes. Wea re sxtn scant secretions. MDI's adm with No changes noted. BS are dim. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-06 00:00:00.000", "description": "Report", "row_id": 1356029, "text": "Addendum\nSee carevue for details of VS and assessment. SVO2 48-50s, CI 1.9-2.10 by fick, MD bridges aware and at bedside. Dobutamine started at 2.5mcg/kg/, increased sbp 150s, ntg started see carevue. See carevue for further vent changes and abgs. Lasix 20mg ivp given for decreased sats, repeat cxr done at 0400.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-19 00:00:00.000", "description": "Report", "row_id": 1356086, "text": "BS CTAB. Remains on CPAP with PEEP weaned to 5. Continue with CPAP as tolerated. Suctioned for small amount white secretions.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-11 00:00:00.000", "description": "Report", "row_id": 1356051, "text": "Respiratory Care: Pt remains intubated and vented. Sedated on propofol. No vent parameter changes made throughout night.BS coarse, although not much secretions. CXR shows pul edema. Possible echo today. No RSBI measured due to peep requirement.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-11 00:00:00.000", "description": "Report", "row_id": 1356052, "text": "Respiratory Care:\nPt remains intubated with no changes today . There has been no echo as of this note. BS's are slightly coarse; Sx'd for thick white secretions x 2 or 3 and has recieved Combivent x 3,and Beclomethesone x 1. RR is in the lo 30's all day with MV about 13 to 15 liters.\nOET re-taped today to the L. See CareVue for details.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-11 00:00:00.000", "description": "Report", "row_id": 1356053, "text": "Neuro: slightly sedated on prop gtt, mae, following commands correctly, pupils are equal and reactive to light, morphine for pain, did later in shift go up on prop gtt for agitation.\n\nCardiac: nsr today with rare pvc's, changed amio gtt over to po, sbp running 120-130 range today per team would like 90-110 for sbp-did start hydralizine and hydrochlorothiazide, continues hep gtt for afib, doplerable pedial pulses, skin warm dry and intact, afebrile.\n\nResp: lungs dim in bases-no vent changes made today, pao2 on 40% fio2 running in the 80's team aware, sxned for scant white thick secretions, retaped and rotated et tube.\n\nSkin: chest with dsd that is cdi, old ct dsd cdi, left leg steri strips cdi, bilat feet with warts dermatology aware and following.\n\nGi/Gu: tf's at goal, did have high residuala at begining of shift now less then this am for residuals, abd is soft and slightly distended with hypoactive bowel sounds, startd lactulose and sipository today and did have x 1 med loose semiformed bm, on riss, started lasix and natrecor gtt to attempt to make patient negative over next few days, see flow sheets for u/o.\n\nSocial: wife and daughter in to visit and updated-daughter is rn whom was updated by team.\n\nPlan: attempt to keep patient negative for u/o, continue with bp meds, monitor blood sugars, monitor ptts, monitor tf residuals.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-12 00:00:00.000", "description": "Report", "row_id": 1356054, "text": "neuro: recieved pt sedated on propofol at 50mcg/kg/. unarousable, only flutter eyes to voices. weaned propofol briefly to check for neuro-easily arouse, nod head appro to questions, maex4 to command, equal bilat hand grasp. resedate at previous propofol dose to keep sedate all night for oxygenation issue per pa e. nillson. perla.\n\nid: low grade temp, started on vanco and zosyn for positive sputum culture. wbc trending down\n\ncv: nsr ->converted to afibs, rate 80s-110s. 6 beats of wide complex ventricular ectopies vs abbarent afib. replete k. no further ectopies noted. on po carvidelol, amiodarone, heparin gtt -^ d/t ptt subtherapeutic. sbp within goal <120 per pa. cvp 10s. con't natrecor gtt at 0.01 and lasix gtt at 10mg/hr. pt diuresis 100s-300cc hourly. peripheral 1+edema, skin warm, very sweaty. dopplerable pulses. hct 32.\n\nresp: ls coarse, diminish bibasilar. rhales in lll, sxn sm amt white sputum. remain on ac .40/420x24/10peep. pt overbreath to rate 30s. gas pao2 80, unchanged. no vent change overnoc per pa. saturation on left side position 92-93%, improved to 94-95% when turned to right side. see careview\n\ngi: belly sl firm, distended, +flatus. tol tf at goal 80cc/hr via ogt. residual.\nendo: bs 130s-140s-treat per csru protocol\ngu: no bm. diuresis via foley\nwound: sternal wound cdi with steristrip-cleaned with betadine and change dsd. left leg mini incis with steri stripp c&d. coccyx intact. both heels and sole of feet re very dry, hard, and scaly-applied vesta cream, toes nail long, yellow and hard.\n\nact: bedrest. dvt proph with heparin gtt\ncomfort: no s/s pain. explain to pt icu/poc. daughter call at hs->status updated.\n\na:s/p POD 6- prolonged icu stayed d/t failed extubation, with pneumonia & pulm edema/chf. afib with hemodynamic consequences.\n\np: con't diuresis with natrecor &lasix to keep negative. abx for pna. ?wean off sedation. monitor vent/oxygenation. f/u ptt for therepeutic. heparin gtt/amio po/carvedilol for afib. need dobhoff?. may need pediatry for foot care. support.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-12 00:00:00.000", "description": "Report", "row_id": 1356055, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on full/assist ventilatory support. No vent changes done. Bs are coarse bil. We are sxtn for small amt of thick whitish secretions. MDI's adm as ordered with Nochanges. Plan: Contine present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-01 00:00:00.000", "description": "Report", "row_id": 1356011, "text": "PT. ADMITTED TO CSRU FROM PT. WAS DOING YARD WORK ON WHEN HE FELT SOB- WENT TO ED AT APPROXIMATELY 0100 WHEN SOB WAS NOT IMPROVING. EKG PERFORMED AND SHOWED ST ELEVATIONS. PT. ADMITTED TO CATH LAB, DECREASED RESPIRATORY PT. INTUBATED AND BROUGHT TO CCU. PT. TO AT 1400 INTUBATED, SEDATED AND ON NO OTHER GTTS. CATH SHOWED RCA STENOSIS, OBT MARGINAL 70%, LAD 90%, MID CIRCUMFLEX 70%\n\nNEURO: PT. INTUBATED, SEDATED ON 40-50MCG PROPOFOL, DID WAKE SLIGHTLY ON 30MCG PROPOFOL, PERRL (4MM), RESPONDED TO PAIN AT ONE POINT- SEDATION INCREASED DUE TO FACT THAT PT. WILL NOT CURRENTLY BE WEANED OFF VENTILATION.\n\nCV: PT. HAS HISTORY OF AFIB, CURRENTLY IN NSR, EKG PERFORMED, SBP <120-125, NITRO GTT STARTED NP FOR HTN, NO ECTOPY NOTED.\n\nRESP: PT. LUNGS CLEAR THROUGHOUT, INTUBATED ON CMV FIO2 60%, PEEP 12, SEE CAREVUE FOR ABGS. ETT SUCTIONED FOR THICK, YELLOW/BLOOD TINGED THIN SECRETIONS. POSSIBLE PLAN TO KEEP INTUBATED OVERNOC.\n\nGI/GU/ENDO: PT. ABD SOFT, +BS, OG TUBE IN PLACE AND DRAINING BROWN SCANT AMT. OF DRAINAGE, FOLEY DRAINING CLEAR, YELLOW URINE- GOOD U/O. LASIX GIVEN IN SEE PT. RECORDS FOR MORE DETAILS. FINGERSTICK GLUCOSE PERFORMED EVERY 6 HOURS.\n\nPLAN: TEE TOMORROW, CAROTID ECHO TOMORROW, WEAN MECHANICAL VENTILATION?, OR THIS WEEK.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-16 00:00:00.000", "description": "Report", "row_id": 1356071, "text": "cv: hr 66-77 nsr no ectopy. sbp 104-125/ reieved hydralzine 10 mg iv times 2 with good response. goal sbp<120.cvp 4-9\n\ngi: tube feed off at 2400. pt to go to OR today for peg and trach.positive bowel sounds. abdomen soft.\n\ngu: foley draining amger urine with sediment 30 -80 cc/hr.\n\nresp: suctioned for small amounts thick white. abg this a.m. with po2 64.. 7.46/44/64/329 sat 92%. pt repositioned and suctioned and sats now 95%. breath sounds coarse bilateral.\n\nlabs: heparin turned off at 2400 for OR today. glucose 177 at 2200 tx with 8 units regular. 0500 gluc = 93 no tx.k=3.6 tx with 20 meq kcl iv.\n\nneuro: sedated on propophol at 35 mics/kg/. opens eyes to name and noise. pu;ils equal and reactive. obeys commands such as open your mouth etc.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-16 00:00:00.000", "description": "Report", "row_id": 1356072, "text": "Respiratory Care Note:\n\nPt remain orally intubated on spontaneous ventilation. No changes done. MDI's adm as ordered with No chamges in BS. Plan: Trach & Peg scheduled today. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-16 00:00:00.000", "description": "Report", "row_id": 1356073, "text": "7A-7P\n***TO OR @ 1600 FOR TRACHEOSTOMY AND PEG PLACEMENT***\n\nNEURO: LIGHTLY SEDATED ON PROPOFOL. AROUSABLE. PERRLA. MAE. CONSISTENTLY FOLLOWS COMMANDS. NODDING HEAD APPROPRIATLY TO QUESTIONS. AFEBRILE. DENIES PAIN. FAMILY VISIT TODAY.\n\nCV: NSR 60S NO ECTOPY NOTED. LYTES PRN. CVP 7-13. SBP 110-130S GOAL SBP <140 NP . PALPABLE PULSES BILAT. HEPARIN GTT HELD PREOPERATIVELY\n\nRESP: CURRENTLY ORALLY INTUBATED CPAP+PS 50% 10PEEP 5 PS. TO OR FOR TRACHEOSTOMY. LS COARSE SUCTIONED FOR SCANT THICK TAN SECRETIONS. 02SAT >93%. ADEQUATE ABGS. MDIS PER RT.\n\nGU/GI: FOLEY TO GRAVITY WITH ADEQUATE HUO. ABD SOFT DISTENDED (+) HYPOACTIVE BS. TO OR FOR PEG PLACEMENT THIS AFTERNOON. TF HELD FOR OR PROCEDURE. IV PPI FOR GI PROPHYLAXIS.\n\nSEE CAREVUE FOR SKIN ASSESSMENT\n\nENDO: GLUCOSE COVERAGE PER CSRU PROTOCOL. PT NOT REQUIRING INSULIN COVERAGE TODAY.\n\nPLAN: CONTINUE TO MONITOR RESP STATUS.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-19 00:00:00.000", "description": "Report", "row_id": 1356087, "text": "increased heparin drip to 1300 units per hour, next PTT due at midnight, OK for pt to wet mouth with swabs dipped in ice water per NP\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356088, "text": "neuro: perla. pt non-verbal cues and nod head appro. equal hand grasp. maex4 to command. no apparent deficit. smiling. cooperative.\n\nid: afebrile.\ncv: nsr with rare pacs/pvcs. repleted lytes. hypertensive. gave scheduled carvedilol/hydralazine/diltiazem po. gave add'l hydralazine doses with effect keeping sbp goal <130 per fellow . anticoagulated with coumadin & heparin gtt->increase d/t ptt subtherapeutic, gtt now at 1500units/hr. diuresis with lasix. skin w&d. no edema. +pp\n\nresp: trach. cpap 50/5/5. saturation marginal 90 with occasional dipped to 85%. thought pt have good Vt with each breathing-no s/s distress. see ccc for cxr r/s. gas sent pao2 50s->per fellow, ^peep to now 10 to keep sat >90%. sxn mod amt blood-tinged sputum. vap\n\ngi: belly distended, soft. pt c/o intermitten achy abdomen pain, non-specifict (not new). transport to CT scan abdomen (gave barium matter pre-procedure via peg tube per fellow with toleration). uneventful. tf held overnoc. lfts & amylase nl\n\nendo: treat bs per ss\ngu: diuresis with lasix. bun &creat trending down slowly. incontinence mod amt liquid stools\nwound: sternal dsd cdi. coccyx intact. heels sl pink. skin in hands/toes dry & scaly, wart?\ncomfort: pt denies incis pain. daughter called at hs, status udpate. support pt. gave ativan iv for sleeping & anxiety with effect. pt slepmt most of night.\n\na/p; pod 14- afib, resp failure now trach & peg. failed peep weaning. abdomen pain with poor tf tolerant- US and CT of abdoment done\nslow weaning of peep. pulm toilet. restart Tf. anticoagulate\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356089, "text": "Respiratory Care\nPt trach on ventilatory support. Peep wean bacxk during day shift, 10 to 8 to 5. SpO2s trended down early in evening, ABG revealed worsening hypoxia and respiratory alkalosis PaO2 of 51 corresponding to a fluctuatingSpO2 90-92%. Peep increased to 8 with minimal improvement after 1 hour, peep further increased to 10 with very gradual ( > 1 hour) increase of SpO2 to 94-95%. Pt noted to have increase in secretions, bloody thick. Good aeration ocaisionally coarse. Transported to CAT scan w/o incident. AM RSBI not performed due to peep dependence (peep of 10). Continue to wean vent support as , a more gradual decrease in peep support.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356090, "text": "addenum:\nd'c mtlc. need piv & need cdiff spec if pt stooling again per fellow\n" }, { "category": "Nursing/other", "chartdate": "2172-06-20 00:00:00.000", "description": "Report", "row_id": 1356091, "text": "add:\n\nrecieved pt with mtlc on r ij->no suture. fellow called to bedside and access line was sutured.\npeg tube to gravity. gave ativan x1 with effect- pt more relax & sleep well\n" }, { "category": "Nursing/other", "chartdate": "2172-06-12 00:00:00.000", "description": "Report", "row_id": 1356056, "text": "Respiratory Care:\nPt weaned to PSV 5/10peep @ 40%. Minute Ventilation still high at\n~17L/M; no more changes today and we will see how he does over noc.\nPaO2 is boarder line low. Cough is ocasionally coarse and suctioned for small amounts of thick white secretions. Still looks tired and not very awake..See CareVue for more info.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-16 00:00:00.000", "description": "Report", "row_id": 1356074, "text": "Resp Care\nPt trached in OR this afternoon with #8.0 unfenestrated cuffed portex, extra inner cannulars ordered. Pt continues on PSV IPS increased after OR to 10 due to tachypnia FiO2 currently 100% awaiting abg post op. BLBS wheezey slightly improved after combivent mdi, pt suctioned for sm-mod amt of thcik tan secretions. PLan to remain on PSV overnight and wean IPS and fio2 as tolerated aft abg.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-17 00:00:00.000", "description": "Report", "row_id": 1356075, "text": "Respiratory Care Note:\nPatient on PSV of and 50%. S/P trachostomy with #8 Portex trach with DIC. Site slightly bloody. Suctioned t/o shift for small to medium amounts of pluggy, bloody secretions. He is on a wet vent circuit. BS initially coarse LUL but now clear and equal. Trach is secure with sutures and velcro strap. He receives morphine prn for pain and appears comfortable at this time. RSBI not done due to PEEP of 10. FIO2 weaned this shift from 100% to 50% with SpO2 now 95%. See Carevue flowsheet for specifics. Plan to continue with slow wean as tolerated per team rounds.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-09 00:00:00.000", "description": "Report", "row_id": 1356043, "text": "RESP CARE: Pt remains intubated/on mechanical ventilation, on PS 10/PEEP to 8 due to copious frothy clear secretions, drop in 02 sats, FI02 .50. ABGs WNL. Febrile this shift,tachycardic.Lungs very coarse with crackles/wheezes. MDIs given per . Sxd copious frothy secretions. RSBI-15.5.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-09 00:00:00.000", "description": "Report", "row_id": 1356044, "text": "Resp Care\n\nPt extubated this morning and currently wearing 100% hi flow setup with marginal oxygenation on ABG and spo2. BS course with good productive cough noted. Bronchodilators given x3 with fair effect noted. Will titrate and wean oxygenation as tol to maintain acceptable spo2.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-09 00:00:00.000", "description": "Report", "row_id": 1356045, "text": "Neuro: A&O X3, usually follows commands but occasionally doesn't listen and is hard to reason with.... i.e. instructed not to take tape off but he kept picking at it. MAE's well, was weak and 2 person assit to get OOB to chair, denies pain or discomfort\nResp: extubated this morning, attempted to wean down O2 but pt needs 100% FM to keep SpO2 > 90%, LS coarse throughout, ABG's OK for patient\nCardiac: Afib at start of shift and converted to SR.... went back into afib this afternoon, repleated KCL, started lopressor PO\nGI: + BS all 4 quads, pt coughed out NGT, tolerated ice chips, SPO2 dropped to upper 70's to low 80's after trial of clear liquids and thickend liquids like soft ice cream/jello, , NPO overnight and swallow eval \nGU: foley to gravity drainage, draining clear yellow urine, I&O matching, increased lasix to 40mg q8hrs with good effect\nAcivity: OOB to chair with 2 person max assist, pad to lift back to bed, to be seen by PT on \nSkin: seen by dermatology team, no new orders\nSocial: pt's daughter and in to see him, daughter called \n: NPO overnight.. swallow eval, wean O2 as tolerated, increase actviity as tolerated, monitor labs and vitals and treat as indicated and as ordered\n" }, { "category": "Nursing/other", "chartdate": "2172-06-10 00:00:00.000", "description": "Report", "row_id": 1356046, "text": "RESPIRATORY CARE:\n\nPt orally intubated, #7.5 ETT(@21/lip), after several hours of attempting NIPPV. Pt's oxygenation tenuous, pt hypertensive, and persistently agitated-despite nippv,meds,etc. Post intubation requiring high levels ventilation to maintain acceptable SaO2. Pt currently on AC 700/18/100% w/15peep. BS's diminished. Post intubation, one large bloody plug sx'd from ETT- after that, minimal secretions. ABG pending. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-22 00:00:00.000", "description": "Report", "row_id": 1356100, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Portex 8.0 DIC trach tube. Sxn for moderate amount thick bloody secretions. Very agitated and breathing over vent. Ve=20 liters, tachypneic. Plan to either sedate adequately or trial trach mask. RSBI completed on PS 5=46.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2172-06-08 00:00:00.000", "description": "Report", "row_id": 1356038, "text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on sponatneous ventilation. We had to increased FIO2 o/n for low Pa02. See careview. ETT retaped twicw. BS are midly coarse bil. We are sxtn for mod amt of thick whitish-yellow secretions form ETT and clear mucoid orally. MDI's adm as ordered with No changes noted. Plan: COPntinue present ICU monitoring. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-22 00:00:00.000", "description": "Report", "row_id": 1356101, "text": "Respiratory Care Note\nPt received on PSV 5/8 as noted. BS essentially clear with good aeration. Pt suctioned for moderate amts thick, bloody secretions. Bronchoscopy done - secretion in airways has improved since yesterday, no source of bleeding detected. PEEP and FiO2 increased secondary to low sats. PEEP weaned back to 8cm when sats improved to high 90's. Pt placed on 70% trach mask - pt tolerated for 1 hour, but was placed back on PSV secondary to increased RR, BP and HR. Plan to continue on PSV settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-22 00:00:00.000", "description": "Report", "row_id": 1356102, "text": "Neuro: calm and cooperative all shift, no attempting oob, restraints off at 0700. PERRLA\nCV: NSR HR 70-90. BP 130-160's, coreg increased and PRN hydralazine x2. Palp pedal pulses. Heparin decreased to 1100units/hr for PTT 74. Repeat due to be checked at 1800. Coumadin 4mg given this pm.\nResp: Pt sats 86-89% this am despite increase PEEP to , fio2 50-100%, Bronch done by Dr. suctioned thick old clot but not significant blockage or bleeding source identified. Pt continues to cough up clots, attempting not to suction a lot. Frequent trach care performed. See carevue for fio2 and peep changes. Attempted Trach collar, tolerated x1 hour before getting hypertensive and tachycardic. Team accepting o2sats>92%. placed by .\nGI: Abd distened, slightly firm. +BS, Lg liquid stool, guaiac negative, Dulcolox supp this pm with mod stool formed, sent for cdiff spec. Pt denies nausea. tolerating tube feeds with no residual via peg.\nGu: Foley patent. Good uop with lasix increased to TID.\nSocial: family updated by NP\nAct: OOB to ch with PT, tolerated well assist x2.\nPlan: Cont assess cardio/resp status. Follow up on PTT. Attempt to wean vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-23 00:00:00.000", "description": "Report", "row_id": 1356103, "text": "NEURO: Pt , awake, able to non-verbally communicate needs, c/o pain , treated with Roxicet, pain improved to , plan for OOB to chair today\n\nRESP: Continues on CPAP 10PEEP/5PS/50%, Sats 97% or higher, desats to low 90s when asleep, Pt coughing up secretions, suctioned for small-mod thick secretions (blood-tinged), trach care done. Plan to wean off vent as Pt tolerates\n\nCV: NSR with HR in 70-80s, SBP in 120-140s, pedal pulses palpable, afebrile, WBC 11.6. Continues on heparin on 1000units/hr (last PTT was 75, plan to recheck at 0700).\n\nGI/GU: Abd soft, denies nausea, no BM, +BS, continues on TF at goal 35cc/hr of Nutren Pulmonary; Foley in place draining yellow/sediment urine at >40cc/hr, given Lasix at midnight with minimal response, no lytes repleted\n\nENDO: On SSRI\n\nSOCIAL: No phone call or visit from family during shift.\n\nPLAN: Wean from vent, increase activity as tolerated (OOB to chair), recheck PTT at 0700\n" }, { "category": "Nursing/other", "chartdate": "2172-06-04 00:00:00.000", "description": "Report", "row_id": 1356022, "text": "neuro: pleasant pt for cabg/mvr . mentation and neuro intact. independently moving in beds. no deficit. conversing.\n\ncv: afebrile. afib 110s-120s, po amiodarone started, po lopressor. pt asymptomatic -denies cp/sob/dyspnea. k nl. converted to nsr in pm. cxr done, con't diuresis with lasix for pulm edema. heparin gtt infusing- increase 1600units/hr with ptt subtherapeutic. no edema, 3+pp L/ 2+pp R. skin w/d. hct 31.\n\nresp: agressive dbc, encourage use of IS ^1500ml. dry cough. sat and gas improved with pao2 ^114, weaned to 4lnc only with sat >95%. ls diminish rll, cta. no distress.\n\nGi poor intake. offer alternatives.\ngu: diuresis with lasix via foley\nendo: bs nl, no coverage required\nwound: r fem site soft, no hematoma with dsd cdi. heels and coccyx intact\nact: pt independently moving in bed. oob to chair with 1 assist-tol well\ncomfort: no pain. wife visit, daughter call throughout day-status update. dr. discussed with pt about surgery-consent sign. rn provide hcp info. pre and post recovery pathway reinforce.\n\na: pt with 3vds, r/i MI and mr for OR for cabg/mvr. Afib-stabled, asymptomatic.\np: npo after midnoc. Hibiclins wash. con't heparin gtt till OR as ordered. diuresis for P. edema. monitor\n" }, { "category": "Nursing/other", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 1356023, "text": "ROS:\n\nNeuro: A+O x's 3, MAE x's 4. OOB w/minimal assist. Steady on feet. Denies pain.\n\nCV: RSR w/o ectopy. VSS. Has right radial ABP line. Peripheral pulses palpable w/ease. Metoprolol 100 mg TID. No edema. Heparin gtt for ACS, PTT 83 on 1600 Units/HR.\n\nResp: Lungs clear. O2 4-5 L/ NP, sats 93-98%. Does well w/C+DB and pulls 1L+ w/IS. No resp distress noted, = rise and fall of chest.\n\nGI: NPO at midnoc for OR in AM. Abd soft w/active BS. Stool per bedside commode.\n\nGU: Foley patent draining clear yellow urine in QS. Lasix w/good effect.\n\nEndo: No coverage for RSSI\n\nLytes: Stable. IC repleted.\n\nSocial: Daughter phoned for update and will be in shortly.\n\nPlan: OR this AM for CABG and MVR.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 1356024, "text": "Nursing Progress Note:\ns/p CABG x3, MV repair (ring), and Ascending aortic patch graft. Arrived on propofol and in NSR. Difficulty with oxygenation in OR. Placed on peep 12 on arrival to maintain O2 saturation.\n\nNeuro: Sedated on propofol but awakened once for neuro exam. MAE to commands. Opened eyes. Perl 3mm brisk. No gag noted.\n\nCV: NSR w/o ectopy. HR 70's. ABP 110/50's. No vasoactive gtts. CI >2 via fick. SVO2 58-60 and mixed venous 61 via PA cath. Low grade temp. Ca repleted. A and V wires intact. Sense and capture appropriately. Ademand at 60. CT to 20cm wall suction. Minimal serosanguinous drainage. No airleak noted. Sternal and mediastinal dressings CDI.\n\nResp: On arrival, peep was set to 15. Able to wean peep to 10 and maintaining sats and pO2. Vent settings: CMV 16, 700, peep 10, 50% Scant ett secretions noted. Coughs when suctioned.\n\nGi/GU: Abdomen soft, nondistended. No BS noted. OGT to LCS. Foley cath. Good UO. Clear, yellow urine.\n\nID: Vanco\n\nEndoc: Insulin gtt\n\nPlan: Wean and extubate. Pain management. Monitor hct and abg's. Replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-08 00:00:00.000", "description": "Report", "row_id": 1356039, "text": "0700-1900:\nneuro: propofol gtt weaned to off, perrl. mae and following all commands. denies pain.\n\ncv: sr 80's, no ectopy. afib 100-140's. nitroglycerin gtt titrated to maintain sbp < 140. trending cuff sbp. dobutamine gtt weaned to off with ci > 2. svo2 57-64, pa aware, no intervention per team as long as ci remains > 2. afib treated with 5 mg iv lopressor, 2 gms magnesium, and 150 mg iv amiodarone bolus. dopplerable pedal pulses bilaterally.\n\nresp: lungs coarse bilaterally. diminished at times. remains orally intubated. weaned to cpap 50% 5/5 with po2 87-93. ct d/c'd by pa . cxr done. o2 sat > 95%.\n\ngi/gu: abd soft, nd. bs positive. replete with fiber started with no residuals currently at 20 cc/hr. advance q 6 hours. foley to gravity, good huo. cr 1.4. lasix .\n\nendo: fs qid, cover per riss.\n\nplan: monitor respiratory status, rest on cpap with pressure support overnight.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-08 00:00:00.000", "description": "Report", "row_id": 1356040, "text": "Resp Care\nPt remains intubated on PSV. Vent settings weaned today to PSV 5/5 Vts ranging 450-650 RR 17-22 sats >95%. BLBS course pt suctioned frequently for thick tan secretions, MDIs given per order. Plan to rest pt overnight on and extubate in am as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-09 00:00:00.000", "description": "Report", "row_id": 1356041, "text": "7p-7a\nNeuro: Pt opens eyes spontaneously,alert, follows commands, perrla, mae weakly. Medicated w/ morphine for incisional pain w/ relief.\n\nCV: HR 100-130s Afib. MD aware, total of 20mg ivp lopressor given, bringing HR 100-120s. Going by cuff pressures, significantly higher than cuff. NTG titrated following cuff pressures. Heparin gtt presently at 700units/hr, next PTT due at 0730. PA 40-50/20s. CVP 12-14. SVO2 57-62, MD aware. CI>2 by thermodilution. SBP 110-130s. + dopplerable pedal pulses.\n\nResp: LS coarse-> clear diminished. Pt orally intubated, see carevue for details of abgs and vent changes. Rresently resting pt on CPAP w/ PS. Peep increased, see carevue. Suctioned for small to moderate amts of clearish frothy secretions MD aware, additional 20mg ivp lasix given at 2050, w/ response, MD aware.\n\nGI/GU: Abd soft, +BS. TF presently at 50cc/hr w/ 0-10cc residual. Foley draining 30-180cc/hr of clear yellow urine.\n\nSkin: See carevue, ?psorisis to hands and feet. ? derm consult. Sternal dsg changed, small amt of serosang, steris intact.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. ? Wean to extubate as pt tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-09 00:00:00.000", "description": "Report", "row_id": 1356042, "text": "Addendum\nMD aware of sternal oozing from mid part of incision, no new orders. MD aware of HR 110-140s afib, no new orders at present time.\n\nTF to be increased to 70cc/hr at 0700, goal of 80cc/hr.\n\nTmax 38.5 C, tylenol 650mg via ngt.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-15 00:00:00.000", "description": "Report", "row_id": 1356067, "text": "NEURO: ORALLY INTUBATED, SEDATED ON PROPOFOL. OPENING EYES TO VOICE CONSISTENTLY, MAE, NODDING/SHAKING HEAD APPROPRIATELY TO QUESTIONS, FOLLOWS COMMANDS ON PROPOFOL AT 35MCG. MORPHINE IV FOR INCREASED GRIMACING AND INCREASED SBP.\n\nPULM: RECEIVED PT ON CPAP MODE 50%, PEEP 8, PS 5, SATS 90-93%, PO2 73-69, PEEP INCREASED TO 10, PO2 UP TO 80. LUNGS COARSER THROUGHOUT SHIFT DESPITE FREQUENT REPOSITIONING AND CHEST PT. MD AWARE OF ABOVE. SX'D FOR SMALL-MOD AMTS THICK WHITE SECRETIONS.\n\nCV: NSR 70'S, RARE PVC. K REPLETED VIA OGT PER LABS. SBP > 120'S DESPITE HYDRALAZINE 10MG IV Q4H, MORPHINE IV AND BOLUSES OF PROPOFOL. MD AWARE. CVP 9-13. PALPABLE PEDAL PULSES.\n\nENDO: QID BS WITH RISS COVERAGE PER CSRU PROTOCOL.\n\nGI: ABDOMEN SOFTLY DESTENDED, + BS. NO STOOL. NUTREN RENAL TUBE FEEDS AT GOAL 35CC/HR VIA OGT, RESIDUALS < 20CC Q4H, TUBE PLACEMENT CHECKED Q4H.\n\nGU: FOLEY TO CD, UO 35-80CC/HR. CREATININE DOWN TO 2.3 FROM 2.6.\n\nPLAN: ? BRONCH THIS AM. CONTINUE TO TRY AND WEAN DOWN PEEP. MD'S TO UPDATE FAMILY. ? NEEDS TRACH/PEG\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-15 00:00:00.000", "description": "Report", "row_id": 1356068, "text": "ADDENDUM: DAUGHTER CALLED IN FOR UPDATE. ASKING TO MEET WITH HO WHEN SHE VISITS ~ 1000.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1356082, "text": "Resp Care\n\nPt remains trached and currently vented on psv 5/5 tol well with Vt >600cc and MV 15-20L when agitated. BS course sxing for small to mod amts of thick white/yellow secretions. Bronchodilators given x3 with good effect noted. Last ABG with acceptable with marginal oxygenation. SPo2 however mid 90s t/o shift and pt appears comfortable on settings. WIll cont with vent support and reassess for possible trach collar trial tomorrow as tol.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-19 00:00:00.000", "description": "Report", "row_id": 1356083, "text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. No changes made overnight. BS's diminished, ess. clear. Sxing thick white secretions. Administering MDI's as ordered. See flowsheet for further pt data, rx times. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-19 00:00:00.000", "description": "Report", "row_id": 1356084, "text": "NEURO: Pt , awake, follows commands approp, denies pain except with activity\n\nRESP: Sats 94% on 10PEEP, 5PS, 50%, lung sounds clear, suctioned for small-mod tan/thick secretions\n\nCV: Currently in afib/aflutter with HR 90-120s. Treated with 10mg IV Lopressor, restarted Nicard drip at 3mcg to keep SBP <120-140, pedal pulses palpable, Heparin at 1200units/hr for goal of 40-60, last PTT was 45.3, please recheck at 1100.\n\nGI/GU: Abd firm/distended, Pt had nausea/vomiting x1, given Reglan, stopped TF, G-tube to gravity drained air/undigested food (about 200mL), two medium soft/brown stools; Foley in place draining amber/sediment at >60cc/hr, creat 1.7, repleted K with 40mEq IVPB\n\nENDO: On SSRI\n\nID: WBC 16.9, max T 100.9\n\nSOCIAL: Family visited last night and updated on Pt's status.\n\nPLAN: Wean vent as Pt tolerates, monitor BP (wean Nicard), OOB to chair today, reassess GI/?restart TF\n" }, { "category": "Nursing/other", "chartdate": "2172-06-19 00:00:00.000", "description": "Report", "row_id": 1356085, "text": "npn 0700-1500;\n\nneuro; feels brighter today but anxious and asking for wellbrupion to be started,appears and orientated mood improve with visit from daughters again asking for wellbutrin from daughters. .5 mgs ativan i.v with good effect pt and wellbutrin started .pt returned to bed at 1330 hrs and has slept well since then.\n\nresp; suctioned for mod amounts thick tan secretions. lungs coarse uppper diminished at bases remians on cpap with p/s of 5 peep weaned to 8 sats 93-95% with adequate t.v and rr 18-25.needs abg .\n\ncvs; tmax 99 po nsr with ocassional afib but not sutained frequent pvcs improved after 40 meq's kcl. bp 148/-150/79 on 3mcgs nicardipine. hydralazine 10 mgs i.v given with good effect and nicardipine drip turned off. diltiazem increased to 90 mgs po hr 65-78 and bp 103/50-116/78.cxr done.awaiting read.\n\ngu; good response to lasix 40 mgs i.v.improving bun/cr therefor increased to .lytes repleted.\n\ngi; belly soft ditended. hypoactive bs abdominal; ultrasound done results pending. lft's pending passing mod amounts formed brown stoolx3 this am. guaiac neg. feeding tube to gravity and draiang mod amounts of yellow bile. clamped aftrer meds. denies nausea no further episodes of nausea.\n\nskin remains intact. has warts on feet and hands unchanged. oob and back to bed with 2 person assist doing better . per other staff members.\n\na/p t/f to remain off currently awaiting results ultrasound and lfts.\ncontinue with pulmonary toilet wean peep and fio2 as tolerated.\ncontinue to encourage increased activity and involvement with adl's case management following.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-21 00:00:00.000", "description": "Report", "row_id": 1356098, "text": "Neuro: and oriented to person and sometimes place, attempts to communicate via mouthing words, writing and communication board with limited effect, medicated with Ativan IVP(total of 9mg) for anxiety, currently asleep, MAE's well, OOB and back to bed with moderate 2 person assist\nResp: see Flow Sheet for details, lungs coarse throughout and diminished at bases, suction via trach multiple times for bloody to marbled bloody sputm, pt pulled on vent tubing several times... ? blood from irritation D/T pulling, lavaged with good results, ABG reported to Dr. , no new orders, patient was very SOB after getting back to bed, placed on a rate to rest overnihgt\nCardiac: SR no ectopy noted, repleatd K+ 3.9 with 40 meq KCL via GT\nGI: GT, + BS, + flatus, scant stool on bed sheets, unable to send stool for C-diff, TF as ordered, minimal residuals 0 to 30cc\nGU: foley to gravity draining clear yellow urine > 40cc/hr, overall patient is negative >1000cc since MN\nEndo: SSRI per and Flow Sheet\nSocial: several visitors, his daughter called and updated \nMisc: heparin drip theraputic at 1400uits/hr, coumadin 2.5mg via GT given\nPlan: monitor labs and vitals and treat as indicated and as ordered especially PT/PTT and lytes, ? rest overnight on ventilator on AC, when patient is awake reevaluate respiratory status, if patient sleeps well with last dose of Ativan can continue with Ativan IVP for anxiety... if he doesn't get several hours of sleep reevaluate treatment with MD, monitor bloody trach secretions, wean vent as tolerated, increase activity as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2172-06-22 00:00:00.000", "description": "Report", "row_id": 1356099, "text": "NEURO: PT. AGITATED, CONFUSED, ATTEMPTING TO GET OUT OF BED AND RE-RESTRAINED. MD NOTIFIED.\n\nCV: PT. NSR, HR 70'S,NO ECTOPY NOTED, SBP 110-130'S, PO DILTIAZEM/HYDRALAZINE/AMIO GIVEN AND TOLERATED. HEPARING GTT AT 1400 UNITS/HR. PTT DRAWN AT 0200-> 101. MD NOTIFIED-> ORDER TO STOP GTT AND RESTART AT 1300 UNITS/HR. NEXT PTT DUE AT 1000.\n\nRESP: PT. LUNG SOUNDS COURSE THROUGHOUT DESPITE SUCTIONING. PT. ON CMV->SEE CAREVUE FOR SPECIFIC VENT SETTINGS. PT. SUCTIONED MULTIPLE TIMES FOR THICK, BLOODY SECRETIONS. OXYGENATION CONTINUES TO BE 90-94% ON 50%FIO2.\n\nGI/GU/ENDO: PT. ABD SOFT, SLIGHTLY DISTENDED, TUBE FEEDS (PULMONARY AT 35CC/HR), NO RESIDUALS, + MUCH FLATUS, PO MEDS THROUGH PEG TUBE, FOLEY DRAINING , SEDIMENT URINE- LASIX GIVEN (40MG)-> NOW DRAINING CLEAR, YELLOW URINE. GOOD H/U/O. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: PT. C/O PAIN IN NECK REGION- 10MG ROXICET GIVEN AND TOLERATED BY PATIENT.\n\nPLAN: REORIENT PATIENT, ENCOURAGE AND SUPPORT AND CALM, MONITOR RESPIRATORY STATUS, WEAN VENT TO CPAP, MONITOR SECRETIONS, TRACH CARE, DRAW PTT AT 1000, ADVANCE ACTIVITY AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-15 00:00:00.000", "description": "Report", "row_id": 1356069, "text": "NPN: \nROS: see carevue for details\n\nNEURO: lightly sedated on propofol. arouses easily to voice. follows commands. denied pain most of day. thsi afternoon nodded head yes to pain and was grimacing more with care. 2mg IV morphine given with good effect. moves all extremities. PERLA , briskly reactive.\n\nCV: HR 70-80s, SR. BP 110-120s/30s-50s, hydralazine x 1 for sbp above 120s. CVP 8-18. +pp. hep. drip cont. at 1250units/hr, PTT as charted\n\nRESP: orally intubated & vented on settings as charted. LS coarse, suctioned for minimal thick white secretions. O2 sat 92-94%, abg acceptable > no vent changes today. trach tomorrow in OR\n\nGI: abd softly distended, +bs, OGT to TF at goal > minimal residuals. protonix as ordered.\n\nGU: amber urine with small amounts of sediment noted. 30-80cc/hr. lytes repleted as indicated\n\nENDO: bs covered with CSRU sliding scale.\n\nID: tmax 99.2, vanco & zosyn as ordered\n\nskin: intact. sternal incision with steristrips intact > painted with betadine and dsd changed.\n\nsocial: daughters & into visit today. spoke with Dr. and RE: plan for trach/peg. and son into visit this afternoon. Per daughter , they all communicate well and is up to date on information. Surgery & anesthesia consent needed for trach/peg tomorrow > daughter .\n\nPLAN: trach/peg tomorrow in OR. TF & Hep drip to be held at 06am tomorrow. otherwise, turn & reposition frequently, cont. TF as ordered, cont. hep gtt until am. monitor & support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-15 00:00:00.000", "description": "Report", "row_id": 1356070, "text": "respiratory care\npt on the vent no changes made tol well. see respiratory care page of carevue for more information.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-07 00:00:00.000", "description": "Report", "row_id": 1356034, "text": "Nursing Note:\nNeuro: Attempted to awaken pt at 1600, propofol off for 15minutes. Pt opened eyes to voice and MAE spontaneously. Withdraws to painful stimuli. Did not follow commands. Had to resedate pt due to high BP and SVO2 decreased to low 50's. Perl 3mm brisk.\n\nResp: LCTA decreased bases. Sats 96% on cpap 10/10/50% Scant ETT secretions. RR 20's.\n\nCV: NSR 70's with rare pac's and pvc's. Amio at 0.5. CI >2 and svo2 58-60 on dobutamine. Attempted to wean dobut after 500cc LR bolus and 1u RBC but svo2 decreased to low 50's. A and V wires intact, sense and capture appropriately. Ademand at 60. Sternal and mediastinal dressings cdi. Afebrile. Pulses palpable. inserted this am but following cuff pressures. abnormal high systolic numbers. Manual BP cuff checked. Team aware. NTG gtt for sbp 90-140. K and Ca repleted.\n\nGI/GU: Abdomen soft, distended. BS hypoactive. NGT to LCS. Moderate bilious drainage but blood tinged this Am. Zantac d/c and started on IV protonix. Foley cath. Good UO. Yellow urine with sediment.\n\nEndoc: Insulin gtt off at this time.\n\nPain: Morphine\n\nPlan: Wean dobutamine for CI >2 and SVO2 >60. Attempt to wean and extubate tomorrow. Monitor hct and ekg rhythm. Replete lytes.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-07 00:00:00.000", "description": "Report", "row_id": 1356035, "text": "Addendum\nRepeat HCT 26.7. 1u RBC transfusing. SVO2 57. CI >2.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-07 00:00:00.000", "description": "Report", "row_id": 1356036, "text": "Patient remains on mechanical ventilation with unstable pa02.Transfused with improved SV02 @ times.Combivent provided,BS coarse,suctioned for mild to moderate amount of thick yellow sputum will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-08 00:00:00.000", "description": "Report", "row_id": 1356037, "text": "NEURO~SEDATED W/ PROPOFOL CURRNTLY @ 60 MCG/KG/ PT COMFORTABLY SEDATED. NOT AWAKENED TONIGHT PER H.O. PT IS RESPONDING TO PAINFUL STIMULI. MORPHINE 4 MG X2 PRIOR TO MOVING PT. LOW GRADE TEMP 99.8. DAUGHTER CALLED SPOKE W/ DR. .\n\nRESP~CPAP~.77/50/10/10. PaO2~69,SAT~93,SVO2~55%. SX FOR SCANT AMTS. DR. NOTIFIED CHANGES MADE ~ ^.. REPEAT ABG~PaO2~81, SAT~96%.SVO2~57%. PT TURNED AND BEGAN COUGHING SX FOR SMALL AMTS OF THICK WHITE SECTETIONS W/ YELLOW PLUGS. LUNGS SL COARSE THROUGHOUT.\n\nCARDIAC~SR 70'S-80'S RARE PVC NOTED. AMIO @ .5 MG/. DOBUTAMINE ~ 3.0 MCG/KG/. NITRO @ 1.25 MCG/KG/ TO MAINTAIN A SBP< 140. & CUFF NOT CORREALATING,FOLLOWING CUFF. TRANSFUSED W/ 1 UNIT PRBC'S FOR HCT~26.7, REPEAT 29.8. PA'S CLIMBING SL FROM 40'S-^50'S DURING TRANSFUSION. GIVEN 20 MG IV LASIX. EFFECTIVE. PA #'S BACK TO LOW 40'S. ELELCTROLYTES REPLETED. POS PEDAL PULSES VIA DOPPLER. ACE WRAP INTACT.\n\nGI/GU~MOD AMTS OF GASTRIC SECRETIONS (BROWN BILIOUS). LARGE DIURESIS AFTER IV LASIX. HYPOACTIVE BS. SCANT STOOL NOTED WHEN TURNED.\n\nSKIN~HANDS & FEET WITH ? ECZEMA. ALOE LOTION APPLIED.\n\nA/P~CURRENTLY STABLE. IN SR AND MAINTAINING SBP< 140. CONT ON AMIO/DOBUTA/NTG/PROP. NO PLAN TO ATTEMPT VENT WEAN THIS AM. MONITOR ELECTROLYTES. CONT W/ ICU INTERVENTIONS.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-03 00:00:00.000", "description": "Report", "row_id": 1356017, "text": "NEURO: PT IS A&OX2-3, HAS DIFFICULTY REMEMBERING PLACE-STATES HE IS @ \" HOSPITAL\". REORIENTS EASILY. STATED \"I FEEL A LITTLE NERVOUS\" EARLY IN SHIFT. MAES EQUALLY TO COMMAND, REPOSITIONS SELF WITHOUT DIFFICULTY. SLEPT ON/OFF THIS SHIFT. AWAKENS FIDGETING, PICKING @ IV TUBING & WIRES. C/O NONSPECIFIC PAIN -\"I HURT ALL OVER\"- TREATED W/TYLENOL W/GOOD EFFECT. PERRL.\n\nCV: INITIALLY ST 100s, NO ECTOPY. NP AWARE, PO LOPRESSOR DOSE INCREASED W/GOOD EFFECT->TO SR 90s, HOWEVER PT TACHYCARDIC AT TIME OF THIS NOTE, MD BRIDGES AWARE, AM LOPRESSOR GIVEN EARLY. HYPERTENSIVE @ SHIFT CHANGE, 160s. SBP GOAL <140. NP AWARE, NTG PARAMETERS INCREASED AS WELL AS IV HYDRALAZINE DOSE W/GOOD EFFECT. +PP, THOUGH RT DP PULSE WEAKER. EXTREMS COOL/DRY. AFEBRILE. PTT 46, MD BRIDGES AWARE, HEPARIN GTT INCREASED TO 1000 UNITS; REPEAT PTT PENDING. K+ & CA+ REPLETED. PT ON OR SCHEDULE FOR AM. PT CONSENTED TO SURGERY & ANESTHESIA. CXR DUE EARLY AM MD ; AS STATED BY MD , SURGERY IS CONTINGENT UPON CXR RESULTS.\n\nRESP: RECEIVED EXTUBATED. LS CLR-COURSE. BASES DIM. SATS INITIALLY 91-93 ON 6L NC. RESP RATE MID TEENS. PT INDICATES NO DIFFICULTY BREATHING. FT ADDED @ .40 W/IMPROVEMENT IN PA02. ABLE TO SLIGTLY WEAN FT & NC DUE TO SATS >96% WHILE PT ASLEEP. FIO2 INCREASED TO 70% & NC TO 5L AT TIME OF THIS NOTE DUE TO SATS IN LOW 90s THIS AM. GOOD COUGH EFFORT, NO SECRETIONS RAISED. USES I.S. TO 1250. NEBS GIVEN. SEE CAREVUE FOR RECENT ABGS.\n\nGI/GU/ENDO: PT TOLERATING SIPS H2O & PO MEDS BEFORE MIDNIGHT, THEN NPO AFTER MIDNIGHT. +BS, NO BM. ABD SOFT, DISTENDED, NT. ADEQUATE HUO-CLR YELLOW. MODERATE DIURESIS AFTER IV LASIX. BS PER SS PROTOCOL.\n\nSOCIAL: FAMILY CALLED & CONFIRMED FOR AM, PLANNING TO ARRIVE EARLY TO SEE PT PRIOR TO SURGERY.\n\nPLAN: CONTINUE MONITORING CARDIO RESP STATUS, LABS. PULM TOILET. MAINTAIN BP GOAL <140. REORIENT PRN. PREPARE PT FOR OR. UPDATE PT/FAMILY RE: STATUS & PLAN OF CARE.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-21 00:00:00.000", "description": "Report", "row_id": 1356094, "text": "neuro; pt very restless and frigidy all noc- tossing self in bed frequently - anxious. non-verbal cues \"unable to sleep and need med to keep relax\" -much reassurance and calm approach use, med with ativan x1 dose with out effect-gave add'l 0.5mg ativan per fellow . maex4 to command. appro orientation. no deficit. need much reassurances. perla\n\nid; low grade temp, wbc trending up today. no abx\ncv: nsr, no ectopies. on po hydralazine, carvedilol, diltiazem and amidarone- effective keep sbp goal <130. peripheral skin w&d. no edema. +pp. cont diamox x 1day for alkalosis, held pm lasix per fellow. anticoagulate with coumadin &heparin gtt at 1400units/hr. ptt therapeutic\n\nresp; trach. sat dipped again at hs when sleep to 88% on .50/5/5. ^peep to now 10 with improved in sat. breathing even when calm. tachypnea 30s when anxious. great Vt intake. no distress. sxn mod amt blood-tinged secretion. trach care done. vap\n\ngi: tf at goal with toleration via peg tube. no residual. belly soft. no n/v. denies abdomen pain.\ngu: adequate huo. incontinence in bed bm x1 (unable to obtain cdiff spec).\nwound: chest wound cdi. cleaned with betadine and changed dsd. left heel pink.\ncomfort: pt denies pain. very anxious tonight. much reasurance and support given to pt. no family call overnoc\n\na/p: con't pulm toilet-weaning peep as . restart lasix dose. tf. f/u ptt. coumadin. need support. ^activity. may need piv vs picc access and d'c mtlc.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-21 00:00:00.000", "description": "Report", "row_id": 1356095, "text": "Respiratory Care\nAM RSBI 20, very large breaths with excessive minute ventilation.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-21 00:00:00.000", "description": "Report", "row_id": 1356096, "text": "Respiratory Care\nPT trached on ventilatory support. Last evening at HS pt began demonstrating low Spo2 values to 88 on 5 peep. peep increased gradually \u0013until SpO2 values improved (10 peep). Pt waxed and waned between 91-94% the remainder of shift. This morning SpO2 values began to improve again able to wean back peep to 5 SpO2 holding at 94%. Pt coughed and raised two very large brown plugs (around cuff!). Cuff pressure check and adequate seal during this episode. Sx for fresh bloody secretions small to mod amounts. Plan is to continue and wean vent support gradually as .\n" }, { "category": "Nursing/other", "chartdate": "2172-06-21 00:00:00.000", "description": "Report", "row_id": 1356097, "text": "respiratory care\npt switched to A/C from PSV at 1500 d/t increased WOB,SPo2 of 84%, tachypnic in 40's.PEEP increased to 10,gradually decreased to 8.SPo2 now is >93% on currunt settings.No A line access.Breath sounds clear,diminished at bases.Pt expectorated a lrg clot from the trach stoma,suctioned for moderate amt of fresh blood tinged thick secretions.Pt occasionally pulls off the vent curcuit,very agitated,ativan to control anxity.Refer to carevue flowsheet for specifics.\nPlan: Monitor Resp status and wean to PSV back as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-13 00:00:00.000", "description": "Report", "row_id": 1356060, "text": "Respiratory Care:\nPt had no changes this shift but noted a lower MV today (10-12L.)\nvs 15-17L. MDI's given x 3 + Beclovent @ ~8am. Changed the swivel,\nthe Sx cath. and the Exhalation valve because of excessive water blowing through. Sx'd for spec. for Cult. and Gm St. via the new setup. See CareVue for ABG's etc.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-14 00:00:00.000", "description": "Report", "row_id": 1356063, "text": "Resp Care: Pt continues on mechanical ventilation PSV 5/8 40%. VE 11-12.5LPM. Pt appears comfortable on current settings-> no respiratory distress noted. LS: clear/diminished bilaterally. Sxn'd for small amounts of thick white secretions. ABG: 7.44/49/90/34/7/96%. RSBI this am: 41. PLAN: continue PS as tolerated. ? extubation on MONDAY.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-14 00:00:00.000", "description": "Report", "row_id": 1356064, "text": "Resp Care\n\nPt remains intubated and on full vent support. MV is maintained in the 12-15L range. Peep decreased to 5 for multiple hrs pao2 decreaseing to 61. Fio2 to 50% and peep back to 8. BS scattered rhonchi and suctioning thick white sputum\n" }, { "category": "Nursing/other", "chartdate": "2172-06-14 00:00:00.000", "description": "Report", "row_id": 1356065, "text": "NEURO: PT. AROUSE TO VOICE, UNABLE TO ASSESS ORIENTATION, MECHANICAL VENTILATION WEANED AND PROPOFOL DECREASED TO 10MCG/KG/ PT. WHEN AROUSED IS ABLE TO NOD HEAD \"YES\" OR \"NO\" AS WELL AS MAE AND OBEYS COMMANDS. PROPOFOL CURRENTLY ON 20MCG/KG/ DUE TO INCREASE IN MECHANICAL VENTILATION SUPPORT (PEEP).\n\nCV: PT. TMAX 99.6- 650 ACETAMINOPHEN GIVEN. PT. NSR, HR 70'S, SBP 110-130-> CARVEDILOL GIVEN AND IV HYDRALAZINE ORDER CHANGED TO PRN Q4HOURS- BOTH GIVEN AND TOLERATED BY PT. WITH DECREASE IN SBP. HEPARING GTT CONTINUES NOW AT 1250 UNITS/HR. FIRST PTT AT 0900 79.8 (HEPARING DECREASED TO 1250), PTT AT 1600 64.7.\n\nRESP: PT. LUNGS SLIGHTLY RHONCHOROUS AT TIMES, MOSTLY CLEAR (ESP AFTER SUCTIONING) IN LUNG FIELDS. LUNG SOUNDS SLIGHTLY DIMINISHED IN LLL. PT. SUCTIONED FOR THICK, WHITE SECRETIONS- MODERATE TO LARGE AMTS. PT. PEEP DECREASED AT 0900 MD. TO 5, PRESSURE AT 5- FIO2 CONTINUED AT 40%. ABG SHOWED 7.46,41,67,30,4,93. FIO2 INCREASED TO 50% MD . RESULTS: 7.46,40,61,4,29,91 WITH 02 SATS 89-92%. PT. PLACED BACK ON PEEP 8, PRESSURE 5 AT 50% AND ABG: 7.47,41,72,5,31,94 WITH O2SATS 92%.\n\nGI/GU/ENDO: PT. ABD SOFT DISTENDED, +BS, TUBE FEEDS CHANGED TO NUTREN AT 35CC/HR MD . +FLATUS, ONE SMALL AMT. OF BROWN, SOFT STOOL, FOLEY DRAINING CLEAR, YELLOW URINE- LYTES REPLETED. BLOOD SUGARS TREATED PER RISS.\n\nPAIN: 2MG MORPHINE SULFATE GIVEN AND 650 MG ACETAMINOPHEN GIVEN FOR PAIN AND RELIEF FOUND VIA GRIMACE SCALE AND NONVERBAL CUES.\n\nSOCIAL: DAUGHTER AND GIRLFRIEND UPDATED TODAY.\n\nPLAN: WEAN MECHANICAL VENTILATION, POSSIBLE BRONCH?, TRIAL, MONITOR WBC AND TEMPERATURE.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-15 00:00:00.000", "description": "Report", "row_id": 1356066, "text": "Resp Care Note, Pt desat ABG'S shows hypoxia. Placed on 10 peep. Increased to 50%. Suctioned for lrg amts thick white secretions. MDI'S given. Sedated with propofol. RSBI not done due to 10 peep.Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-03 00:00:00.000", "description": "Report", "row_id": 1356018, "text": "npn 0700-1500\n surgery cancelled will diuresis asnd reassess for surgery in am.\n please inform family through kirsty (Daughter when surgery is scheduled as they would like to be here and have some distance to travel.\n\nneuro; still figity and picky attimes.aoox3 mae to command perla 3mm. plasant tearful at times, taling about family and life,\"feels that he is at peace with god\" decline clergy visit.. lisw aware.\n\nresp; lungs clear upper diminished at bases. strong productive cough attempted too wean from face mask moving well until placed on 6l n/c when sats down to 93% with abg reflective at 7.52/29/59/24/ base excess +1,,sats 93-95% on n/c5l and 40%.sm. rr 18-22.\n\ncvs;tmax 100. 99-103, lopressor increased to 75 mgs po with min effect on hr. nitro weaneed off by 230 p with bp 110-123/60 with lopressor and hydralazine. maybe start to wean back on hydralazine as increased lopressor takes affect. no ectopy observed.\n\ngu; mod response to lasix 20 mgs frequency increased to q8. lytes repleaed as nec.\n\ngi; pos bs no stool no flatus taking adequate diet ? npo from mn for pos surgery in am after cxr's are assessed.\n\nskin intact.\n\nsoc; daughters into visit and updated with pts current plan of care. and are aware of delay in surgery at this point.wife and son will be into visit this evening.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-06-03 00:00:00.000", "description": "Report", "row_id": 1356019, "text": "1500-1900\nCV: 0.5mcg Nitro restarted to keep SBP < 140, increased Lopressor to 100mg PO, diuresed with increased Lasix to 40mg IV, fem a-line discontinued and heparin drip was shut off, plan to restart drip at 1200units at , recheck PTT with morning LABS, radial a-line placed to monitor ABGs, K was 3.1 after 40mEq KCl PO (ask plan to replete K)\n" }, { "category": "Nursing/other", "chartdate": "2172-06-04 00:00:00.000", "description": "Report", "row_id": 1356020, "text": "Respiratory Therapy\nPt presents on N/C BS clear bilaterally no wheezing No bronchodilators given.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-04 00:00:00.000", "description": "Report", "row_id": 1356021, "text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4. Denies pain. Figity.\n\nCV: RSR w/o ectopy. VSS. NTG gtt weaned off, on Hydralazine 20 q 6 hr and metoprolol 100 mg TID, 0200 dose of metoprolol held d/t timing w/hydralazine and boarderline hypotension. Peripheral pulses palpable. Groin site CDI w/o ecchymosis or hematoma. Heparin gtt resumed at Hrs @ 1200 U/hr. PTT at 0300 = 40, gtt rate ^ to 1400 U/hr at 0500. Heparin gtt on for ACS.\n\nResp: Lungs clear diminished in bases, on 4 L/ NP + 40% cool neb shovel mask. Sats 93-97%. ABGs w/metabolic alkolosis, and marginal oxygenation, Dr aware.\n\nGI: Abd soft w/active BS. H2 blocker for GI prophylaxis. Taking diet w/o complaints of N/V.\n\nGU: Foley patent draining clear yellow urine in QS. Lasix given w/great effects.\n\nEndo: FSG not requiring coverage.\n\nLytes: IC and K both repleted several times this shift.\n\nPlan: Mobilize, OOB. Pulmonary toileting. FOllow ABGS. Next PTT due at 1100 AM. Monitor, tx, support, and comfort. Awaiting OR once CXR and pulmonary status clears.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-13 00:00:00.000", "description": "Report", "row_id": 1356061, "text": "NEURO: PT. LIGHTLY SEDATED ON PROPOFOL (25MCG), PERRL, MOVES ALL EXTREMITIES INDEPENDENTLY, OBEYS COMMANDS.\n\nCV: PT. NSR, HR 70'S, SBP 110-125, 10 MG HYDRALAZINE GIVEN ACCORDING TO ORDER FOR SBP >120, CARVEDILOL GIVEN AT 0800 AND TOLERATED BY PATIENT. NO ECTOPY NOTED. HEPARING GTT AT 1500 UNITS/ PTT CHECKED EVERY 6 HOURS (NEXT PTT AT 2200) CARDIAC ECHO PERFORMED TODAY.\n\nRESP: PT. LUNG SOUNDS COURSE AT TIMES, BUT IMPROVEMENT MADE WITH SUCTIONING. ETT SUCTIONED FOR THICK, WHITE MODERATE AMT. OF SECRETIONS. SPUTUM SAMPLE SENT. PT. CPAP, FIO2 40%, - SEE CAREVUE FOR ABGS. PT. RESPIRATORY RATE 10-15.\n\nGI/GU/ENDO: PT. ABD SOFT DISTENDED, +BS, TUBE FEEDS AT 70CC/HR- RESIDUALS 5-10CC, +FLATUS WITH EVERY POSITION TURN, FOLEY DRAINING SEDIMENT/CLEAR MOST TIMES YELLOW URINE- LASIX GTT DC/D AT 1300. PT. HAD LARGE H/U/O (>100CC/HR)- LASIX DC/D. LAST POTASSIUM LEVEL 3.1- MD NOTIFIED OF LEVEL- IV AND PO K GIVEN. OTHER LYTES REPLETED. CREATININE 2.3- RENAL CONSULT TODAY AS WELL AS A RENAL ULTRASOUND PERFORMED. URINE CULTURES SENT AS WELL.\nBLOOD SUGARS TREATED PER RISS. LAST BLOOD SUGAR AT 1600-> 107.\n\nID: ZOSYN ORDER CHANGED-> PT. ON ZOSYN AND VANCOMYCIN IV.\n\nPAIN: TYLENOL AND 2MG MORPHINE SULFATE IV GIVEN AND TOLERATED WITH NO PAIN REPORTED BY GRIMACE SCALE AND VITAL SIGNS.\n\nPLAN: CONTINUE PT. ON CPAP (), WEAN MECHANICAL VENTILATION AND MONITOR PULMONARY STATUS, MONITOR FLUID STATUS, REPLETE LYTES, MONITOR TUBE FEED RESIDUALS, CHECK SPUTUM SAMPLE RESULTS AND URINE CULTURE.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-14 00:00:00.000", "description": "Report", "row_id": 1356062, "text": "NEURO: OPENING EYES SPONTANEOUSLY AND TO VOICE, MAE, FOLLOWS COMMANDS. PEARL AT 2-3MM/.\n\nPULM: CPAP MODE ALL SHIFT AT 40%, PS 5, PEEP 10 DECREASED TO 8 ~ 0300. ABG PENDING. LUNGS CLEAR AFTER SX. SX'D ~ Q90 MINUTES FOR SCANT THIN WHITE SECRETIONS. WBC UP TO 12K, TEMP MAX 99.3. VANCO HELD AT FOR LEVEL 21. RANDOM LEVEL SENT AT 0450. ZOSYN DECREASED TO , GIVEN AT 2200. RSBI 41.\n\nPAIN: MORPHINE 2MG IV X 1 FOR PAIN.\n\nCV: NSR 70'S WITH RARE PVC. HYDRALAZINE 10MG IVP Q6H FOR SBP > 120. HEPARIN GTT DECREASED TO 1350 @ 0300 FOR PTT 92.9. PEDAL PULSES PALPABLE.\n\nENDO: QID BS WITH RISS COVERAGE.\n\nGI: ABDOMEN SOFTLY DISTENDED, + BS. REGLAN, LACTULOSE, COLACE GIVEN D/T NO BM, + MEDIUM SIZED SOFT-LIQUID BROWN STOOL. RESIDUAL OF 150CC X 1, TF OFF X 1H.\n\nRENAL: BUN 70/CREATININE UP TO 2.6. UO 35-100CC. URINE AMBER-ICTERIC. AWAITING RENAL US RESULTS.\n\nSOCIAL : DAUGHTER CALLED IN FOR UPDATE ~ 2100.\n\nPLAN: ? WEAN PEEP TO 5 AND CONTINUE CPAP MODE ON 40/5/5 UNTIL TOMORROW AM, IF TOLERATED, THEN DC PEEP AND IF ABLE TO MAINTAIN OXYGENATION WITHOUT PEEP, EXTUBATE. CONTINUE TO MONITOR LYTES Q4H AND REPLETE PRN. CHECK PTT AT 0900. RENAL FOLLOWING. ? INCREASE FREQUENCY/DOSE OF HYDRALAZINE.\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1356080, "text": "NEURO: Pt , awake, follows commands approp, denies pain, MAE\n\nRESP: Weaned O2, Sats 94-95%, lung sounds clear, Pt able to expectorate secretions, suctioned for small-mod blood tinged secretions, plan to continue to wean vent settings\n\nCV: SR with HR in 90s, SBP 120s on 3mcg Nicard/2mcg Nitro, keep <140, pedal pulses present, had two episodes of afib in 120s, given 5mg IV lopressor and converted to SR on both occassions\n\nGI/GU: Plan to restart TF today, GT to gravity except for meds, BS present, abd soft/distended; Foley in place draining amber urine with sediment at >60cc/hr, repleted Ca/K\n\nENDO: On SSRI\n\nSOCIAL: Updated daughter about plan of care.\n\nPLAN: Wean vent, wean Nicard/Nitro, continue pulm toilet/trach care, OOB to chair today\n" }, { "category": "Nursing/other", "chartdate": "2172-06-18 00:00:00.000", "description": "Report", "row_id": 1356081, "text": "NPN: Review of Systems\nNeuro: Pt is / cooperative. Trying to communicate by mouthing words and writing notes. Not always successful. Moves all extremities. OOB to cardiac chair w/ RN and physical therapist. Heavy assist. Denies pain.\n\nResp: Current vent settings: 50% PS5 PEEP5 (decreased from 10) Breathing unlabored and Pt denies SOB. ABG on these settings w/ SaO2=90-91%=7.51/ 32/61/+2. Discussed results w/ NP and Dr.. Plan to keep Pt on current setting since he appears comfortable. Sa02 now =94-95%. Instructed Pt on use of incentive spirometer, but didn't grasp how to use. Pt encouraged to deep breathe. Sxned for thick white secretions.\n\nCV: Flips between SR/ atrial flutter and atrial fibrillation. PVCsHigh rate of 130s when in afib, but self limited. K+=3.6->40meq KCL via PEG. Current HR in 70s. NSR. No ectopy. Arterial line positional. Unable to draw back on it. NBP systolic pressure 120s-130s. mAP 60s-90s. Nitroglycerin and nicardipine have bee titrated to off. Skin warm dry. Chest dressings dry and intact. Heparin drip infusing at 800units/hr. PTT pending.\n\nGI: Abdomen is soft/distended. (+) bowel sounds. Large soft/ brown bowel movement. Nutren Renal FS started at 15cc/hr via PEG. No c/o nausea.\n\nEndo: Fingerstick glucose=179->8 units regular insulin per sliding scale.\n\nGU: Foley to gravity. BUN/Cr=55/1.8. 40mg lasix administered. Pt's uo=700cc 8am-1300.\n\nSkin: Feet very dry. Warts present. No pressure wounds on present.\n\nSocial: Wife in to visit.\n\nA Hemodynamics stable at this time off drips. No resp distress.\n\nP: ? remove arterial line. Continue to encourage Pt to deep breathe. F/U w/ PTT result. Advance tubefeedings as ordered. Monitor as ordered.\n" }, { "category": "ECG", "chartdate": "2172-06-05 00:00:00.000", "description": "Report", "row_id": 226276, "text": "Sinus rhythm. Left atrial abnormality. Non-specific inferior ST-T wave\nabnormalities. Non-diagnostic Q waves in leads II, III and aVF. No previous\ntracing available for comparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2118-11-29 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 941365, "text": " 2:52 AM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: ?vasculitis, ?subQ air, ?abscess\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with hypotn, tachycardia, and L neck erythma and tenderness\n REASON FOR THIS EXAMINATION:\n ?vasculitis, ?subQ air, ?abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa TUE 7:23 AM\n Swelling of the left parotid gland which contains low attenuation areas\n concerning for developing abscess. No drainable fluid collections identified.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Left neck erythema and tenderness, question vasculitis,\n question subcutaneous air.\n\n CT SCAN OF THE NECK WITH INTRAVENOUS CONTRAST MATERIAL. A venous catheter\n enters the right internal jugular vein, and there is a small amount of gas\n anteriorly within this vein. There is some gas also seen within the\n innominate vein anteriorly in the mediastinum. On the left side of the neck,\n there is diffuse swelling superficially, extending somewhat into the deep\n structures and particularly in the region of the parotid gland where there are\n multiple areas of low density raising the question of early abscess formation.\n A deep parapharyngeal space in the left appears to be relatively clear,\n although there is limitation of the scan from dental amalgam artifact. There\n is no definite evidence of abnormality in the right side of the neck, although\n there are some alterations in density in the right parotid gland. The lung\n apices appear clear.\n\n IMPRESSION: Extensive abnormality left side of the neck involving the parotid\n gland concerning for inflammation and early abscess formation in this clinical\n setting. No definite evidence of internal jugular vein thrombosis. From the\n scan alone neoplasm involving the parotid gland with extension is not entirely\n excluded.\n\n" }, { "category": "Radiology", "chartdate": "2118-11-29 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 941366, "text": " 2:53 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for colitis, abscess, free air\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F w/ hx R flank abscess, s/p abdominal p/w hypotension, hypothermia,\n tachy\n REASON FOR THIS EXAMINATION:\n eval for colitis, abscess, free air\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old female with right flank abscess status post abdominal\n surgery presenting with hypotension and hypothermia.\n\n COMPARISON: Multiple priors, the most recent CT abdomen from .\n\n TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis\n were obtained following administration of oral and 80 cc of IV Optiray\n contrast. Multiplanar reconstructions were performed.\n\n CT ABDOMEN WITH IV CONTRAST: Interstitial and ground glass opacities at the\n lung bases likely represent atelectasis. There is no pericardial or pleural\n effusion. The patient is status post cholecystectomy. The liver, pancreas,\n spleen, and adrenal glands are normal. Mild dilatation of the common bile\n duct to 9 mm is without change. The kidneys enhance symmetrically and excrete\n contrast normally. Oral contrast is seen within the stomach and passes\n through loops of small bowel into the patient's right-sided ileostomy. There\n is no evidence of bowel wall thickening or obstruction. No extravasation of\n oral contrast material is demonstrated. Multiple small mesenteric lymph nodes\n are demonstrated, which are unchanged compared to the prior study.\n\n A right- sided pigtail catheter is seen with its tip located within a large\n retroperitoneal fluid collection. This collection measures approximately 7 cm\n in the oblique transverse dimension x 7.4 cm in the oblique AP dimension x 18\n cm in the sagittal oblique dimension, and appears slightly larger since the\n prior examination. Again documented is evidence of fistulization of this\n collection through the quadratus lumborum muscles in the right flank as well\n as involving the right psoas and extending inferiorly to involve the iliacus\n and iliapsoas muscle. A smaller lobulated collection along the lateral aspect\n of the psoas muscle is unchanged. No free intraperitoneal air is identified.\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is seen within a partially\n distended bladder. Air within the bladder is likely iatrogenic. Visualized\n bowel within the pelvis is unremarkable. There is no ascites,\n lymphadenopathy, or free intrapelvic gas.\n\n No osseous findings suspicious for malignancy are identified. Sclerosis on\n both sides of the sacroiliac joints on the right may be secondary to osteitis\n condensans ilii.\n\n (Over)\n\n 2:53 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for colitis, abscess, free air\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Interval increase in size of a large right-sided peritoneal fluid\n collection despite a pigtail catheter, which appears appropriately placed.\n Catheter exchange or upsizing of the catheter is recommended for further\n drainage.\n 2. No evidence of small-bowel obstruction or free intraperitoneal air.\n 3. Bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-11-29 00:00:00.000", "description": "CT RETROPERITONEAL DRAINAGE", "row_id": 941409, "text": " 9:49 AM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: Please evaluate and drain abscess.\n Admitting Diagnosis: R/O SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with\n REASON FOR THIS EXAMINATION:\n Please evaluate and drain abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT-guided retroperitoneal drainage .\n\n COMPARISON: CT-guided drainage and CT abdomen and pelvis\n dated .\n\n INDICATION: Please evaluate and drain abscess.\n\n PROCEDURE:\n\n NON-CONTRAST CT OF THE ABDOMEN: After explaining the risks and benefits of\n the procedure to the patient's husband, written informed consent was obtained.\n The patient was placed in the supine position on the CT table. Limited non-\n contrast CT of the abdomen and pelvis was performed in the supine position for\n localization of the right-sided retroperitoneal abscess.\n\n CT-GUIDED LOCALIZATION: CT fluoroscopy was used to evaluate the pigtail\n catheter which was already in place. A preprocedural timeout was performed\n verifying the patient's identity, site of procedure, and proposed procedure\n using two patient identifiers.\n\n CT-GUIDED CATHETER MANIPULATION/EXCHANGE: The catheter which was already in\n placed was flushed and only a small amount of purulent drainage was aspirated.\n It was then decided to exchange the catheter over a wire. wire was\n inserted into the catheter after the pigtail catheter was cut and the wire was\n advanced. After the wire was placed, the indwelling catheter was removed.\n Then, a 10 French dilator was placed over the wire. Over a wire, a new 10\n French catheter was placed and secured to the patient's skin. Approximately\n 450 cc of purulent material was aspirated. A portion of this material was\n sent to the lab for gram stain and culture. The abscess cavity was flushed\n with 40 cc of normal saline and aspirated. A drainage bag was attached to the\n catheter. The pigtail catheter was secured to the patient's skin and a\n sterile dressing was placed. The patient tolerated the procedure well without\n immediate post-procedure complication and left the department in stable\n condition.\n\n MEDICATIONS: Patient received total of 25 mcg of fentanyl. The patient's\n hemodynamic parameters were continuously monitored during the procedure.\n\n IMPRESSION: Successful CT-guided exchange of a right-sided retroperitoneal\n drainage catheter. A total of 450 cc of purulent material was aspirated. A\n sample of this fluid was sent for Gram stain and culture.\n (Over)\n\n 9:49 AM\n CT RETROPERITONEAL DRAINAGE; CT GUIDANCE DRAINAGE Clip # \n Reason: Please evaluate and drain abscess.\n Admitting Diagnosis: R/O SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2118-11-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 941362, "text": " 11:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/ p/w hypotension, tachy, hypothermia\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88-year-old female status post abdominal surgery presenting with\n tachycardia and hypothermia.\n\n COMPARISON: .\n\n AP SUPINE CHEST: The heart size, mediastinal and hilar contours are normal.\n Lungs are clear. There are no pleural effusions or pneumothoraces. The\n pulmonary vasculature is not congested. Visualized soft tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-11-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 941363, "text": " 12:11 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48F s/ p/w hypotension, tachy, hypothermia\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate right IJ line placement. The patient is status post\n abdominal surgery.\n\n COMPARISON: .\n\n AP SEMIUPRIGHT CHEST: The tip of a right internal jugular central venous\n catheter terminates at the caval atrial junction. The cardiomediastinal\n silhouette is normal. There is no pneumothorax. Lungs are clear, without\n consolidation. There are no pleural effusions. The pulmonary vasculature is\n not congested. Surgical clips are seen in the right upper abdominal quadrant.\n\n IMPRESSION: Satisfactory position of the right internal jugular catheter. No\n evidence of pneumonia or CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2118-12-07 00:00:00.000", "description": "PICC W/O PORT", "row_id": 942414, "text": " 7:34 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC.\n Admitting Diagnosis: R/O SEPSIS\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with abdominal abscess, poor IV access, has had PICC placed\n in IR in past, on IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Please place PICC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old woman with abdominal abscess, poor IV access, PICC\n placement in O.R. in the past. Please place PICC for antibiotics.\n\n RADIOLOGISTS: Drs. and Dr. , the attending\n radiologist, was present and supervising throughout.\n\n TECHNIQUE/FINDINGS: Using sterile technique and 1% lidocaine for local\n anesthesia, the right basilic vein was localized with ultrasound and punctured\n under direct ultrasound guidance using a micropuncture set. Hard copy\n ultrasound images were stored documenting vessel patency. Peel-away sheath\n was placed over the wire. There is difficulty advancing the wire centrally\n and a venogram was performed. This demonstrates central right subclavian\n occlusion with multiple collateral vessels. Findings were discussed with Dr.\n during the procedure, who reported PICC line was for vancomycin and\n that midline axis was not acceptable. Subsequently, using sterile technique\n and 1% lidocaine for local anesthesia, the left basilic vein was localized\n with ultrasound and punctured under direct ultrasound guidance using a\n micropuncture set. Hard copy ultrasound images were stored documenting vessel\n patency. Peel-away sheath was placed over the wire and a single-lumen PICC\n was then placed through the peel-away sheath with is tip positioned in the SVC\n under constant fluoroscopic guidance. Position of the catheter was confirmed\n with subsequent single fluoroscopic spot view. Peel-away sheath was removed\n and catheter secured to the skin. Patient tolerated the procedure well with\n no immediate complications.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound and fluoroscopically guided PICC placement via\n the left basilic venous approach, with tip positioned in the SVC. Line is\n ready for use.\n 2. Venogram performed demonstrating central occlusion of the right subclavian\n vein with multiple collaterals.\n\n These findings were discussed with Dr. during time of the\n procedure.\n\n (Over)\n\n 7:34 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC.\n Admitting Diagnosis: R/O SEPSIS\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2118-12-06 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 942367, "text": " 4:28 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate drainage of abscess\n Admitting Diagnosis: R/O SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 y/o female s/p CT guided drainaged of right-sided abdominal abscess.\n REASON FOR THIS EXAMINATION:\n evaluate drainage of abscess\n CONTRAINDICATIONS for IV CONTRAST:\n No need for IV contrast.;No need for IV contrast.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CT-guided drainage of right-sided abdominal abscess.\n Evaluate drainage of abscess.\n\n COMPARISON: CT abdomen and pelvis, and .\n\n TECHNIQUE: MDCT acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness after the administration of\n oral contrast and 100 cc of IV Optiray contrast. Coronal and sagittal\n reformats were performed.\n\n CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are small to moderate\n bilateral pleural effusions, increased in size compared to prior exam. There\n is also small dependent atelectasis. The patient is status post\n cholecystectomy. There is mild intrahepatic biliary dilatation as well as\n dilatation of the common bile duct up to 12 mm, not significantly changed from\n prior exam. There is a focal hypodense area at the anterior aspect of the\n left lobe of the liver that is ill defined and may represent focal fatty\n change. This area is stable in appearance dating back to . The liver,\n pancreas, spleen and adrenal glands are normal. The kidneys enhance\n symmetrically and excrete contrast normally. The patient is status post\n colectomy with a right-sided ileostomy. No evidence of bowel wall thickening\n or obstruction. Small mesenteric lymph nodes are demonstrated. A mesenteric\n lymph node just anterior to the confluence of the portal vein measures 0.6 x\n 1.5 cm, decreased from 0.9 x 1.6 cm.\n\n A right-sided pigtail catheter is seen with its tip located within a fluid\n collection layering along the right iliac bone. There has been near-complete\n resolution of the fluid collection with only a small amount of fluid layering\n within it. There is also decrease in size in the fistulization of the\n collection through the muscles in the right flank. No free intraperitoneal\n air is identified.\n\n CT PELVIS WITH IV CONTRAST: The bladder, uterus, and rectum are unremarkable.\n No ascites, lymphadenopathy, or free intrapelvic gas.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. There\n is stable sclerosis of bilateral sacroiliac joints, likely secondary to\n osteitis condensans ilii.\n\n Coronal and sagittal reformats confirm the above findings.\n (Over)\n\n 4:28 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: evaluate drainage of abscess\n Admitting Diagnosis: R/O SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Near-complete resolution of right lower quadrant fluid collection with\n pigtail catheter in place. Also decrease in size of posterior fistulous tract\n through the right flank muscles.\n\n 2. Increase in size in the bilateral pleural effusions and atelectasis.\n\n A wet read was given to Dr. at 5:30 p.m. on .\n\n" }, { "category": "Nursing/other", "chartdate": "2118-11-29 00:00:00.000", "description": "Report", "row_id": 1450819, "text": "Pt alert, lethargic after pain medication. Oriented x3 at time speech nonsensical and pt disoriented but reorients easily. Otherwise neurologically intact. Pain right side of neck pain, Morphine IVP with good effect. Hypothermic this am, placed on bearhugger with good effect, temp wnl this afternoon, see careview for details. Normal sinus HR 70-80's no ectopy. On levophed gtts titrate MAP >55. See careview for details. HX RLE DVT, per team ok to have venodynes on BLE. On coumadin at home, upon admission INR 3.5, given total of 5 units FFP this am prior to abcess drainage. HCT down from 25.7 in ED to 22.6 this am. Given 1 unit PRBC and HCT up to 25.7. Team aware of all lab values. Lungs clear. Abd soft, tender on right sided around drain site. Ileostomy draining thin green/brown liquid. Pigtail to right flank area not draining this am. To CT for CT guided drainage of abcsess. 500 cc purulent/bloody drainage aspirated and cx sent. Drain patent and draining moderate amounts. Foley with good amts clear yellow urine although tapering off this afternoon. Midline abd wound open, packed with gauze and DSD intact. Stoma pink, skin around site intact. Sm area of breakdown around pigtail drain site, dsg CDI. No breakdown noted. Plan to wean off levophed gtts and call out to floor when hemodynamically stable. Monitor drain, monitor labs and replete prn.\n" }, { "category": "Nursing/other", "chartdate": "2118-11-29 00:00:00.000", "description": "Report", "row_id": 1450820, "text": "Addendum to previous note: to left side of neck, no pain to right side of neck.\n" }, { "category": "Nursing/other", "chartdate": "2118-11-30 00:00:00.000", "description": "Report", "row_id": 1450821, "text": "NPN\nPlease see CareVue for full assessments.\nNEURO: Lethargic. Oriented x2, confused on where she is at present time. Unable to find coorect words in conversation. Extremely weepy. Pain to left neck and left hip rating . Morphine PRN w/effect but altered mentation also worsens once medicated but easily reoriented.\n\nCV: NSR, no ectopy noted. HR 80's. SBP w/MAP grtr than 55 maintained. Levo gtt infusing. Titrated to maintain goal. Attempted to turn off gtt-MAP to 53. SICU HO and primary team aware. IVF cont. Bolus x1 this AM for BP and Levo turned off again per primary team. K repleted w/20mEq. INR to 2.5 acceptable.\n\nLeft neck with decreased erythema and edema. Parotid massage z2 this shift. Extremely painful for pt. Premed w/no effect per pt. Warm compresses to neck PRN.\n\nRESP: NARD. BLS CTA. Infequent nonproductive cough.\nGI: BS+. ABD S/NT/ND. Ileostomy w/green liquid stool. Guaiac neg. Abd wound draining minimal amt thick tan drg. Pigtail draining serosang/pus drg. Stripped by MD.\n: Adequate amts lt yellow clr urine.\n\nPLAN: Monitor CV, wean Levo gtt as tol, bolus LR for BP, pain management, parotid massage/hot compresses to left neck QID, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2118-11-29 00:00:00.000", "description": "Report", "row_id": 1450818, "text": "NPN\nPlease see CareVue for full assessments.\nNEURO: Slightly confused but answers most questions. MAE and follows commands. Low temp noted on admission.\n\nCV NSR. HR70's. Arrived on Levo w/goal of MAP grtr 60 and CVP 12-14 MD . Unsuccessful at attempt to wean Levo from 0.2mcg/kg/min. Transfused w/FFPx4Units upon arrival due to INR of 3.5. Pt.'s husband reports \" clot\" in her RLE during recent admission and finished Lovenox approx 2 weeks ago. Pboot removed from RLE until clarified w/SICU team. Plan to go to IR @0800 for drain of abcsess.\n\nRESP: Sats WNL on 4L NC. BLS CTA. Denies cough but states DOE.\nGI: Abd S/NT/ND. NPO at present. Abd midline wound w/w-d changed. Opening @umbilicus w/serosang drg. Pigtail drain in place. Ileostomy emptied for lg amt. dark green liquid stool. Stool guaiac negative.\nGU: Foley patent draining light yellow urine.\n\nINTEG: Cool. Intact. Pigtail drain in right side to gravity w/minimal drg.\nPLAN: Administer FFP, obtain labs, monitor CV, wean Levo gtt as tol, monitor drains, monitor erythema @left neck. prepare for IR scheduled @0800.\n" }, { "category": "Nursing/other", "chartdate": "2118-11-30 00:00:00.000", "description": "Report", "row_id": 1450822, "text": "NPN\nsee carevue for further details\n\nN: Alert, oriented x2. periodically confused about time and place, reoriented as needed. MAE well. Tearful/sad throughout the shift. Sw notified of pt.\n\nC: HR 70-80s, nsr. Levo successfully weaned this shift. Bolus given early a.m. with good effect. BP 70-100s, MAP ok greater than 50 per team. Pboots on. + CSM + PP.\n\nR: BLSCTA even unlabored. 2L N.C. 02 sats 98-100.\n\nGI: + BS x4 abd soft appropiately tender, nondistended. Ileostomy intact, stoma pink, draining green liquid stool mod amounts. Small abdominal quarter sized wound with purulent foul smelling drainage. Dsg changed-intact. Pigtail draining thick sanguinous purulent drainage. Tol clears without incident.\n\nGU: Foley draining clear yellow urine large amounts.\n\nID: Afebrile this shift. Continues on IV ABX. Cultures pending. L parotid gland firm & reddened-able to express small amt of purulent drainage after massage. Continue with parotid massage and heat packs prn. Pre-medicate with Morphine as needed.\n\nENDO: SSRI, no coverage needed this shift. FS within normal.\n\nPLAN: Awaiting primary team to assess transfer to floor. Continue to monitor VS, pain, GI/GU, labs, i/os, continue with parotid massage. Provide comfort and support as needed.\n" } ]

[ { "category": "Echo", "chartdate": "2139-02-18 00:00:00.000", "description": "Report", "row_id": 77933, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for mycotic aneurysm of aortic arch\nHeight: (in) 70\nWeight (lb): 152\nBSA (m2): 1.86 m2\nBP (mm Hg): 106/64\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 17:16\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild PA systolic\nhypertension.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. LV systolic function appears moderately depressed\n(ejection fraction ?40%).Regional wall motion could not be fully assessed due\nto suboptimal views. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets are mildly thickened. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension.\n\nNo vegetations are seen (cannot exclude). The aortic arch was not well\nvisualized.\n\n\n" }, { "category": "Echo", "chartdate": "2139-02-16 00:00:00.000", "description": "Report", "row_id": 77934, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Evaluation for abscess.\nHeight: (in) 38\nWeight (lb): 150\nBSA (m2): 1.19 m2\nBP (mm Hg): 18/250\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 11:00\nTest: Portable TTE (Focused views)\nDoppler: Color doppler only\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Cannot assess\nLVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nOverall left ventricular systolic function cannot be reliably assessed. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets are mildly thickened. A vegetation is not seen, but cannot be\nexcluded due to suboptimal technical quality. The mitral valve leaflets are\nmildly thickened. A vegetation is not seen, but cannot be excluded due to\nsuboptimal technical quality. Mild (1+) mitral regurgitation is seen. There is\nno pericardial effusion.\n\nIf the clinical suspicion for endocarditis is high, a follow-up TTE by a lab\nson or a TEE are suggested.\n\n\n" }, { "category": "Radiology", "chartdate": "2139-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851935, "text": " 11:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: aortic tear, effusion ?\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with aortic perforation\n REASON FOR THIS EXAMINATION:\n aortic tear, effusion ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic perforation. Evaluate for effusion.\n\n FINDINGS:\n\n Comparisons made to a CT from the previous day.\n\n A pacemaker overlies the left chest with pacer leads overlying the region of\n the right atrium and right ventricle. There is abnormal contour of the aortic\n arch lateral to atherosclerotic calcifications of the aortic arch. The heart\n is enlarged. Calcified pleural plaques are seen. Small bilateral pleural\n effusions are identified. There is no evidence of pneumothorax. No failure\n seen. No osseous abnormalities are identified.\n\n IMPRESSION:\n\n 1) Abnormal contour of the aortic arch corresponding to the patient's known\n aortic arch pseudoaneurysm that is better demonstrated on the CT examination\n from .\n\n 2) Small bilateral pleural effusions.\n\n 3) Calcified pleural plaques, indicating prior asbestos exposure.\n\n" }, { "category": "Radiology", "chartdate": "2139-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 851965, "text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aortic pseudoanneurysm w/dropping HCT-r/o effusion\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with aortic perforation\n\n REASON FOR THIS EXAMINATION:\n aortic pseudoanneurysm w/dropping HCT-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 77-year-old man with aortic perforation status post aortic\n pseudoaneurysm. Now with dropping hematocrit. Rule out effusion.\n\n Comparison is made with a prior AP view of the chest dated .\n\n SINGLE AP VIEW OF THE CHEST: A left-sided aortic permanent pacemaker is seen\n with the leads in place adjacent to the right atrium and right ventricle.\n There is no evidence of pneumothorax.\n\n Compared with the prior study dated , there has been mild\n interval enlargement of the cardiac silhouette. The mediastinal and hilar\n contours remain stable. There is no definite evidence of a pleural effusion.\n There is significant background lung disease with calcified plaques,\n predominantly along the left lung base, and possible underlying emphysema.\n Surrounding soft tissues and osseous structures reveal degenerative joint\n disease.\n\n IMPRESSION:\n\n No definite evidence of pleural effusion. Diffuse background lung disease\n including calcified plaques, and possible emphysema. CT is recommended for\n further evaluation.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2139-02-19 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 852182, "text": " 3:05 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for enlarging aortic pseudaneurysmPlease do\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with aortic pseudaneurysm and pacer with positive blood\n cultures\n REASON FOR THIS EXAMINATION:\n Please evaluate for enlarging aortic pseudaneurysmPlease do I minus study\n CONTRAINDICATIONS for IV CONTRAST:\n Please do without contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic arch pseudoaneurysm. The patient with positive blood\n cultures.\n\n TECHNIQUE: Axial noncontrast CT imaging of the chest. Comparison is made\n with CT of the chest performed on .\n\n CT OF THE CHEST WITHOUT CONTRAST: There is a large soft tissue\n density consistent with a hematoma adjacent to the lateral aspect of the\n aortic arch, which measures approximately 5.6 x 3.7 cm. On the prior\n examination of this periaortic hematoma measured approximately 3.6\n x 1.7 cm. There is apparent disruption of calcification along the lateral\n contour of the aorta that is new when compared to the prior examination of\n seen best on (series 2, image 21). There is an significantly\n increased size of a left-sided pleural effusion. The pleural fluid on the left\n measures approximately 20 Hounsfield unit. A small left-sided pneumothorax\n was seen on the prior examination with the left- sided pleural fluid measuring\n approximately 40 Hounsfield units. A small right-sided pleural effusion\n appears unchanged. Multiple calcified pleural plaques are seen bilaterally.\n The heart is enlarged with a pacemaker in place. The stomach is dilated and\n fluid fills the lower esophagus. Likely atelectasis is present within the\n left lung base. No pulmonary nodules are seen. No pericardial effusion is\n seen.\n\n In the visualized portions of the upper abdomen, a distended stomach is seen.\n The spleen and visualized portion of the liver are within normal limits. There\n are dense nephrograms seen bilaterally. A stone versus retained contrast is\n seen within the mid left kidney.\n\n Bone windows show no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1) Increased size of a mediastinal hematoma adjacent to the patient's known\n aortic arch pseudoaneurysm. This finding cannot be further evaluated without\n IV contrast; however, however, this suggests worsening of mediastinal\n hemorrhage.\n\n 2) Increased size of left-sided pleural effusion with associated Hounsfield\n units of 20. This finding could represent a reactive pleural effusion or\n (Over)\n\n 3:05 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please evaluate for enlarging aortic pseudaneurysmPlease do\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n subacute hemothorax given the presence of blood within the pleural space on\n the prior CT of .\n\n 3) Dense bilateral nephrograms presumably reflecting contrast nephropathy in\n the absence of recent contrast administration.\n\n 4) Calcified pleural plaques are consistent with prior asbestos exposure.\n\n These findings were discussed with the clinical team responsible for this\n patient's care at the time of interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2139-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 852083, "text": " 11:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please eval for widening mediastinum, pneumonia\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with aortic pseudoaneurysm, COPD\n REASON FOR THIS EXAMINATION:\n Please eval for widening mediastinum, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old man with aortic pseudoaneurysm, chronic obstructive\n pulmonary disease. Please evaluate for widening mediastinum.\n\n COMPARISON made with prior AP chest of at 08:18.\n\n SINGLE AP VIEW OF THE CHEST: The cardiac silhouette is stable. The\n mediastinum appears to have widened since prior study of approximately 15\n hours earlier. Additionally, there is increased opacification of the left\n lung extending approximately two thirds of the way up. Complete evaluation of\n the left lung is complicated by the presence of multiple pleural plaques, as\n well as left hemidiaphragm elevation. There is, however, a small left pleural\n effusion and fluid within the pleural space should be considered.\n\n The right lung appears unchanged. Multiple pleural plaques are identified\n within bilateral lungs and along the left lung base. A left chest \n is seen with the electrodes in good position adjacent to the\n right atrium or right ventricle. The surrounding soft tissue and osseous\n structures remain stable.\n\n IMPRESSION:\n Within the past 15 hours, there has been interval widening of the mediastinum\n and aortic arch. Additionally, there is increased consolidation in the area\n of the left lung, extending approximately two thirds of the way up, with a new\n left pleural effusion. Fluid within the left pleural space should be\n considered.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-20 00:00:00.000", "description": "Report", "row_id": 1356928, "text": "CCU NPN 1900-0700\nO:\nDr spoke again with pt. and family ~ 2100- frank discussion about enlarging pleural effusion seen on CT c/w increasing aortic leaking aneursym. still awaiting final decesion about surgery from , however pt. and family aware that situation is very grim and futile without surgery. all appeared to understand, discussion also centered around pt. wanting to be home if possible to die with hospice. agreed to wait for Dr. final word, family went home ~ 2200. full code at that time with continuing of full support with IV nipride, Beta blockage and pain management.\n\nnipride gtt started at at .2mcq/k/min, titrated up to 2.3mcq/k/min with goal SBP 110-120/. BP 120-150's/70's. HR 70's paced. pt. has been pain free all night. no c/o SOB. sats 93-95% on 3lnc.\n-----0400: pt. vomited large amt. of coffee grounds (~500cc). no nausea. BP 190/80. HR 70's. no c/o pain. pt. awake and alert.\n team aware. attempted NG lavage without success- pt. unable to tolerate. Dr. called and updated by resident. agreed to not attempt any further lavage for pt. comfort. frank discussion with pt. and resident about code status. agreed to DNR/DNI at this time.\nnipride d/c'd at 0445. all po meds d/c'd. lopressor po changed to IV PRN. stat HCT 32.\nalso started on prn morphine and ativan with IV GTT's if/when necessary. given total 2mg morphine ~ 0500. pt. able to sleep/doze.\npt. also seen by priest ~ 0500. He also was able to call and speak to son and wife. THey are headed to hospital at this time.\npt. appearing calm, denies pain/SOB. no further emesis.\n\nA: worsening aortic aneursym with new coffee grounds.\nDNR/DNI. morphine prn. family on their way in at 0500.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-20 00:00:00.000", "description": "Report", "row_id": 1356929, "text": "pt. was last seen awake at 0600- watching T.V. he was found at 0615 with aganal respirations. no pulse. pronounced by intern at 0620. Resident called wife - she is on her way.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-18 00:00:00.000", "description": "Report", "row_id": 1356924, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 70's BP 115-148/50-80 esmolol titrated up now at 300mcg/kg/min nipride off and now started po lopressor. BP still not consistently within range. mag 1.5 this am repleted with 2gms repeat 2.2\n\nResp: lungs clear,sats 96-98 on 3l np,has pain across chest sometimes with cough,prod clear\n\nID: Tmax 99.7 on linzolid,two sets of blood cultures sent as last set still positive. has hx of MRSA now on precautions WBC's increasing now 21.5(19.2)\n\nNeuro: alert and oriented x3\n\nGI: NPO all day until dinner ate fair amount. +BS\n\nGU: urine output 40-100/hr due to large amount of fluid with esmolol +2l BUN/Creat 37/2.2\n\nendocrine: FS 141-166 covered with SSI as ordered\n\nHeme: transfused third unit packed cells HCT before third unit .2 post 28.2\n\nSocial: wife called twice\n\nA/P: cont to titrate lopressor if possible wean off esmolol\n follow HCT's\n cont with abx\n follow FS and cover as needed\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-19 00:00:00.000", "description": "Report", "row_id": 1356925, "text": "CCU NPN 1900-0700\nS: \" I'm having trouble breathing \"\nO:\nID: TM 98.0 - 97.6po. contin. on linezolid IV for (+) BC GPC .\nCV: HR 70's paced. no VEA. BP aline 130-160/50's. ~ even to 20pts. lower than aline. aline very dampened at times.\ncontin. lopressor po 75mg q6hr- given at 12am. then gave additional 25mg at 0100. BP contin. unchanged. esmolol at 300mcq/k/min. decreased to 250mcq/k/min at 0400 for 130/. HO aware.\n\nRESP: pt. on 3lnc with sats 95%. LS with scatt. wheezes initially- had episode of SOB ~ 2200- LS with change : I/E wheezes throughout. sat up in bed and given atrovent neb with good relief. also had CXR to assess pseudoaneursym. pt. felt better and resting comf. HE still has mild to mod. voice hoarseness which is concerning per HO for possible impingement of laryngeal nerve by AA\n0300: pt. awake again, called RN to state he was SOB. sats 95% on 3lnc. LS with crackles at bases with faint. exp. wheezes. sat up, given atrovent neb and 20mg Iv lasix. pt. verbalized relief with neb.\n\nPt. is NPO for CT in AM to assess AA. he has remained comfortable since last episode. he was started on IVF at 100cc/hr pre CT but was d/c'd with SOB.\n\nGU: foley draining only 20-50cc/hr , (+) 2L LOS. 140cc first hour following lasix.\nGI: NPO for Chest CT today. no stool. abd flat, NT.\nneuro: A/O x3. more talkative tonight. denies pain. MAE.\n\naccess: right radial aline. PIV x2 on left.\nA: 77yo male with new small ascending aortic pseudoaneursym, contained rupture. s/p total 3UPRBC since admit with stable HCT. also with elevated WBC, (+) BC started on linizolid.\nBP contin. elevated - req. esmolol gtt. started on po betablocker . now s/p 2 episodes of SOB with new crackles rx with lasix.\nNPO for CT today.\nalso with new voice hoarseness concerning for laryngeal nerve.\nP: follow lytes, HCT. plan CT (A?) today. NPO. contin. esmolol gtt, lopressor, ? start ACE today.\nfollow sats, Lung exam for change. follow u/o for responce to lasix.\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-19 00:00:00.000", "description": "Report", "row_id": 1356926, "text": "Respiratory Care:\nPatient received two RX of 0.5 mg ipratropium bromide, as noted in CareVue for relief of dyspnea.\n" }, { "category": "Nursing/other", "chartdate": "2139-02-19 00:00:00.000", "description": "Report", "row_id": 1356927, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 70's BP 120-145/54-60 esmolol d/ced 9am. lopressor now at 100mg qid,hydralazine 10mg IV q6 added. hoarsness which was first noticed yesterday afternoon unchanged but now has difficulty swallowing pills. concern that aneursym could be worse,repeat chest CT done- aneursym bigger with leak and new left pleural effussion.\n\nResp: lungs clear did have exp wheezes left base this am. on 3l NP with sats 96-98,productive cough thick yellow secretions. no episodes of SOB today\n\nID: afebrile,tmax 98.9,remains on linezolid. WBC 26.2 up from yesterday.ID team now in examining pt\n\nGU: BUN/Creat 33/2.1 urine output 30-150/hr +150 for day,+2l LOS\n\nGI: has been NPO all day for possible TEE,now NPO for possible surgery\n\nEndocrine: FS 143-142 no insulin required\n\nNeuro: alert and oriented x3\n\nSocial: wife in to visit with two sons earlier today,family is returning this evening. Dr spoke with pt and explained that he would die without surgery. Dr to come and see pt this evening.\n\nA/P: worsening aneursym with leak and new left pleural effusion\n continue to medically manage and await surgery consult\n emotional support pt and family\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2139-02-18 00:00:00.000", "description": "Report", "row_id": 1356923, "text": "CCU NPN 1900-0700\nO: 77 yo male with hx HTN, MI admitted for rx of small ascending aortic pseudoaneurysm and elevated WBC. started on esmolol and nipride in EW.\n\nArrived to CCU ~ 2230 , awake, alert and oriented.\nHR 70's vpaced. SBP goal per resident <110. Since admit, BP 90's-120/30's , esmolol gtt at 85mcq/k/min, nipride gtt currently at 2mcq/k/min. right radial aline very positional with freq. dampened waveform, labile BP\npt. denies chest/back pain. lytes WNL from last draw in EW. AM labs pnd at 0400.\n- pt. also contin. on po norvasc and amio, due in AM.\n- MD note: nl cath in ' with EF ~40%\nID: TM 99.5po. tylenol x2. last WBC 18.2. AM pnd.\nreceived first dose of linezolid IV at MN. pt. with (+) BC GPC.\ns/p allergic reaction to vanco in EW (~ ) which was rx with IV benadryl. on admit, pt. with no further hives or redness , however c/o mild chills/shaking. given tylenol/benadry with good effect.\n\nResp: sats 94-97% on 3lnc. RR 20's. denies SOB. LS diminished.\nGU: foley draining 30-40cc/hr. mucumist x2 more doses (s/p CTA)\nGI: diet order changed to clear liqs. sips of apple juice with meds.\nABD soft, NT.\n\nheme: first of 2 UPRBC up at 0100 for HCT 25.(drawn in EW). AM HCT pnd at 0400. no stool.\n\nA: good control with esmolol/nipride despite dampened, labile aline.\n no further pain.\n tol. IVAB well with no sign of reaction.\n (+) BC- no vegetation per TEE\nP: follow HCT's per team. complete total 2UPRBC. follow lytes. monitor u/o. goal SBP <110. ? increase po meds and wean IV meds. mucomyst x one more dose today.\nSSRI.\nfamily support.\n" }, { "category": "ECG", "chartdate": "2139-02-16 00:00:00.000", "description": "Report", "row_id": 193004, "text": "A-V sequential pacing, rate 68. Probable fusion beats between spontaneously\nconducted and paced ventricular complexes with underlying right bundle-branch\nblock and possible old inferior myocardial infarction and/or anterior\nmyocardial infarction.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2165-06-23 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 764054, "text": " 3:48 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Contrast: OPTIRAY Amt: 140\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT EXT CAROTID BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: This is a 38 year-old male who was finished with coitus when\n he developed a back headache. He took two aspirin and went to bed. When he did\n not feel better he went to Hospital. At , CT scan demonstrated\n interventricular hemorrhage. Patient is transferred to for angiographic evaluation and possible therapy.\n\n PROCEDURE: The risks, benefits, and alternatives to the procedure were\n explained in detail to the paient who understood and signed the consent form.\n\n The patient is brought to the Neurointerventional Suite and placed supine on\n the table. The patient is evaluated with help of MAC anesthesia.\n\n Right groin is prepped and draped in the usual sterile fashion. Using standard\n Seldinger technique a 4 Fr arterial sheath was placed.\n\n Suspecting a potential posterior circulation problem the left vertebral artery\n is cathterized. AP , AP lateral, and lateral oblique\n projections are obtained. Rotational arteriography is obtained with 3D\n postprocessing. This demonstrates essentially codominant vertebral arteries.\n There is no evidence of dissecting aneurysm of the distal intradural\n vertebral. There is a massive right pica developed from the proximal basilar.\n Distally, in an inferior vermian branch there is an inferiorly directed\n outpouching of the vessel suggesting a pseudoaneurysm. It is wide necked. A\n small branch is seen to arise immediately proximally directed superiorly.\n\n The right vertebral is selectively cathterized and demonstrates the same\n finding. This small, 2 mm pseudoaneurysm is seen on all AP, lateral and\n lateral oblique images.\n\n The right internal carotid artery is catheterized, examined in AP, lateral and\n rotational projections. There is no evidence of aneurysm, parenchymal phase is\n unremarkable. Patient has an excellent anterior communicator and posterior\n communicator. Parenchymal phase is unremarkable. Venous drainage is to\n bilateral patent transverse sinuses.\n\n The external carotid artery is catheterized. AP and lateral images demonstrate\n no evidence of dural AV fistula.\n\n (Over)\n\n 3:48 PM\n CAROT/CEREB Clip # \n Reason: SAH\n Contrast: OPTIRAY Amt: 140\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The left internal carotid artery is catheterized. AP lateral examination as\n well as rotational arteriography demonstrates no evidence of aneurysm. The\n cervical, petrous, cavernous and supraclinoid artery are unremarkable.\n Parenchymal portal venous phase is unremarkable.\n\n The left external carotid artery is catheterized. AP and lateral examination\n centered over the head demonstrates no evidence of dural AV fistula.\n\n At the termination of the procedure the sheath is removed and adequate\n hemostasis is achieved with twelve minutes of manual compression. A Syvek\n patch was utilized. There was no hematoma. There are no complications.\n\n IMPRESSION: Pseudoaneurysm directed from distal posterior-inferior cerebellar\n artery on right. This was discussed with Dr. and Dr. . And this\n patient will undergo open repair.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2165-06-23 00:00:00.000", "description": "CT EMERGENCY HEAD W/O CONTRAST", "row_id": 764047, "text": " 2:05 PM\n CT EMERGENCY HEAD W/O CONTRAST; CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: Transfer, known 3rd ventricle bleed, assess for progress.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with above.\n REASON FOR THIS EXAMINATION:\n Transfer, known 3rd ventricle bleed, assess for progress.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transfer from outside hospital with blood in the third ventricle,\n assess for progression.\n\n TECHNIQUE: Standard non-contrast head CT.\n\n COMPARISON: Outside CT scan from Hospital from . These will\n be digitized as soon as possible.\n\n FINDINGS: There is high attenuation material within the fourth ventricle\n consistent with an intraventricular hemorrhage. On the outside scan, there is\n also high-attenuation material noted in the third ventricle and the occipital\n horns of the lateral ventricle on the right. This is not present on the\n current exam. There is a hazy appearance to the interpeduncular cistern but\n no frank hemorrhage is noted. No subarachnoid or extraaxial hemorrhage is\n noted. There is no shift of normally midline structures or mass effect. The\n temporal horns of the lateral ventricles are visualized. This may represent\n mild hydrocephalus in a young patient. There is no definite effacement of the\n sulci. There is no major vascular territorial infarction. The orbits and\n paranasal sinuses are within normal limits. There is no evidence of skull\n fracture.\n\n IMPRESSION: Intraventricular hemorrhage within the fourth ventricle. No\n definite subarachnoid hemorrhage or extraaxial hemorrhage noted. Mild\n hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2165-06-28 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 764406, "text": " 8:54 AM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING\n Contrast: OPTIRAY Amt: 150\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM EXT UNILAT A-GRAM *\n * -52 REDUCED SERVICES IV CONSCIOUTIOUS SEDATION PRO *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Distal PICA aneurysm status post surgical clipping.\n\n POSTOPERATIVE DIAGNOSIS: Clipped aneurysm with no evidence of residual filling\n and no evidence of branch occlusion.\n\n INDICATION: This patient suffered a subarachnoid hemorrhage and was found to\n a distal aneurysm of the prominent right ICA PICA vessel in the\n position of the PICA artery. This aneurysm was noted to be present at the\n bifurcation and although an endovascular approach could have been chosen this\n would have resulted in a parent vessel sacrifice and as a result the decision\n was made to procede with operative surgical clipping. The patient returns now\n for angiography to determine how well the aneurysm has been surgically\n isolated from circulation. The patient and his significant other were given a\n full and complete explanation of the procedure including the risks, benefits\n and possible complications which include but are not limited to stroke,\n infection, death, as well as other unforeseen complications. They understood\n and wished to procede with the operation.\n\n ANESTHESIA: By conscious sedation using divided doses of Versed and Fentanyl\n during the entirety of the procedure with hemodynamic monitoring supervised by\n the operator.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion and a 5 Fr vascular sheathn\n was placed into the right common femoral artery. Through this sheath which was\n kept on a heparinized saline flush, a 5 Fr Barenstein catheter was used to\n selectively catheterize the right common carotid artery, followed by the right\n subclavian artery, followed by the right vertebral artery, followed by the\n right internal carotid artery, followed by the left common carotid artery,\n followed by the left internal carotid artery. The catheter was then withdrawn\n from the patient and the vascular sheath was removed with manual compression\n to achive hemostasis.\n\n RESULTS: Injection of the right common carotid artery and of the left common\n carotid artery reveals no evidence of stenosis or dissection with no evidence\n of intimal irregularity in the cervical region of these arteries. Injection of\n the right subclavian artery reveals a smooth origin of the right vertebral\n artery and injection of the right vertebral artery reveals a dominant vessel\n on the right vertebral artery along with a very prominent right-sided ICA PICA\n (Over)\n\n 8:54 AM\n CAROT/CEREB Clip # \n Reason: S/P CLIPPING\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n which crosses the midline in its distal portion. It is at this point that it\n harbors an aneurysm at the bifurcation of this vessel which has been clipped\n successfully compared to the preoperative angiogram and there is no evidence\n of residual filling and there is no evidence of parent vessel occlusion or\n compromise of the branch point. Injection of the right internal carotid artery\n reveals a prominent fetal-type posterior cerebral artery with no evidence of\n stenosis or dissection and no intracranial aneurysm. There is no significant\n evidence of vasospasm angiographically. Injection of the left internal carotid\n artery reveals a prominent posterior communicating artery with no evidence of\n proximal vasospasm.\n\n IMPRESSION: Clipped aneurysm of distal PICA present in the midline with no\n evidence of residual or parent vessel occlusion and no evidence of significant\n intracranial vasospasm of the carotid arteries.\n\n\n\n\n\n" }, { "category": "ECG", "chartdate": "2165-06-24 00:00:00.000", "description": "Report", "row_id": 123269, "text": "Sinus rhythm\nNormal ECG\nNo previous report available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2165-06-24 00:00:00.000", "description": "Report", "row_id": 1470412, "text": "NEURO; A&Ox3, SPEECH CLEAR, MAE, FOLLOWS COMMANDS, EOM'S INTACT, NO PRONATOR DRIFT DETECTED, SHORT-TERM MEMORY DEFICIT NOTED OCCASIONALLY AND PT REQUIRES REPEAT EXPLANATIONS, MEDIC X 1 FOR NAUSEA WITH EFFECT,\nAPPARENTLY NOT ABLE TO COIL IN ANGIO\nCARDIOVASCULAR; EXTREMITIES WARM, PEDAL AND PT PULSES EASILY PALPABLE, BILAT GROIN PULSES PALPABLE, RT FEMORAL SITE C/D/NO OOZING OR HEMATOMA, TEMP 99.2-99.3\n\nRESPIR; LUNGS CLEAR, N/C AT 2L/MIN, 02 SAT 100%\n\nGI; ABD SOFT, PT TAKING SIPS WITH PO MEDS ONLY,\n\nRENAL; VOIDED LARGE AMT CLEAR YELLOW URINE X 1, DOES NOT WANT A FOLEY CATHETER\n\nPLAN; EVALUATE FOR ? O.R. FOR ANEURYSM CLIPPING, KEEP SYS BP < 130 PER NEURO TEAM\n" }, { "category": "Nursing/other", "chartdate": "2165-06-24 00:00:00.000", "description": "Report", "row_id": 1470413, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3. PERRL. MAE. NORMAL, EQUAL STRENGTH. NO NEURO DEFICITS NOTED. DR. IN TO SEE PT. LIKELY TO OR TOMORROW.\n\nCV-AFEBRILE. HRR. ALINE INSERTED. NIPRIDE GTT STARTED AND TITRATED TO KEEP SBP <130. SKIN W+D. +PP. DENIES CARDIAC COMPAINTS. ANGIO SITE C/D/I. NO S/S HEMATOMA NOTED.\n\nRESP-O2 SAT 98% RA. LS CTA. NARD NOTED.\n\nGI-NPO. ABD SOFT, NT/ND. +BS. ZOFRAN PRN FOR C/O NAUSEA WITH + EFFECT. NO VOMITING NOTED.\n\nGU-VOIDING SPONT ADEQ AMTS CL YELLOW URINE.\n\nCOMFORT-MSO4 PRN FOR C/O HA WITH + EFFECT.\n\nPLAN-CON'T WITH CURRENT PLAN. NEURO CHECKS. KEEP SBP <130. MONITOR FOR CHANGES. LIKELY TO OR TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-25 00:00:00.000", "description": "Report", "row_id": 1470414, "text": "preop note\nD: PT NPO AFTER MIDNIGHT. MEDICATED X 3 WITH MORPHINE WITH RELIEF. NEURO SIGNS ARE INTACT. PUPILS ARE EQUAL AND REACTIVE TO LIGHT. HE HAS NORMAL STRENGTH IN ALL EXTREMITIES. NO DRIFT NOTED. PT REMAINS ON NIPRIDE AT .5MCGS/KG/MIN. PREOP COAGS DRAWN AND INR IS 1.4.\nA: PT TRANSFUSED WITH 2 UNITS OF FFP. REPEAT LABS SENT AFTER TRANSFUSIONS COMPLETE.\nR: NO REACTION TO FFP. MORPHINE IS EFFECTIVE IN CONTROLLING PAIN. NEURO SIGNS ARE INTACT. PT STATES HE HAS NO QUESTIONS ABOUT UPCOMING ;PROCEDURE. CONSENTS SIGNED AND IN CHART. READY FOR OR THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-25 00:00:00.000", "description": "Report", "row_id": 1470415, "text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT A+OX3. MAE. NORMAL EQUAL STRENGTH. PERRL. NO NEURO DEFICITS NOTED. MSO4 X 1 FOR C/O HA. CON'T ON NIPRIDE GTT TO KEEP SBP <130. NPO. FAMILY PRESENT THIS AM. PT TO OR AT 7:45 AM ACCOMPANIED BY ANESTHESIA.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-27 00:00:00.000", "description": "Report", "row_id": 1470420, "text": "CONDITION UPDATE:\nD/A: T MAX 100.8\n\nNEURO: REMAINS UNCHANGED, A+OX3, MAE, SPEECH CLEAR. VENT DRAIN REMAINS @ 10 ABOVE THE TRAGUS, ICP ~ , CPP > 70. HOB ELEVATED TO 45 DEGREES WITHOUT HA OR INCREASED PAIN.\n\nCV: HR 70'S-80'S NSR, GOAL ABP < 150 CHANGED TO < 160 PER DR. , MET WITH NIPRIDE GTT, CURRENTLY @ .5 MCG/KG/MIN. + PPP BILAT. SQ HEPARIN ORDERED TODAY. PT , PT IS - ~ 360CC SINCE MN.\n\nRESP: LS CLEAR, O2 SAT 100% ON 2 L/M NC. IS ENCOURAGED.\n\nGI: TOLERATED SMALL AMOUNTS OF REG DIET, TAKING LIQUIDS PO.\n\nGU: FOLEY TO BSD WITH > 100CC/HOUR OUT.\n\nR: NEURO STATUS INTACT, VENT DRAIN FUNCTIONING WELL\n\nP: ANGIO TOMORROW. CONTINUE TO TITRATE NIPRIDE GTT TO KEEP SBP <160. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-28 00:00:00.000", "description": "Report", "row_id": 1470421, "text": "NSG PROGRESS NOTE\nNEURO- A+O X3, MAE, PEARL. BP GOAL PR NEURO- 150-160- NIPRIDE OFF AND NOW RECEIVING 500 CC 0.9 BOLUS PRN IF SBP < 150. UP 350-400 HR. MAINTAINENCE IVF INC TO 200HR. CONT 15O MG DILANTIN PO Q8. NIMODIPINE 2TABS Q4 AND TAPER DOSE DECADRON. TO ANGIO THIS AM HAS BEEN NPO X SIPS WITH MEDS SINCE MIDNIGHT.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-28 00:00:00.000", "description": "Report", "row_id": 1470422, "text": "STATUS UPDATE\nD: PT ALERT AND ORIENTED X3. NEURO SIGNS STABLE DENIED HA THIS AM.\nVENT DRAIN LEVELED TO 10CMS ABOVE TRAGUS AND DRNG MOD AMTS BLD TINGED.\nICP 10-14 PT WENT TO ANGIO THIS AFTERNOON AND RETURNED C/O SEVERE HA\nNEURO SIGNS STABLE. R GROIN SITE D+I NO SIGNS OF BLEEDING OR HEMATOMA NOTED. VENT DRAIN PATENT HYPERTENSIVE 170'S HR 59-65\nC/O NAUSEA AFTER TAKING HIS MEDS. IV'S REMAIN AT 200CC/HR HUO ^500-700CC WITH CURRENT I/O -1500CC\nA: MEDICATED WITH MS X2 IV AND REPOSTIONED WITH BACKRUB DUE TO PAIN MEDICATED WITH ZOFRAN FOR NAUSEA STARTED NIPRIDE GTT TO MAINTAIN BP BETWEEN 150-160 DR NOTIFIED OF CURRENT I/O BALANCE AND TO MONITOR FOR NOW. MONITORED R FEM ANGIO SITE\nR: CONTINUES TO HAVE A HEADACHE NAUSEA RESOLVED AFTER ZOFRAN. BP IMPROVED 150'S CURRENTLY ON .6MCG/KG OF NIPRIDE\nPLAN: WEAN NIPRIDE AS TOL KEEPING SBP <160 > 150 CONTINUE TO MONITOR FOR SIGNS OF VASOSPASM TO REEVAL MEDICATION FOR HEADACHE\nPT ^HOB AFTER 19:30\n" }, { "category": "Nursing/other", "chartdate": "2165-06-29 00:00:00.000", "description": "Report", "row_id": 1470423, "text": "NEURO STATUS\nPT ALERT AND ORIENTED X3. PUPILS ARE EQUAL AND REACITVE TO LIGHT. NO DRIFT NOTED. NORMAL STRENGTH IN ALL EXTREMITES. VENT AND DRIANIGE BLOOD TINGED CSF. ICP 7-11. PT C/O HEADACHE A START OF SHIFT. MEDICATED WITH 4MG OF MORPHINE IV. PT C/O NAUSEA AFTER MOPRHINE MEDICATION. NIPRIDE TITRATED FOR SBP OF 150-160.\nA: ZOFRAN FOR NAUSEA AFTER MORPHINE. NIPRIDE WEANED OFF FOR SBP < 150.\nR: MORPHINE EFFECTIVE IN RELIEVING PAIN. SBP STILL LESS THAN 150 AFTER NIPRIDE WEANED OFF.\nA: PT GIVEN 500CC OF NS FLUID BOLUS.\nR: SBP GREATER THAN 150. TEMP UP TO 101.6. NEURO SIGNS ARE UNCHANGED. PT SLEPT IN SHORT NAPS.\nA: CONTINUE WITH NEURO CHECKS. MEDICATE FOR PAIN AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-01 00:00:00.000", "description": "Report", "row_id": 1470427, "text": "7p-7a: Full assessment in flow sheet.\n\nPt slept on and off most of the night. Neurological intact. Clear speech. Follow commands. MAE - strong, equal. Tongue midline, equal smile, no arms drift. PERL - 3mm brisk. Pt c/o pain in neck , back of head - Morphine ivp given (1 to 2 mg depending on pain level) - relief stated. problem short and long distant. No nausea. Draining straw color drainage, 10 cm at tragus, site intact. +CSF (WBC 222) - d/c cefazoli, start - vancomycin and ceftazidime (no allergic reaction). CVP 5-10, CPP >80. problem swallowing. Calcium and potassium replace. Warm, dry, no edema. SBP 150-180 maintain (once drop to 125 when in deep sleep). Urine output >100 cc/hr. Temp max 101 - tylenol given. Encourage to deep breath and cough and use of spirometer when awake.\n\nPlan: neurological monitor (vasospasm), hemodynamic.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-01 00:00:00.000", "description": "Report", "row_id": 1470428, "text": "nsg note\nSEE CARVUE FOR SPECIFICS.\n\nNEURO-A+OX3. PERRL. MAE. NORMAL EQUAL STRENGTH. TONGUE MIDLINE. NO DRIFT. NO NEURO DEFICITS NOTED. VENT DRAIN RAISED TO 15 CM ABOVE TRAGUS, OPEN WITH SL BLOODTINGED DRG. ICP 9-12. PT C/O HA, PERCOCET WITH ADEQ STATED EFFECT.\n\nCV-AFEBRILE. HEMODYNAMICALLY STABLE. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 98% RA. LS CTA. USING IS WITH ENC. NARD NOTED.\n\nGI-ABD SOFT, NT/ND. +BS. TOL PO'S WITHOUT N/V.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-OOB TO CHAIR WITH 1 ASSIST. TOL WELL X SEVERAL HRS.\n\nPLAN-CON'T WITH CURRENT PLAN. NEURO CHECKS.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-02 00:00:00.000", "description": "Report", "row_id": 1470429, "text": "nsg progress note\npt c/o increase in headache pain this pm. vent drain at 20. (was at 10 increased to 15 am and 20 pm).pain not relieved with percocett. remaining a+o, pearl, equal strength all ext. neuro md notified. vent drain decrease to 15. 25 cc blood tinged out 2 hrs post change. cont c/o ha 2-3 hrs post drain change but currently reports pain level better and declining rx for ha. cont dilantin 300 mg po, ancef and vanco iv anbx, ivf 200hr.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-02 00:00:00.000", "description": "Report", "row_id": 1470430, "text": "nsg note\nSEE CARVUE FOR SPECIFICS.\n\nNEURO-PT REMAINS A+OX3. PERRL. MAE. NORMAL, EQUAL STRENGTH. TONGUE MIDLINE. NO DRIFT. NO NEURO DEFICITS NOTED. HAD HEAD CT THIS AM, UNCHANGED FROM PRIOR. VENT DRAIN WAS OPEN AT 15CM ABOVE TRAGUS THIS AM WITH BLOODTINGED DRG. DRAIN NOW CLAMPED. WILL MONITOR RESPONSE. ICP 9-15. PT C/O HA, IMPROVED WITH PERCOCET.\n\nCV-LOW GRADE TEMP. HEMODYNAMICALLY STABLE. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 98% RA. LS CTA. NARD NOTED.\n\nGI-ABD SOFTLY DISTENDED. +BS. +RF. PT C/O FEELING \"BLOATED\". DUCOLAX SUPP GIVEN. PT HAD LG SEMIFORMED BM. TOL PO'S. PT C/O INTERMITTENT NAUSEA, ZOFRAN WITH + EFFECT. NO EMESIS.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-OOB TO CHAIR. TOL WELL. MOVES I IN BED.\n\nPLAN-CON'T WITH CURRENT PLAN. VENT DRAIN CLAMPED. NEURO CHECKS.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-25 00:00:00.000", "description": "Report", "row_id": 1470416, "text": "SICU Nursing Progress Note 3p-7p\nNeuro-\nSedated on Propofol @ 80mcg/k/m, decreased to 60 mcg/k/m as patient warmed to 97.7 in preparation for extubation if possible tonight. Pupils 3mm/NR, no response to stimuli.\nVent drain open @ 10 mm @ tragus, drainage blood tinged. ICP 2-3.\nDilantin and Decadron given IV\nCV-\nSBP 122-154/ titrated on Nipride @ 1.5-2.3 mcg/kg/m. HR SR 70's.\nPeripheral pulses 3+ throughout. CVP 7-10.\nI/O- u/o 100-200/hr; NS w/20 KCl @ 100/hr.\nTemp- Warmed w/ Bair hugger until 1830 when 97.7 when removed, blankets remain in place.\nSocial- S.O. visited, status explained to her. She will return after dinner tonight.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-26 00:00:00.000", "description": "Report", "row_id": 1470417, "text": "7p-7a: Full assessment in flow sheet.\n\nPt slept on and off most of the night. Neurologically intact- MAE - strong bilaterally and follow commands. PERL - 3mm brisk. A+OX3. Garble speech. Good short and long term memory. No arms drift. equal smile. tongue midline. Rate pain in neck 5 (relief with morphine ivp X3 - rate 2). No headache - slight headache when bed elevated slightly to drink water and take pills. problem swallowing liquid or pill. Good gag and cough reflex. Extubated at - lung sound clear bilaterally, maintain RR -16-22, SaO2 96-100% (4l NC). soft abd, no pain on palpation, +BSX4. no BM. Foley patent - yellow/clear urine >30 cc/hr. Drain dressing intact - 10cm above tragus - blood tinge. Nipride drip titrate to SBP <150.\n\nPlan: Neurological and hemodynamic monitor.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-26 00:00:00.000", "description": "Report", "row_id": 1470418, "text": "CONDITION UPDATE:\nD/A: T MAX 100.8\n\nNEURO: NEURO STATUS INTACT. PT A+OX3, MAE STRENGHTS, PERL, SPEECH WITH ACCENT, CLEAR. NECK PAIN TX WITH MSO4 WITH GOOD EFFECT. VENT DRAIN @ 10 ABOVE THE TRAGUS, DRAINING SERO-SANG DRG ~249 CC SINCE MN. ICP ~5, CPP ~ 76-90. NECK DRESSING WITH SERO-SANG DRG, DRAIN WITH TRANSPARENT DSG INTACT.\n\nCV: HR 70'S NSR, GOAL SBP < 150 MET WITH TITRATION OF NIPRIDE GTT. CURRENTLY @ 1.5 MCG/KG/MIN. + PPP BILAT. X2 HL D/C'D. PT IS - ~362 CC SINCE MN.\n\nRESP: LS CLEAR, NO SOB, NO COUGH. 4 L/M NC. IS DONE WITH PT Q1-2 HOURS.\n\nGI: CLEAR LIQUIDS TOLERATED WELL. BM X 1. NO NAUSEA.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE, PT IS AUTO DIURESING.\n\nR: LOW GRADE TEMP, NEURO INTACT, NIPRIDE GTT.\n\nP: TITRATE/WEAN NIPRIDE GTT AS TOLERATED TO KEEP SBP < 150. CONTINUE TO MONITOR VENT DRAIN. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGMENT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2165-06-27 00:00:00.000", "description": "Report", "row_id": 1470419, "text": "7P-7A: Full assessement in flow sheet.\n\nPt slept most of the night. Neurological intact - Clear speech, apprioprate words and sentences. MAE - strong, bilaterally, squeeze hands and let go, lift arms without drift. Strong pulses bilaterally. Follow commands. Equal smile. midline tongue. PERL - 3mm brisk, good corneal reflex, good gag, good cough. Pain in neck and headache - rate 5, treated morphine ivp, decrease pain and resting comfortable - rate 2. Encourage use of Incentive Spirometry - 500-800. Finacee and brother from called - answer all questions. pt verbally. VSS, afebrile. Nipride titrate for SBP <150. Increase IVF to 150 (NS with 20 KCL) because of increase urine output >100 cc/hr. Soft abd, +BS X4, no BM. Ventricular sites intact - no drainage, no pain at site. Pt continue to be reminded of not touching sites.\n\nPlan: Continue to monitor neurological (vasospasm precaution) and hemodynamic monitor.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-29 00:00:00.000", "description": "Report", "row_id": 1470424, "text": "7a-7p update\ncv: hr nsr, no ectopy, sbp 148-159, continues off snp gtt, sbp > 160 ok per neuro team\n\nresp: on room air, sats 96-99, rr 16-18, no resp distress, bs+ all lobes & clear, encouraged to deep breath & cough, non-productive cough noted\n\ngi: dat tol well, no stool, short episode of mild nausea, resolved on own\n\ngu: foley cath patent, lg uo, uo clear, ua/cs sent due to temp spike\n\nneuro: intact, see flowsheet, ventricular drain draining well\n\nplan: continue with q 2 hr neuro/vs\n" }, { "category": "Nursing/other", "chartdate": "2165-06-30 00:00:00.000", "description": "Report", "row_id": 1470425, "text": "7P-7A: Full assessment in flow sheet.\n\nNeurologically intact. Slept most of the night. Follow all commands. A+OX3. Easily awaken and return to sleep. Good short term and long term memory. Clear speech. MAE - strong bilaterally. No arms drift. Able to bring cup to mouth. problem swallowing. Neck pain relief with hot pack and morphine X2 ivp. General pain - Percocet (2) po given - relief stated per pt. Awaken at 0100 with nausea from activities of turning - no vomit, zofran ivp given - pt state relief and return to sleep. Drain site intact, 10 cm above tragus, red tinge drainage. Suture sites intact. Temp max 101.2. Warm, dry, no edema. HR - NSR. SBP 110-170 depending on level of activities. Lung sound clear in upper lobes and dimish at bases. SaO2 - 96-100% at Room air. Soft abd, +BSX4. No bm. Foley patent - diuresis 160-500 cc/hr. IVF of NS with 20 KCL given and pt drinking well. Blood glucose cover by sliding scale.\n\nPlan: Neurological monitor. AM lab done.\n" }, { "category": "Nursing/other", "chartdate": "2165-06-30 00:00:00.000", "description": "Report", "row_id": 1470426, "text": "CONDITION UPDATE:\nD/A:\n\nNEURO: REMAINS UNCHANGED. PT IS NEUROLOGICALLY INTACT, PLEASE SEE CAREVIEW FOR Q2 HOUR ASSESSMENTS. PAIN WELL CONTROLLED WITH MSO4 PRN. OOB TO CHAIR TODAY, PT TOLERATED WELL. VENTRICULAR DRAIN @ 10 ABOVE TRAGUS, DRAINAGE IS CLEARING TO A STRAW COLOR AND OUTPUT IS DECREASING (167 CC SINCE MN). ICP 3-7, CPP > 87.\n\nCV: HR 60'S-80'S NSR, ABP 143-165/70'S-80'S. PA, SBP PARAMETERS > 150-160 < 180-200. CVP 3-6. FLUID BALANCE + ~ 700 CC SINCE MN. IVF CONTINUES @ 200CC/HR.\n\nRESP: LS CLEAR, NO SOB, NO COUGH. O2 SATS ~ 99% ON ROOM AIR.\n\nGI: TOLERATED REGULAR DIET WITH HOME COOKED FOOD FROM WIFE. NAUSEA X1 TX WITH ZOFRAN WITH GOOD EFFECT.\n\nGU: FOLEY-BSD > 80CC/HR.\n\nID: T MAX 101.6, DR. AWARE. DLCL CHANGED OVER A WIRE TO A TLCL, TIP SENT FOR CX. ALL OTHER CX RESULTS PENDING FROM .\n\nR: FEBRILE, NEURO STATUS INTACT, DRAIN FUNCTIONING WELL.\n\nP: CONTINUE WITH CURRENT MANAGEMENT AND CLOSE MONITORING.\n" }, { "category": "Nursing/other", "chartdate": "2165-07-03 00:00:00.000", "description": "Report", "row_id": 1470431, "text": "7p-7a: Full assessment in flow sheet.\n\nneuro: A+OX3. MAE - strong bilaterally. Good gag and cough reflex. Follow commmands. Clear speech. No arms drift. Equal smile. Tongue midline. Pain (headache and eyebrow areas) - Percocet or morphine given - good effect (decrease pain). Drain clamped - pt tolerated, drain site intact. problem swallowing. Ate soup - fish chowder - wife bought from home without difficulty.\n\ncv: VSS. Temp max - 100.4. Warm, dry, no edema.\n\nresp: lung sound clear to dimish at bases. Encourage use of IS () and chest Pt done. Room air - 97-100%.\n\ngu/gi: Soft abd. +BSX4. no pain on palpation. foley patent - clear yellow urine >100 cc/hr.\n\nint: skin intact.\n\nBlood glucose cover with insulin scale.\n\nPlan: Neuro and hemodymic monitor. AM Lab. Poss d/c drain AM.\n" } ]

[ { "category": "Respiratory ", "chartdate": "2114-08-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 415988, "text": "Lung sounds\n RLL Lung Sounds: Insp/Exp Wheeze\n RUL Lung Sounds: Ins/Exp Wheeze\n LUL Lung Sounds: Ins/Exp Wheeze\n LLL Lung Sounds: Ins/Exp Wheeze\n Comments:\n Plan\n Pt is a 32yo female with Asthma. Pt received from ER on 100%\n Non-rebreather. Pt had been on continuous nebs in ER. Pt placed back\n on neb upon arrival\n dose 2.5mg/hour. BS diminished with expiratory\n wheezes throughout. ABG\ns reveal a mild respiratory acidosis. Dose of\n continuous nebs increased to 10mg/hour. BS now have improved aeration,\n but expiratory wheezes persist. Pt has a slightly congested\n non-productive cough at this time. Plan to continue with nebs at this\n time and monitor ABG\ns closely.\n" }, { "category": "Nursing", "chartdate": "2114-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415992, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n" }, { "category": "Nursing", "chartdate": "2114-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 415995, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Insp/Exp wheezes, SOB, DOE, labored breathing. ABG with PaO2 66(91, 70)\n while on continuous albuterol nebs but pt noted to be taking mask\n on/off.\n Action:\n 4L NC added to continuous albuterol nebs so that pt will have O2 even\n if removing mask.\n Response:\n Plan:\n Headache\n Assessment:\n C/O headache x several hours not relieved by 1gm Tylenol. Headache\n with no associated meningococcal signs/symptoms.\n Action:\n Given 1 fiorocet.\n Response:\n Pain level decreased to and HA verbalized as tolerable.\n Plan:\n Continue to monitor for HA. Monitor for acute changes in LOC as HA\n could be sign of hypoxia.\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416062, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Cont with exp/insp wheezing. Received on cont neb. Last ABG 7.36/43/79.\n off mask pt desat to 88-89% on 4l NC. Cont cough. After cough c/o of\n pain under her breasts\n Action:\n Start Atroven neb. D./ced cont neb around 0300.placed on cool neb 50%.\n Start guaifenesin\n Response:\n Sat remains 94%\n Plan:\n Cont nebs-puffs tx, wean continuous neb\n Headache\n Assessment:\n Cont c/o of HA moderate to severe\n Action:\n Given fioroset 2tab q4hr. also given valium 10mg po\n Response:\n Some response after meds\n Plan:\n Cont follow HA, cont pain meds, ?restart Valium\n Around 0400 pt c/o of sharp chest pain, ECG doneX2,shown some T waves\n , MD aware,cardiac enzymes sent. Pain stopped w/o any\n intervention.\n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 416172, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and periferal\n 24H ICU events: SaO2 90s on continuous nebs, solumedrol, magnesium, no\n heliox, no abx. Blood gasses demonstrate persistent hypoxemia,\n hyperbarbia.\n Blood cultures gpc pairs and chains in bottles\n 330 am L sided chest pain, rapidly resolved,different than her usual\n pain, ekg obtained at that time demonstrated new TWI V2-V4 that\n resolved, now getting ROMI.\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n valium 10 mg\n celexa 40 mg po daily\n Advair\n omeprazole 40 mg\n HCTZ 25 qday\n Heparin 5000 TID\n RISS\n PRed 80 q 8\n atrovent\n albuterol\n fioricet\n guafenesin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 96 (79 - 105) bpm\n BP: 118/66(82) {107/55(73) - 143/130(137)} mmHg\n RR: 17 (16 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 296 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 296 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 90%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n General: obese, well-appearing, speaking in full sentences, occasional\n cough, no accessory muscles\n HEENT: PERRL, EOMI\n NECK: supple\n CV: S1/S2 distant, R\n CHEST: distant, prolonged exp phase, insp/exp wheeze\n ABD: obese, soft, nt\n Ext: wwp, no c/c/e\n Peripheral Vascular: (Right radial pulse: 1+), (Left radial pulse: 1+),\n (Right DP pulse: 1+), (Left DP pulse: 1+)\n Skin: cool, dry\n Neurologic: conversant, alert and oriented x 3, cn 2-12 grossly intact,\n no focal abnormalities\n Labs / Radiology\n 13.2 g/dL\n 303 K/uL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR low lung volumesd improved from , improved patch\n opacity RNL\n Microbiology: urine legionella neg\n blood cx gpc pairs and chains 1/2 bottles\n ECG: nsr\n Assessment and Plan\n 32 yo F smoker h.o crohns, now with asthma exacerbation\n 1. Asthma exacterbation:\n exam with persistent insp/exp wheeze, speaking in full sentences\n - will decrease solumedrol to 80 with plan to taper to pred 60\n tomorrow if continued improvement\n - was on continuous nebs - will change to PRN nebs and monitor needs\n - given persistent cough, low grade temps, and slower improvement,\n will start azithro for empiric atypical mycobacterial coverage,\n although likely viral infection\n 2. Chest pain with EKG changes: likey RH strain in setting of flare\n - PE ct was negative for central PE\n - ruling out, cont cycle enzymes and monitor ekgs\n 3. + blood culture: likely contaminant, but has had lines in place\n - will cont empiric vanc coverage, await speciation\n 4. Hyperglycemia:\n - cont RISS esp while on steroids\n 5. Anxiety:\n - previously on high dose valium, but concern for respiratory\n depression\n - ativan as needed for anxiety\n 6. Crohns: stable\n ICU Care\n Nutrition:\n Comments: had been npo for ? urgent intubation, but improving so will\n advance to clears\n Glycemic Control:\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: not intubated\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: full code\n Disposition : ICU\n Total time spent: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with Dr.\n for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points\n 32 yo female with obesity, asthma admitted with status asthmaticus with\n recent sick contact (son). Overnight she was treated with continuous\n nebs with slight improvement today. Afebrile, conversant in full\n sentences with no accessory muscle use. O2 sats 93% RA. Lungs with fair\n air movement, diffuse insp and exp wheezes. HR mildly tachycardic, no\n murmurs. Abdomen obese, soft +bs. Ext no edema.\n No worsening with status asthmaticus though she remains mildly hypoxic\n with high nebulizer requirement. Will attempt to wean down neb\n frequency as tolerated, and continue steroids. Azithromycin added for\n possible atypical infection. Plans otherwise as per above.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:27 ------\n" }, { "category": "Nursing", "chartdate": "2114-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 416340, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Headache\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 416343, "text": "37 yo F with Crohn's s/p resection,.asthma presents with severe asthma\n exacerbation\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP, was R/O\nd VS stable\n Action:\n Monitor VS\n Response:\n Stable no CP\n Plan:\n Contine to assess for CP and monitor VS\n Asthma\n Assessment:\n Rec\nd on 35% cool face mask with O2 sats 92-96%, L/S wheezes bilat,\n does desat with activity, A-line taken out no new ABG\ns has productive\n cough.\n Action:\n Rec\ning respir treatments q2-3hrs per RT, IV steroids to change to PO\n tomorrow, had rec\n IV dose Soulmedrol today.Started on Singular PO.\n Response:\n Still wheezy with activity intolerance. On PO and IV antibx\n Plan:\n Continue with respire treatments, assess O2 sats, continue antibx\n Ineffective Coping\n Assessment:\n Very anxious, requesting Ativan, c/o\ning HA.\n Action:\n Rec\nd Ativan 2mg PO and Pain med\n Response:\n Mild response\n Plan:\n Assess anxiety and continue Ativan as needed, does take Valium @ home.\n Also Request to see a Social Worker for personal issues.\n Headache\n Assessment:\n States has constant HA\n Action:\n Rec\nd Fioricet 2 tabs.\n Response:\n Stated pain had subsided\n Plan:\n Continue with Fiorcet as needed.\n" }, { "category": "Nursing", "chartdate": "2114-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 416344, "text": "37 yo F with Crohn's s/p resection,.asthma presents with severe asthma\n exacerbation\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n No CP, was R/O\nd VS stable\n Action:\n Monitor VS\n Response:\n Stable no CP\n Plan:\n Contine to assess for CP and monitor VS\n Asthma\n Assessment:\n Rec\nd on 35% cool face mask with O2 sats 92-96%, L/S wheezes bilat,\n does desat with activity, A-line taken out no new ABG\ns has productive\n cough.\n Action:\n Rec\ning respir treatments q2-3hrs per RT, IV steroids to change to PO\n tomorrow, had rec\n IV dose Soulmedrol today.Started on Singular PO.\n Response:\n Still wheezy with activity intolerance. On PO and IV antibx\n Plan:\n Continue with respire treatments, assess O2 sats, continue antibx\n Ineffective Coping\n Assessment:\n Very anxious, requesting Ativan, c/o\ning HA.\n Action:\n Rec\nd Ativan 2mg PO and Pain med\n Response:\n Mild response\n Plan:\n Assess anxiety and continue Ativan as needed, does take Valium @ home.\n Also Request to see a Social Worker for personal issues.\n Headache\n Assessment:\n States has constant HA\n Action:\n Rec\nd Fioricet 2 tabs.\n Response:\n Stated pain had subsided\n Plan:\n Continue with Fiorcet as needed.\n" }, { "category": "Respiratory ", "chartdate": "2114-09-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 416246, "text": "Pt admitted status asthmaticus. BS wheezes tx with albuterol nebulizer\n given by RN. Pt switched from cool aerosol to nasal cannula throughout\n the night. States nasal canula makes her nose too dry. Tolerates the\n cool aerosol. Weaned FIO2 from 50% throughout the night pt maintained\n sats 96-98%.\n" }, { "category": "Nursing", "chartdate": "2114-09-02 00:00:00.000", "description": "Nursing 1900-0700", "row_id": 416238, "text": "Ineffective Coping\n Assessment:\n Pt expressed her frustration and lack of support surrounding the care\n of her children and ineffective coping. Pt states,\nThere is no one\n that I can really talk to because I do not have family around.\nI can\n not sleep cause all I think about are my kids.\n Action:\n HO was made aware, Nursing spent time with pt allowing her to vent her\n frustration and concerns regarding her care and family difficulties. SW\n consult placed.\n Response:\n Waiting for response from pt and SW consult.\n Plan:\n SW to see pt. Allow pt to vent her feelings and concerns\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt continues to c/o mild chest discomfort mostly after pt has coughing\n event.\n Action:\n PT was given nebulizer treatment. Last levels of cardiac enzymes were\n negative.\n Response:\n ECG obtained in AM.\n Plan:\n Continue to monitor ECG and cardiac enzymes PRN if recurrent chest pain\n as night prior.\n Asthma\n Assessment:\n Assumed care of pt on 4L NC, pt with expiratory wheezes in all fields.\n Pt has had no c/o SOB or DOE. Pt with episodes of prolonged coughing\n spells.\n Action:\n ABG obtained on 4L NC. Pt given nebulizer treatment of albuterol and\n inhalers per . Pt was changed from 4L NC to cool air aerosol 0.35%,\n 15L. Sputum culture sent.\n Response:\n ABG on 4 L 7.42/40/73. SpO2 on cool air aerosol 94-96%. Pt with notable\n decrease in wheezes after treatment.\n Plan:\n Continue to titrate O2 requirements, monitor ABG\ns, nebulizer\n treatments PRN.\n Headache\n Assessment:\n Pt c/o of having a HA of .\n Action:\n Pt given fioricet PO, lights were turned off per pt request, pt given\n cold packs for HA.\n Response:\n Pt states that HA pain level has decreased to . Pt states,\nit has\n calmed down a lot but it is never really gone.\n Plan:\n Continue to provide pt with PO medications for discomfort.\n" }, { "category": "Respiratory ", "chartdate": "2114-09-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 416157, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on 50% cool aerosol mask as well as supplemental 02 via\n nasal cannula. Bronchodilators administered via cool aerosol mask\n q4hrs. No evidence of acute shortness of breath evident. Patient is\n infact speaking in whole sentences without stopping to take a breath.\n Bilateral breath sounds positive for diffuse expiratory wheezes with\n better air movement while sitting upright.\n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416094, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and peripheral\n - 330 AM transient shrp l chets pain, EKG with new TWI in\n V2-V4 compared with admission EKG, CE sent, partial resolution of\n changes, no further symptoms\n - Received one dose of 10mg valium b/c of anxiety\n - Blood cx: GPC pairs & chains in\n blood cx from ,\n started on Vanco pending speciation\n -\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 79 (79 - 105) bpm\n BP: 107/55(73) {107/55(73) - 143/130(137)} mmHg\n RR: 24 (16 - 28) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 268 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 268 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -182 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 87%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Skin: Warm dry well-perfused, no rashes\n Labs / Radiology\n 303 K/uL\n 13.2 g/dL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2114-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416274, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 08:01 PM\n EKG - At 04:51 AM\n - Cardiac negative\n - Advanced diet\n - Changed to Solumedrol 40 \n - Started Azithromycin\n - Social Work c/s requested by RN for support/coping\n - Changed Vanco to Ampicillin for Enterococcus since sensitive\n to both\n - 8pm ABG: 7.42/40/73/27\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Ampicillin - 02:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 62 (62 - 101) bpm\n BP: 125/68(89) {107/53(70) - 155/90(111)} mmHg\n RR: 21 (8 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 1,305 mL\n 220 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 535 mL\n 100 mL\n Blood products:\n Total out:\n 1,300 mL\n 0 mL\n Urine:\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5 mL\n 220 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 93%\n ABG: 7.42/40/73./29/0\n PaO2 / FiO2: 209\n Physical Examination\n Gen: NAD, occasional coughing, speaking in full sentences\n HEENT: PERRL\n Lungs: Wheezes bilaterally\n Heart: s1s2 RRR\n Abd: obese, soft, NT/ND\n Ext: wd/wp\n Labs / Radiology\n 301 K/uL\n 12.5 g/dL\n 136 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 11 mg/dL\n 96 mEq/L\n 134 mEq/L\n 37.7 %\n 17.1 K/uL\n [image002.jpg]\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n 11:05 AM\n 05:42 PM\n 08:00 PM\n 01:59 AM\n WBC\n 21.3\n 17.1\n Hct\n 41.0\n 37.7\n Plt\n 303\n 301\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 29\n 28\n 25\n 25\n 27\n Glucose\n \n Other labs: CK / CKMB / Troponin-T:77//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n CXR :\n MICRO:\n - Blood cx x 2: pending\n -: Legionella: negative\n -: Blood cx: Enterococcus\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:24 PM\n 22 Gauge - 10:06 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2114-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416276, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 08:01 PM\n EKG - At 04:51 AM\n - Cardiac negative\n - Advanced diet\n - Changed to Solumedrol 40 \n - Started Azithromycin\n - Social Work c/s requested by RN for support/coping\n - Changed Vanco to Ampicillin for Enterococcus since sensitive\n to both\n - 8pm ABG: 7.42/40/73/27\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Ampicillin - 02:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 62 (62 - 101) bpm\n BP: 125/68(89) {107/53(70) - 155/90(111)} mmHg\n RR: 21 (8 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 1,305 mL\n 220 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 535 mL\n 100 mL\n Blood products:\n Total out:\n 1,300 mL\n 0 mL\n Urine:\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5 mL\n 220 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 93%\n ABG: 7.42/40/73./29/0\n PaO2 / FiO2: 209\n Physical Examination\n Gen: NAD, occasional coughing, speaking in full sentences\n HEENT: PERRL\n Lungs: Wheezes bilaterally\n Heart: s1s2 RRR\n Abd: obese, soft, NT/ND\n Ext: wd/wp\n Labs / Radiology\n 301 K/uL\n 12.5 g/dL\n 136 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 11 mg/dL\n 96 mEq/L\n 134 mEq/L\n 37.7 %\n 17.1 K/uL\n [image002.jpg]\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n 11:05 AM\n 05:42 PM\n 08:00 PM\n 01:59 AM\n WBC\n 21.3\n 17.1\n Hct\n 41.0\n 37.7\n Plt\n 303\n 301\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 29\n 28\n 25\n 25\n 27\n Glucose\n \n Other labs: CK / CKMB / Troponin-T:77//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n CXR :\n MICRO:\n - Blood cx x 2: pending\n -: Legionella: negative\n -: Blood cx: Enterococcus\n Assessment and Plan\n 32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n .\n 1. Respiratory distress, status. Pt appears more comfortable,\n improving although still wheezing, moving fair amount of air. ABG with\n pCO2 stable in 40s. Elevated pCO2 concerning in asthmatic patient, will\n need close monitoring for fatiguing.\n - CTA negative from OSH\n - Continue Solumedrol 40 \n - Received magnesium\n - Continuous nebs (albuterol), spacing to q 4H nebs but hypoxic off\n oxygen\n - Also on atrovent and advair\n - Advance to clears\n - f/u sputum cultures, blood cultures\n - urine legionella negative\n - Pertussis (cough, episode of post-tussive emesis, child at home with\n cough) sent\n - Will start Azithromycin in case of atypical infection given\n persistent hypoxia despite 24h of steroids/nebs\n - a-line for ABG monitoring\n - Consider heliox, NIPPV if pCO2 rises\n - If not improving consider re-imaging\n .\n 2. Positive blood cx. GPC in pairs & chains, possible contaminant but\n identified as ENTEROCOCCUS, pt afebrile with leukocytosis in setting of\n steroids.\n - Switched to Ampicillin, re-cultured\n - F/U repeat cx\n .\n 3. Hyperglycemia. No hx Diabetes, but BS elevated. Given steroid use,\n expect BS to possibly rise.\n - RISS\n .\n 4. Anxiety. Hx of high doses of valium, confirmed with pt's pharmacy.\n Given respiratory status, concerning to administer benzos. - CIWA scale\n to monitor for signs of withdrawal\n - Switch to Ativan prn since shorter acting\n .\n 5. Crohn's Disease. Not active x years.\n - NTD\n .\n 6. Chest pain. Atypical for cardiac ischemia, lasting less than 5\n minutes and sharp. Initial EKG around time of pain was sinus with TWI\n in V2, V3, no STE. Approximately one hour later, similar but now TW\n more biphasic. Compared to admission EKG, TW changes appear different.\n - Cycled CE although low suspicion for active ischemia: negative x 3,\n no further pain\n - Non-specific changes can be seen in PE, but CTA from OSH negative\n (for central PE) and clinical picture not consistent with PE.\n .\n Ppx: Heparin SQ, PPI, bowel regimen.\n .\n .\n presumed FULL CODE\n ICU Care\n Nutrition: Diet\n Glycemic Control: RISS\n Lines:\n Arterial Line - 03:24 PM\n 22 Gauge - 10:06 PM\n Prophylaxis:\n DVT: boots, heparin sq\n Stress ulcer: diet\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: Possible call-out if spaced to q 4H but still hypoxic\n" }, { "category": "Physician ", "chartdate": "2114-08-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 415941, "text": "Chief Complaint: Respiratory distress\n HPI:\n PCP: (, MA)\n History of present illness: 32F hx asthma transferred from OSH with\n status asthmaticus. Pt reports onset of URI sxs 1 week ago in setting\n of two sons at home with similar URi sxs (cough, rhinorrhea).\n Yesterday, pt developed worsening SOB, felta s though she could not\n catch her breath, despite using her Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n ROS: Neg for chest pain, rash, abd pain, diarrhea. Yesterday had one\n episode of post-tussive emesis.\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n .\n Medications:\n Celexa 80 qd\n Diazepam 10-15 mg qid prn anxiety (confirmed with pt's pharmacy)\n HCTZ 25 qd\n Prilosec 40 qd\n Adavir 250 \n Albuterol MDI prn\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Past medical history:\n Asthma\n Pancreatitis x1 (med-related)\n Crohn's s/p prox colonic resection\n s/p lap ventral hernia\n s/p c-section x 2\n N/C\n Occupation:\n Drugs: None\n Tobacco: Former, quit few wks ago\n Alcohol: None\n Other:\n Review of systems:\n Respiratory: Cough, Dyspnea, Wheeze\n Gastrointestinal: Emesis\n Pain: Mild\n Pain location: Headache, abd sore from coughing\n Flowsheet Data as of 02:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 85 (79 - 97) bpm\n BP: 93/46(58) {93/42(56) - 126/68(80)} mmHg\n RR: 17 (17 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,640 mL\n PO:\n 90 mL\n TF:\n IVF:\n 550 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,190 mL\n Respiratory\n O2 Delivery Device: High flow neb, Other\n SpO2: 93%\n ABG: 7.33/53/91/26/0\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, Speaking in\n full sentences\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 205 mg/dL\n 0.8 mg/dL\n 10 mg/dL\n 26 mEq/L\n 102 mEq/L\n 4.7 mEq/L\n 135 mEq/L\n [image002.jpg]\n \n 2:33 A9/26/ 10:31 AM\n \n 10:20 P9/26/ 12:30 PM\n \n 1:20 P9/26/ 12:42 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 11.0\n Hct\n 45.3\n Plt\n 289\n Cr\n 0.8\n TC02\n 28\n 29\n Glucose\n 205\n Other labs: Lactic Acid:1.2 mmol/L, Ca++:8.9 mg/dL, Mg++:2.8 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR: Low lung volumes, + atelectasis\n Microbiology: Blood cx sent from ED, pending\n ECG: NSR 89, NA/NI, Q in III, NSST-T changes\n Assessment and Plan\n A/P: 32F with hx asthma who is transferred from OSH with status\n asthmaticus, admitted to the MICU for continued management.\n .\n 1. Respiratory distress, status. Pt appears comfortable, although\n loud wheezing, moving fair amount of air. ABG on neb: 7.33/51/70/28 at\n 10:30 AM. Elevated pCO2 concerning in asthmatic patient, will need\n close monitoring for fatiguing.\n - CTA negative from OSH\n - Continue Solumedrol 80 IV q 8\n - Continuous nebs\n - NPO for now pending improvement\n - f/u sputum cultures, blood cultures\n - urine legionella but low suspicion\n - Pertussis (cough, episode of post-tussive emesis, child at home with\n cough)\n - Hold further abx given no infiltrates on CT\n - a-line for ABG monitoring\n - Consider heliox, NIPPV if pCO2 rises\n .\n 2. Hyperglycemia. No hx Diabetes, but BS elevated. Given steroid use,\n expect BS to possibly rise.\n - RISS\n .\n 3. Anxiety. Hx of high doses of valium, confirmed with pt's pharmacy.\n Given respiratory status, concering to administer benzos.\n - CIWA scale to monitor for signs of withdrawal\n .\n 4. Crohn's Disease. Not active x years.\n - NTD\n .\n .\n Ppx: Heparin SQ, PPI, bowel regimen.\n .\n .\n presumed FULL CODE\n .\n , MD\n p \n .\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:28 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2114-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416007, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Insp/Exp wheezes, SOB, DOE, labored breathing. ABG with PaO2 66(91, 70)\n while on continuous albuterol nebs but pt noted to be taking mask\n on/off.\n Action:\n 4L NC added to continuous albuterol nebs so that pt will have O2 even\n if removing mask.\n Response:\n Plan:\n Headache\n Assessment:\n C/O headache x several hours not relieved by 1gm Tylenol. Headache\n with no associated meningococcal signs/symptoms.\n Action:\n Given 1 fiorocet.\n Response:\n Pain level decreased to and HA verbalized as tolerable.\n Plan:\n Continue to monitor for HA. Monitor for acute changes in LOC as HA\n could be sign of hypoxia.\n" }, { "category": "Nursing", "chartdate": "2114-08-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416009, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Insp/Exp wheezes, SOB, DOE, labored breathing. ABG with PO2 66(91, 70)\n while on continuous albuterol nebs but pt noted to be taking mask\n on/off.\n Action:\n 4L NC added to continuous albuterol nebs so that pt will have O2 even\n if removing mask.\n Response:\n Most recent ABG 7.38/40/78 which shows some improvement in PO2.\n Plan:\n Cont with continuous albuterol nebs along with 4L NC. Consider heliox\n or BiPAP if indicated.\n Headache\n Assessment:\n C/O headache x several hours not relieved by 1gm Tylenol. Headache\n with no associated meningococcal signs/symptoms.\n Action:\n Given 1 fiorocet.\n Response:\n Pain level decreased to and HA verbalized as tolerable.\n Plan:\n Continue to monitor for HA. Monitor for acute changes in LOC as HA\n could be sign of hypoxia.\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416206, "text": "32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n Asthma . Respiratory distress, status\n Assessment:\n Dyspneic @ rest RR>24 ^>30 w/ activity. Lungs I/E wheezes to clear\n moving fair amt of air. O2 4L/min NC and High flow aresol 50% most of\n shift . intermittent dry cough sm amt oral secretions.\n Action:\n Wean O2 NC 2L/min altermnating w/ Areosol High flow O2 50%, wean from\n cont nebs to intermittent alb/atr q2-4hrs. received Advir per routine.\n Solumedrol taper. Abx vancomycin and started azythromycin.\n Response:\n Fair tolerance of 02 wean.\n Plan:\n Monitor resp status for ^ Co2 andf resp fatique\n Follow cult data. , sent sputum when able to produce.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n c/o generalized chest soreness throught day different then during noc.\n Denies chest pressure/ sharp pain as described @ 0300 previous shift.\n EKG TWI V2-4\n Action:\n Seriel Cardiac enzymes.\n Response:\n CK neg troponin neg\n Plan:\n EKG in am, seriel Cardiac enzymes\n" }, { "category": "Physician ", "chartdate": "2114-08-31 00:00:00.000", "description": "ICU Fellow Admission Note - MICU", "row_id": 415916, "text": "Chief Complaint: status asthmaticus\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 32 y/o F w/asthma & Crohn's, who started having URI symptoms about a\n week ago after her kids developed a URI. Over past several days felt\n increasing shortness of breath so went to hospital yesterday.\n CXR with ? pneumonia, CTA neg for PE or pna, given ceftriaxone,\n azithromycin, and solumedrol. Transferred here.\n While here, has been on continuous nebulizer. Feels slightly better.\n Did not require heliox.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Crohn's disease s/p colonic resection 10 years ago, not requiring\n further rx\n 2. Asthma: usually on advair & albuterol, does not require frequent\n prednisone tapers, no intubations or hospitalizations\n 3. Anxiety\n : celexa, hctz, prilosec, albuterol prn, advair, diazepam 15 mg\n four times/day\n Occupation:\n Drugs:\n Tobacco: quit recently\n Alcohol:\n Other: has cat at home\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Neurologic: Headache\n Flowsheet Data as of 10:15 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 94 (93 - 97) bpm\n BP: 116/68(80) {116/62(79) - 126/68(80)} mmHg\n RR: 22 (21 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,047 mL\n PO:\n TF:\n IVF:\n 47 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,047 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n Physical Examination\n General Appearance: Overweight / Obese, speaking in full sentences\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffusely, although good air movement)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 289\n 45\n 243\n 0.9\n 10\n 22\n 99\n 6.4 (hemolyzed)\n 132\n 11\n [image002.jpg]\n Other labs: Differential-Neuts:91, Lymph:7.4, Mono:0.8, Eos:0.2\n Imaging: CXR here: low inspired lung volumes, ? linear atelectasis in R\n mid lung zone, cardiomegaly\n ECG: NSR at 89, normal axis/int, Q in III, nonspecific ST changes\n Assessment and Plan\n 32 y/o F with asthma who presents with status asthmaticus.\n 1. Asthma: Currently appears stabilized, although diffusely wheezy on\n exam. Is able to speak in full sentences and not using accessory\n muscles so will continue current management for now.\n - solumedrol q8h\n - advair 500/50\n - no current need for heliox or intubation\n - check ABG - hypoxemia likely V/Q mismatch but will need to closely\n monitor as atypical for asthma\n - will hold on abx given neg CT scan, but will obtain OSH scan\n - cont Magnesium\n - send urinary legionella antigen, pertussis antibody, sputum cx\n 2. Anxiety: Pt reports she takes valium 15 mg q6h at home, which seems\n like a high dose of benzo. Will confirm with pharmacy. Hold off on\n additional benzos for now as \n to depress her respiratory\n drive, although will need some to prevent withdrawal.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 09:28 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416079, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Cont with exp/insp wheezing. Received on cont neb. Last ABG 7.36/43/79.\n off mask pt desat to 88-89% on 4l NC. Cont cough. After cough c/o of\n pain under her breasts\n Action:\n Start Atroven neb. D./ced cont neb around 0300.placed on cool neb 50%.\n Start guaifenesin\n Response:\n Sat remains 94%\n Plan:\n Cont nebs-puffs tx, wean continuous neb\n Headache\n Assessment:\n Cont c/o of HA moderate to severe\n Action:\n Given fioroset 2tab q4hr. also given valium 10mg po\n Response:\n Some response after meds\n Plan:\n Cont follow HA, cont pain meds, ?restart Valium\n Around 0400 pt c/o of sharp chest pain, ECG doneX2,shown some T waves\n , MD aware,cardiac enzymes sent. Pain stopped w/o any\n intervention.\n BX growing GCP, start on Vanco, new set of BX sent in the morning, WBC\n 21\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416202, "text": "32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n Events: @ 330 am L sided chest pain, rapidly resolved,different\n than her usual pain, ekg obtained at that time demonstrated new TWI\n V2-V4 that resolved, now getting ROMI.\n Asthma . Respiratory distress, status\n Assessment:\n Dyspneic @ rest RR>24 ^>30 w/ activity. Lungs I/E wheezes to clear\n moving fair amt of air. O2 4L/min NC and High flow aresol 50% most of\n shift . intermittent dry cough sm amt oral secretions.\n Action:\n Wean O2 NC 2L/min altermnating w/ Areasol High flow O2 50%, wean \n cont nebs to intermittent alb/atr q2-4hrs. received Advir per routine.\n Solumedrol taper. Abx vancomycin and started azythromycin.\n Response:\n Fair tolerance of 02 wean.\n Plan:\n Monitor resp status for ^ Co2 andf resp fatique\n Follow cult data. , sent sputum when able to produce.\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416198, "text": "Asthma\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416199, "text": "24H ICU events: SaO2 90s on continuous nebs, solumedrol, magnesium, no\n heliox, no abx. Blood gasses demonstrate persistent hypoxemia,\n hyperbarbia.\n Blood cultures gpc pairs and chains in bottles\n 330 am L sided chest pain, rapidly resolved,different than her usual\n pain, ekg obtained at that time demonstrated new TWI V2-V4 that\n resolved, now getting ROMI.\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-09-02 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 416346, "text": "Demographics\n Attending MD:\n S.\n Admit diagnosis:\n ASTHMA\n Code status:\n Full code\n Height:\n Admission weight:\n 153.5 kg\n Daily weight:\n 153.5 kg\n Allergies/Reactions:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Precautions:\n PMH: Asthma, Pancreatitis, Smoker\n CV-PMH:\n Additional history: Crohn's Disease, ileo cecetomy , C/S x2 (,\n ), ventral hernia repair & , morbid obesity\n Surgery / Procedure and date: ileo cecetomy , C/S x2 (, ),\n ventral hernia repair & \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:72\n Temperature:\n 97.2\n Arterial BP:\n S:112\n D:60\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 92% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 900 mL\n 24h total out:\n 800 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 01:59 AM\n Potassium:\n 4.5 mEq/L\n 01:59 AM\n Chloride:\n 96 mEq/L\n 01:59 AM\n CO2:\n 29 mEq/L\n 01:59 AM\n BUN:\n 11 mg/dL\n 01:59 AM\n Creatinine:\n 0.7 mg/dL\n 01:59 AM\n Glucose:\n 136 mg/dL\n 01:59 AM\n Hematocrit:\n 37.7 %\n 01:59 AM\n Finger Stick Glucose:\n 122\n 12:00 PM\n Valuables / Signature\n Patient valuables: with pt\n valuables:\n Clothes: Sent home with: with pt\n / Money:\n No money / \n Cash / Credit cards sent home with:\n Jewelry: yellow rings on both hands\n Transferred from:\n Transferred to: \n Date & time of Transfer: \n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416099, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and peripheral\n - 330 AM transient shrp l chets pain, EKG with new TWI in\n V2-V4 compared with admission EKG, CE sent, partial resolution of\n changes, no further symptoms\n - Received one dose of 10mg valium b/c of anxiety\n - Blood cx: GPC pairs & chains in\n blood cx from ,\n started on Vanco pending speciation\n -\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 79 (79 - 105) bpm\n BP: 107/55(73) {107/55(73) - 143/130(137)} mmHg\n RR: 24 (16 - 28) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 268 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 268 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -182 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 87%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Skin: Warm dry well-perfused, no rashes\n Labs / Radiology\n 303 K/uL\n 13.2 g/dL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n .\n 1. Respiratory distress, status. Pt appears more comfortable,\n although still wheezing, moving fair amount of air. ABG with pCO2\n stable in 40s. Elevated pCO2 concerning in asthmatic patient, will need\n close monitoring for fatiguing.\n - CTA negative from OSH\n - Continue Solumedrol 80 IV q 8\n - Received magnesium\n - Continuous nebs (albuterol), also on atrovent and advair\n - NPO for now pending improvement\n - f/u sputum cultures, blood cultures\n - urine legionella but low suspicion\n - Pertussis (cough, episode of post-tussive emesis, child at home with\n cough)\n - Hold further abx given no infiltrates on CT\n - a-line for ABG monitoring\n - Consider heliox, NIPPV if pCO2 rises\n - If not improving consider re-imaging\n .\n 2. Positive blood cx. GPC in pairs & chains, possible contaminant, pt\n afebrile but leukocytosis in setting of steroids.\n - Started vanco pending speciation\n - F/U repeat cx\n .\n 3. Hyperglycemia. No hx Diabetes, but BS elevated. Given steroid use,\n expect BS to possibly rise.\n - RISS\n .\n 4. Anxiety. Hx of high doses of valium, confirmed with pt's pharmacy.\n Given respiratory status, concering to administer benzos. Received one\n dose of 10mg overnight with improvement.\n - CIWA scale to monitor for signs of withdrawal\n .\n 5. Crohn's Disease. Not active x years.\n - NTD\n .\n .\n Ppx: Heparin SQ, PPI, bowel regimen.\n .\n .\n presumed FULL CODE\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n" }, { "category": "ECG", "chartdate": "2114-09-02 00:00:00.000", "description": "Report", "row_id": 144939, "text": "Sinus rhythm. Prolonged Q-T interval. T wave inversions in leads V1-V2\nsuggestive of right ventricular pathology. Compared to the previous tracing\nof the findings are similar, although patient is less tachycardic.\n\n" }, { "category": "ECG", "chartdate": "2114-09-01 00:00:00.000", "description": "Report", "row_id": 144940, "text": "Baseline artifact. Sinus rhythm. Non-specific ST-T wave changes with\nright to mid-precordial T wave inversions that are non-diagnostic but could be\ndue to right ventricular overload, etc. QTc interval prolongation. Compared to\nthe previous tracing of ST-T wave changes are more apparent. Clinical\ncorrelation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2114-08-31 00:00:00.000", "description": "Report", "row_id": 144941, "text": "Baseline artifact. Sinus rhythm. Slow R wave progression. Non-specific\nST-T wave changes with mild QTc interval prolongation. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2114-09-09 00:00:00.000", "description": "Report", "row_id": 144893, "text": "Artifact is present. Sinus rhythm. The Q-T interval is prolonged. Compared\nto the previous tracing ST-T wave changes have resolved.\n\n" }, { "category": "ECG", "chartdate": "2114-09-05 00:00:00.000", "description": "Report", "row_id": 144894, "text": "Baseline artifact. Sinus bradycardia. Consider left atrial abnormality.\nModest right precordial lead/anterior T wave changes. Borderline\nprolonged/upper limits of normal QTc interval. Findings are non-specific\nbut clinical correlation is suggested. Since the previous tracing of \nthe QTc interval appears shorter.\n\n" }, { "category": "Physician ", "chartdate": "2114-08-31 00:00:00.000", "description": "ICU Fellow Admission Note - MICU attednign addendu", "row_id": 415963, "text": "Chief Complaint: status asthmaticus\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 32 y/o F w/asthma & Crohn's, who started having URI symptoms about a\n week ago after her kids developed a URI. Over past several days felt\n increasing shortness of breath so went to hospital yesterday.\n CXR with ? pneumonia, CTA neg for PE or pna, given ceftriaxone,\n azithromycin, and solumedrol. Transferred here.\n While here, has been on continuous nebulizer. Feels slightly better.\n Did not require heliox.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. Crohn's disease s/p colonic resection 10 years ago, not requiring\n further rx\n 2. Asthma: usually on advair & albuterol, does not require frequent\n prednisone tapers, no intubations or hospitalizations\n 3. Anxiety\n : celexa, hctz, prilosec, albuterol prn, advair, diazepam 15 mg\n four times/day\n Occupation:\n Drugs:\n Tobacco: quit recently\n Alcohol:\n Other: has cat at home\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Diarrhea\n Neurologic: Headache\n Flowsheet Data as of 10:15 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.5\n Tcurrent: 35.8\nC (96.5\n HR: 94 (93 - 97) bpm\n BP: 116/68(80) {116/62(79) - 126/68(80)} mmHg\n RR: 22 (21 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,047 mL\n PO:\n TF:\n IVF:\n 47 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,047 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 94%\n Physical Examination\n General Appearance: Overweight / Obese, speaking in full sentences\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n diffusely, although good air movement)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 289\n 45\n 243\n 0.9\n 10\n 22\n 99\n 6.4 (hemolyzed)\n 132\n 11\n [image002.jpg]\n Other labs: Differential-Neuts:91, Lymph:7.4, Mono:0.8, Eos:0.2\n Imaging: CXR here: low inspired lung volumes, ? linear atelectasis in R\n mid lung zone, cardiomegaly\n ECG: NSR at 89, normal axis/int, Q in III, nonspecific ST changes\n Assessment and Plan\n 32 y/o F with asthma who presents with status asthmaticus.\n 1. Asthma: Currently appears stabilized, although diffusely wheezy on\n exam. Is able to speak in full sentences and not using accessory\n muscles so will continue current management for now.\n - solumedrol q8h\n - advair 500/50\n - no current need for heliox or intubation\n - check ABG - hypoxemia likely V/Q mismatch but will need to closely\n monitor as atypical for asthma\n - will hold on abx given neg CT scan, but will obtain OSH scan\n - cont Magnesium\n - send urinary legionella antigen, pertussis antibody, sputum cx\n 2. Anxiety: Pt reports she takes valium 15 mg q6h at home, which seems\n like a high dose of benzo. Will confirm with pharmacy. Hold off on\n additional benzos for now as \n to depress her respiratory\n drive, although will need some to prevent withdrawal.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 09:28 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n ------ Protected Section ------\n MICU attending addendum\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 32 yo F, former smoker, with hx asthma and crohn's ds transferred from\n OSH with status asthmaticus. URI sx last week, child sick with\n bronchitis --> past few days has developed increased SOB--> \n hospital --> had elevated dd, cxr with ? pna. Antibx, steroids, and\n nebs given. Had cta neg for PE and pna per report--> transferred to\n ED for further management.\n Asthma has been stable, takes advair 500/50 and albuterol, no prior\n hospitalizations for asthma, no intubations, no PO steroids for asthma\n Exam AF 97 126/62 18-22 o2 sat 94% continuous neb\n obese f, speaking full sentences, no acc muscle use, wheezy throughout,\n exp>ins, sym air movement, rr, obese benign abd, noperipheral edema\n Labs wbc 11, hct 45 plt 289\n diff 91 polys, na 132 K 6.4 (hemolytyzed) gap 11, bun/cr 10/0.9\n CXR--small lung volumes, atelecatsis vs infiltrate right mid zone\n ecg sinus 89, q in 3, nonsp st changes\n A/P: 32 yo F with h/o asthma presents with\n * status asthmaticus\n * hypoxia\n * obesity\n * hyponatremia\n Asthma exacerbation likely secondary to a viral URI. AF with nl wbc\n ct. HYyoxia is atypical for athma, but may be to obesity,\n atelectasis and v/q mismatch. Seems to be responding to treatment byt\n remains with very tenuous respiratory status with diffuse wheeze.\n Agree with plan for continuous nebs, solumedrol, advair. CXR\n appears most c/w atelectasis, but will obtain OSH CTA report, image if\n possible, and have low thresh hold to reimage. Check abg, monitor\n closely for CO2 elevation or fatigue. Does not appear to be CO2\n retainer at baseline based upon nl serum CO2. Reasonable to hold on\n antibx given no fever or wbc ct. But would check sputum cx, urine\n legionella antigen and pertussis antibody. Could consider NVPPV in this\n patient, though if hypoxia, fatigue, or respiratory status worsens\n would need intubation. Takes valium QID at home for anxiety--would\n limit benzos as do not want to compormise respiratory drive. WIll\n contact PCP and home pharmacy to verify dosing. Monitor for\n withdrawal.\n Remainder per note above\n critically ill\n 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:23 ------\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416038, "text": "Asthma\n Assessment:\n Action:\n Response:\n Plan:\n Headache\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416041, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Cont with exp/insp wheezing. Received on cont neb. Last ABG 7.36/43/79.\n off mask pt desat to 88-89% on 4l NC. Cont cough. After cough c/o of\n pain under her breasts\n Action:\n Start Atroven neb. D./ced cont neb around 0300.placed on cool neb 50%.\n Start guaifenesin\n Response:\n Sat remains 94%\n Plan:\n Cont nebs-puffs tx, wean continuous neb\n Headache\n Assessment:\n Cont c/o of HA moderate to severe\n Action:\n Given fioroset 2tab q4hr. also given valium 10mg po\n Response:\n Some response after meds\n Plan:\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 416039, "text": "32F hx asthma transferred from OSH with status asthmaticus. Pt reports\n onset of URI sxs 1 week ago in setting of two sons at home with similar\n URI sxs (cough, rhinorrhea). Yesterday, pt developed worsening SOB,\n felt as though she could not catch her breath despite using her\n Albuterol MDI at home.\n .\n No hx of intubation or ICU admission in the past; hospitalized in the\n past for asthma. Well-controlled on Advair 250, albuterol prn, no\n recent steroids.\n .\n At , pt treated with CTX/azithro, Solumedrol, CTA of the chest\n negative for central PE or PNA, + atelectasis. ABG at 4 am at :\n 7.33/44.9/71.7/23 (on unclear amt oxygen).\n .\n In ED here, received magnesium, continuous neb; currently 94% on\n continuous albuterol neb and feeling improved. Complaining of HA which\n she has had since last night, gradual onset, hx HA in the past, has\n used Fioricet previously.\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n Headache\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 416134, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and periferal\n 24H ICU events: SaO2 90s on continuous nebs, solumedrol, magnesium, no\n heliox, no abx. Blood gasses demonstrate persistent hypoxemia,\n hyperbarbia.\n Blood cultures gpc pairs and chains in bottles\n 330 am L sided chest pain, rapidly resolved,different than her usual\n pain, ekg obtained at that time demonstrated new TWI V2-V4 that\n resolved, now getting ROMI.\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n valium 10 mg\n celexa 40 mg po daily\n Advair\n omeprazole 40 mg\n HCTZ 25 qday\n Heparin 5000 TID\n RISS\n PRed 80 q 8\n atrovent\n albuterol\n fioricet\n guafenesin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 96 (79 - 105) bpm\n BP: 118/66(82) {107/55(73) - 143/130(137)} mmHg\n RR: 17 (16 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 296 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 296 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 90%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n General: obese, well-appearing, speaking in full sentences, occasional\n cough, no accessory muscles\n HEENT: PERRL, EOMI\n NECK: supple\n CV: S1/S2 distant, R\n CHEST: distant, prolonged exp phase, insp/exp wheeze\n ABD: obese, soft, nt\n Ext: wwp, no c/c/e\n Peripheral Vascular: (Right radial pulse: 1+), (Left radial pulse: 1+),\n (Right DP pulse: 1+), (Left DP pulse: 1+)\n Skin: cool, dry\n Neurologic: conversant, alert and oriented x 3, cn 2-12 grossly intact,\n no focal abnormalities\n Labs / Radiology\n 13.2 g/dL\n 303 K/uL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR low lung volumesd improved from , improved patch\n opacity RNL\n Microbiology: urine legionella neg\n blood cx gpc pairs and chains 1/2 bottles\n ECG: nsr\n Assessment and Plan\n 32 yo F smoker h.o crohns, now with asthma exacerbation\n 1. Asthma exacterbation:\n exam with persistent insp/exp wheeze, speaking in full sentences\n - will decrease solumedrol to 80 with plan to taper to pred 60\n tomorrow if continued improvement\n - was on continuous nebs - will change to PRN nebs and monitor needs\n - given persistent cough, low grade temps, and slower improvement,\n will start azithro for empiric atypical mycobacterial coverage,\n although likely viral infection\n 2. Chest pain with EKG changes: likey RH strain in setting of flare\n - PE ct was negative for central PE\n - ruling out, cont cycle enzymes and monitor ekgs\n 3. + blood culture: likely contaminant, but has had lines in place\n - will cont empiric vanc coverage, await speciation\n 4. Hyperglycemia:\n - cont RISS esp while on steroids\n 5. Anxiety:\n - previously on high dose valium, but concern for respiratory\n depression\n - ativan as needed for anxiety\n 6. Crohns: stable\n ICU Care\n Nutrition:\n Comments: had been npo for ? urgent intubation, but improving so will\n advance to clears\n Glycemic Control:\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: not intubated\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: full code\n Disposition : ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416137, "text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and peripheral\n - 330 AM transient shrp l chets pain, EKG with new TWI in\n V2-V4 compared with admission EKG, CE sent, partial resolution of\n changes, no further symptoms\n - Received one dose of 10mg valium b/c of anxiety\n - Blood cx: GPC pairs & chains in\n blood cx from ,\n started on Vanco pending speciation\n -\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:05 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.2\nC (97.2\n HR: 79 (79 - 105) bpm\n BP: 107/55(73) {107/55(73) - 143/130(137)} mmHg\n RR: 24 (16 - 28) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 268 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 268 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -182 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 87%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n Gen: Comfortable, speaking in full sentences\n HEENT: PERRL\n Lungs: Diffuse wheezes throughout\n Heart: s1s2 RRR\n Abd: soft, obese, nt/nd\n Ext: wd/wp, no edema\n Skin: No rashes\n Labs / Radiology\n 303 K/uL\n 13.2 g/dL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n CXR : Improved aeration, no clear infiltrates noted today\n MICRO:\n - Legionella negative\n - Blood cx : CPC\n Enterococcus in one bottle, to\n vanco\n - cx: NGTD\n -\n Assessment and Plan\n 32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n .\n 1. Respiratory distress, status. Pt appears more comfortable,\n although still wheezing, moving fair amount of air. ABG with pCO2\n stable in 40s. Elevated pCO2 concerning in asthmatic patient, will need\n close monitoring for fatiguing.\n - CTA negative from OSH\n - Continue Solumedrol 40 \n - Received magnesium\n - Continuous nebs (albuterol), also on atrovent and advair\n - Advance to clears\n - f/u sputum cultures, blood cultures\n - urine legionella negative\n - Pertussis (cough, episode of post-tussive emesis, child at home with\n cough) sent\n - Will start Azithromycin in case of atypical infection given\n persistent hypoxia despite 24h of steroids/nebs\n - a-line for ABG monitoring\n - Consider heliox, NIPPV if pCO2 rises\n - If not improving consider re-imaging\n .\n 2. Positive blood cx. GPC in pairs & chains, possible contaminant but\n identified as ENTEROCOCCUS, pt afebrile with leukocytosis in setting of\n steroids.\n - Started vanco, re-cultured\n - F/U repeat cx\n .\n 3. Hyperglycemia. No hx Diabetes, but BS elevated. Given steroid use,\n expect BS to possibly rise.\n - RISS\n .\n 4. Anxiety. Hx of high doses of valium, confirmed with pt's pharmacy.\n Given respiratory status, concering to administer benzos. Received one\n dose of 10mg overnight with improvement.\n - CIWA scale to monitor for signs of withdrawal\n - Switch to Ativan prn since shorter acting\n .\n 5. Crohn's Disease. Not active x years.\n - NTD\n .\n 6. Chest pain. Atypical for cardiac ischemia, lasting less than 5\n minutes and sharp. Initial EKG around time of pain was sinus with TWI\n in V2, V3, no STE. Approximately one hour later, similar but now TW\n more biphasic. Compared to admission EKG, TW changes appear different.\n - Cycle CE although low suspicion for active ischemia\n - Non-specific changes can be seen in PE, but CTA from OSH negative\n (for central PE) and clinical picture not consistent with PE.\n .\n Ppx: Heparin SQ, PPI, bowel regimen.\n .\n .\n presumed FULL CODE\n ICU Care\n Nutrition: Clears, may advance later if better and no indication that\n pt may need NIPPV or intubation\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT: Boots, SQ heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU pending improvement\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing 1900-0700", "row_id": 416225, "text": "Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Asthma\n Assessment:\n Action:\n Response:\n Plan:\n Headache\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2114-09-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 416311, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 08:01 PM\n EKG - At 04:51 AM\n continues to have wheezing\n History obtained from Patient\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Ampicillin - 09:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n celexa 40 qday\n advair 250/50\n omeprazole\n hctz 25\n heparin tid\n riss\n atrovent\n solumedrol 40 \n azithro 500\n ampicillin 1 g q6H\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 52 (52 - 101) bpm\n BP: 112/58(78) {107/53(70) - 155/90(111)} mmHg\n RR: 20 (8 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 1,305 mL\n 320 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 535 mL\n 200 mL\n Blood products:\n Total out:\n 1,300 mL\n 0 mL\n Urine:\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: 7.42/40/73./29/0\n PaO2 / FiO2: 209\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Wheezes : improved from )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 301 K/uL\n 136 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 11 mg/dL\n 96 mEq/L\n 134 mEq/L\n 37.7 %\n 17.1 K/uL\n [image002.jpg]\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n 11:05 AM\n 05:42 PM\n 08:00 PM\n 01:59 AM\n WBC\n 21.3\n 17.1\n Hct\n 41.0\n 37.7\n Plt\n 303\n 301\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 29\n 28\n 25\n 25\n 27\n Glucose\n \n Other labs: CK / CKMB / Troponin-T:77//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR with low lung volumes, clear diaphragmaitic borders, no\n infiltrate\n Microbiology: blood cx x2 ngtd\n legionella negative\n blood - pan S enterococcus x 1\n pertussis p\n Assessment and Plan\n 37 yo F with Crohn's s/p resection,.asthma presents with severe asthma\n exacerbation.\n 1. Asthma:\n - improving respiratory status but still significantly wheezy\n - hypoxia on movement\n - likely hyperreactive airways with obesity hypoventilation +/- sleep\n apnea\n - will decrease GC to prednisone 60 qday\n - cont alb/atrovent nebs q 4 hr\n - supplemental O2 as needed\n - 5 d azithro\n - f/u sputum, pertussis cultures\n - will d/c aline today\n 2. Enterococcus blood culture: atypical for contaminant\n - cont ampicillin\n - f/u repeat blood cx\n 3. Hyperglycemia:\n - cont RISS, regular diet\n 4. Anxiety:\n - started ativan for baseline benzo-dependent anxiety with some\n improvmeent\n 5. Chest Pain:\n - Ruled out MI, likely GERD, worsened w steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:24 PM\n 22 Gauge - 10:06 PM\n Prophylaxis:\n DVT: SQ UF Heparin(PPI)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2114-09-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 416312, "text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 08:01 PM\n EKG - At 04:51 AM\n - Cardiac negative\n - Advanced diet\n - Changed to Solumedrol 40 \n - Started Azithromycin\n - Social Work c/s requested by RN for support/coping\n - Changed Vanco to Ampicillin for Enterococcus since sensitive\n to both\n - 8pm ABG: 7.42/40/73/27\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Ampicillin - 02:02 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 62 (62 - 101) bpm\n BP: 125/68(89) {107/53(70) - 155/90(111)} mmHg\n RR: 21 (8 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 1,305 mL\n 220 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 535 mL\n 100 mL\n Blood products:\n Total out:\n 1,300 mL\n 0 mL\n Urine:\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5 mL\n 220 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 93%\n ABG: 7.42/40/73./29/0\n PaO2 / FiO2: 209\n Physical Examination\n Gen: NAD, occasional coughing, speaking in full sentences\n HEENT: PERRL\n Lungs: Wheezes bilaterally but good air entry\n Heart: s1s2 RRR\n Abd: obese, soft, NT/ND\n Ext: wd/wp\n Labs / Radiology\n 301 K/uL\n 12.5 g/dL\n 136 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 11 mg/dL\n 96 mEq/L\n 134 mEq/L\n 37.7 %\n 17.1 K/uL\n [image002.jpg]\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n 11:05 AM\n 05:42 PM\n 08:00 PM\n 01:59 AM\n WBC\n 21.3\n 17.1\n Hct\n 41.0\n 37.7\n Plt\n 303\n 301\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 29\n 28\n 25\n 25\n 27\n Glucose\n \n Other labs: CK / CKMB / Troponin-T:77//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n CXR : Low lung volumes, no infiltrate\n MICRO:\n - Blood cx x 2: pending\n -: Legionella: negative\n -: Blood cx: Enterococcus\n Assessment and Plan\n 32F with hx asthma who is transferred from OSH with status asthmaticus,\n admitted to the MICU for continued management.\n .\n 1. Respiratory distress, status. Pt appears more comfortable,\n improving although still wheezing, moving fair amount of air. ABG with\n pCO2 stable in 40s since arrival in MICU, suspect some component of\n obesity hypoventilation.\n - CTA negative from OSH\n - Switch to prednisone 60 qd\n - Spaced to q 4H nebs but hypoxic off oxygen\n - Also on atrovent and advair\n - f/u sputum cultures, blood cultures\n - urine legionella negative\n - Pertussis (cough, episode of post-tussive emesis, child at home with\n cough) sent\n - Azithromycin in case of atypical infection given persistent hypoxia\n despite 24h of steroids/nebs\n - d/c a-line as ABGs stable and likely call-out\n - Consider heliox, NIPPV if pCO2 rises\n - If not improving consider re-imaging\n .\n 2. Positive blood cx. GPC in pairs & chains, possible contaminant but\n identified as ENTEROCOCCUS, pt afebrile with leukocytosis in setting of\n steroids.\n - Switched to Ampicillin, re-cultured\n - F/U repeat cx\n .\n 3. Hyperglycemia. No hx Diabetes, but BS elevated. Given steroid use,\n expect BS to possibly rise.\n - RISS\n .\n 4. Anxiety. Hx of high doses of valium, confirmed with pt's pharmacy.\n Given respiratory status, concerning to administer benzos. - CIWA scale\n to monitor for signs of withdrawal\n - Switch to Ativan prn since shorter acting\n .\n 5. Crohn's Disease. Not active x years.\n - NTD\n .\n 6. Chest pain. Atypical for cardiac ischemia, lasting less than 5\n minutes and sharp. Initial EKG around time of pain was sinus with TWI\n in V2, V3, no STE. Approximately one hour later, similar but now TW\n more biphasic. Compared to admission EKG, TW changes appear different.\n - Cycled CE although low suspicion for active ischemia: negative x 3,\n no further pain\n - Non-specific changes can be seen in PE, but CTA from OSH negative\n (for central PE) and clinical picture not consistent with PE.\n .\n Ppx: Heparin SQ, PPI, bowel regimen.\n .\n .\n presumed FULL CODE\n ICU Care\n Nutrition: Diet\n Glycemic Control: RISS\n Lines:\n Arterial Line - 03:24 PM\n 22 Gauge - 10:06 PM\n Prophylaxis:\n DVT: boots, heparin sq\n Stress ulcer: diet\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: Call out\n" }, { "category": "Physician ", "chartdate": "2114-09-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 416316, "text": "Chief Complaint:\n Continues to feel anxious and dyspneic, but this is improving\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n SPUTUM CULTURE - At 08:01 PM ngtd\n EKG - At 04:51 AM no ischemia\n History obtained from Patient\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Ampicillin - 09:02 AM\n Infusions:\n Other ICU medications:\n Other medications:\n celexa 40 qday\n advair 250/50\n omeprazole\n hctz 25\n heparin tid\n riss\n atrovent\n solumedrol 40 \n azithro 500\n ampicillin 1 g q6H\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 52 (52 - 101) bpm\n BP: 112/58(78) {107/53(70) - 155/90(111)} mmHg\n RR: 20 (8 - 29) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 1,305 mL\n 320 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 535 mL\n 200 mL\n Blood products:\n Total out:\n 1,300 mL\n 0 mL\n Urine:\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5 mL\n 320 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: 7.42/40/73./29/0\n PaO2 / FiO2: 209\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Wheezes : improved from )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.5 g/dL\n 301 K/uL\n 136 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 4.5 mEq/L\n 11 mg/dL\n 96 mEq/L\n 134 mEq/L\n 37.7 %\n 17.1 K/uL\n [image002.jpg]\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n 11:05 AM\n 05:42 PM\n 08:00 PM\n 01:59 AM\n WBC\n 21.3\n 17.1\n Hct\n 41.0\n 37.7\n Plt\n 303\n 301\n Cr\n 0.8\n 0.7\n 0.7\n TropT\n <0.01\n <0.01\n <0.01\n TCO2\n 29\n 28\n 25\n 25\n 27\n Glucose\n \n Other labs: CK / CKMB / Troponin-T:77//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.8\n mg/dL, Mg++:2.3 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR with low lung volumes, clear diaphragmaitic borders, no\n infiltrate\n Microbiology: blood cx x2 ngtd\n legionella negative\n blood - pan S enterococcus x 1\n pertussis p\n Assessment and Plan\n 37 yo F with Crohn's s/p resection,.asthma presents with severe asthma\n exacerbation.\n 1. Asthma:\n - improving respiratory status but still significantly wheezy\n - hypoxia on movement\n - likely hyperreactive airways with obesity hypoventilation +/- sleep\n apnea\n - will decrease GC to prednisone 60 qday\n - cont alb/atrovent nebs q 4 hr\n - supplemental O2 as needed\n - 5 d azithro\n - f/u sputum, pertussis cultures\n - will d/c aline today\n 2. Enterococcus blood culture: atypical for contaminant\n - cont ampicillin\n - f/u repeat blood cx\n 3. Hyperglycemia:\n - cont RISS, regular diet\n 4. Anxiety:\n - started ativan for baseline benzo-dependent anxiety with some\n improvmeent\n 5. Chest Pain:\n - Ruled out MI, likely GERD, worsened w steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:24 PM\n 22 Gauge - 10:06 PM\n Prophylaxis:\n DVT: SQ UF Heparin(PPI)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n" }, { "category": "Physician ", "chartdate": "2114-09-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 416120, "text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 03:24 PM\n EKG - At 03:52 AM\n BLOOD CULTURED - At 04:02 AM\n arterial and periferal\n 24H ICU events: SaO2 90s on continuous nebs, solumedrol, magnesium, no\n heliox, no abx. Blood gasses demonstrate persistent hypoxemia,\n hyperbarbia.\n Blood cultures gpc pairs and chains in bottles\n 330 am L sided chest pain, rapidly resolved,different than her usual\n pain, ekg obtained at that time demosntrated new TWI V2-V4\n Allergies:\n Metronidazole\n Nausea/Vomiting\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:01 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n valium 10 mg\n celexa 40 mg po daily\n Advair\n omeprazole 40 mg\n HCTZ 25 qday\n Heparin 5000 TID\n RISS\n PRed 80 q 8\n atrovent\n albuterol\n fioricet\n guafenesin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.3\nC (97.3\n HR: 96 (79 - 105) bpm\n BP: 118/66(82) {107/55(73) - 143/130(137)} mmHg\n RR: 17 (16 - 28) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 153.5 kg (admission): 153.5 kg\n Total In:\n 4,709 mL\n 296 mL\n PO:\n 120 mL\n TF:\n IVF:\n 589 mL\n 296 mL\n Blood products:\n Total out:\n 550 mL\n 450 mL\n Urine:\n 550 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,159 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 90%\n ABG: 7.36/43/78./26/-1\n PaO2 / FiO2: 158\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 13.2 g/dL\n 303 K/uL\n 189 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 10 mg/dL\n 97 mEq/L\n 135 mEq/L\n 41.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:31 AM\n 12:30 PM\n 12:42 PM\n 03:50 PM\n 06:38 PM\n 10:08 PM\n 03:27 AM\n WBC\n 21.3\n Hct\n 41.0\n Plt\n 303\n Cr\n 0.8\n 0.7\n TropT\n <0.01\n TCO2\n 28\n 29\n 28\n 25\n 25\n Glucose\n 205\n 189\n Other labs: CK / CKMB / Troponin-T:75//<0.01, Differential-Neuts:89.9\n %, Lymph:7.5 %, Mono:2.6 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:8.7\n mg/dL, Mg++:2.6 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR low lung volumesd improved from , improved patch\n opacity RNL\n Microbiology: urine legionella neg\n blood cx gpc pairs and chains 1/2 bottles\n ECG: nsr\n Assessment and Plan\n 32 yo F smoker h.o crohns, now with asthma exacerbation\n 1. Asthma exacterbation:\n exam with persistent insp/exp wheeze, speaking in full sentences\n - will decrease solumedrol to 80 with plan to taper to pred 60\n tomorrow if continued improvement\n - was on continuous nebs - will change to PRN nebs and monitor needs\n - given persistent cough, low grade temps, and slower improvement,\n will start azithro for empiric atypical mycobacteria coverage, although\n likely viral infection\n 2. Chest pain with EKG changes: likey RH strain in setting of flare\n - PE ct was negative for central PE\n - ruling out, cont cycle enzymes and monitor ekgs\n 3. + blood culture: likely contaminant, but has had lines in place\n - will cont empiric vanc coverage, await speciation\n 4. Hyperglycemia:\n - cont RISS esp while on steroids\n 5. Anxiety:\n - previously on high dose valium, but concern for respiratory\n depression\n - ativan as needed for anxiety\n 6. Crohns: stable\n ICU Care\n Nutrition:\n Comments: had been npo for ? urgent intubation, but improving so will\n advance to clears\n Glycemic Control:\n Lines:\n 20 Gauge - 09:28 AM\n Arterial Line - 03:24 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition :\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2114-09-01 00:00:00.000", "description": "Nursing 1900-0700", "row_id": 416226, "text": "Ineffective Coping\n Assessment:\n Pt expressed her frustration and lack of support surrounding the care\n of her children and ineffective coping. Pt states,\nThere is no one\n that I can really talk to because I do not have family around.\n Action:\n HO was made aware, Nursing spent time with pt allowing her to vent her\n frustration and concerns regarding her care and family difficulties. SW\n consult placed.\n Response:\n Waiting for response from pt and SW consult.\n Plan:\n SW to see pt. Allow pt to vent her feelings and concerns\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt continues to c/o mild chest discomfort mostly after pt has coughing\n event.\n Action:\n PT was given nebulizer treatment. Last levels of cardiac enzymes were\n negative.\n Response:\n ECG obtained in AM.\n Plan:\n Continue to monitor ECG and cardiac enzymes PRN if recurrent chest pain\n as night prior.\n Asthma\n Assessment:\n Assumed care of pt on 4L NC, pt with expiratory wheezes in all fields.\n Pt has had no c/o SOB or DOE. Pt with episodes of prolonged coughing\n spells.\n Action:\n ABG obtained on 4L NC. Pt given nebulizer treatment of albuterol and\n inhalers per . Pt was changed from 4L NC to cool air aerosol 0.50%,\n 5L. Sputum culture sent.\n Response:\n ABG on 4 L 7.42/40/73. SpO2 on cool air aerosol 94-96%. Pt with notable\n decrease in wheezes after treatment.\n Plan:\n Continue to titrate O2 requirements, monitor ABG\ns, nebulizer\n treatments PRN.\n Headache\n Assessment:\n Pt c/o of having a HA of .\n Action:\n Pt given furoset PO, lights were turned off per pt request, pt given\n cold packs for HA.\n Response:\n Pt states that HA pain level has decreased to . Pt states,\nit has\n calmed down a lot but it is never really gone.\n Plan:\n Continue to provide pt with PO medications for discomfort.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2195-05-14 00:00:00.000", "description": "Report", "row_id": 1631232, "text": "Nursing Progress Note\n\nO: Please see FHP and flow sheet for objective data. 71 yo women s/p R carotid stenting today with good BP throughout the procedure. Tele: sinus brady with PAC's & PVC's. SBP 110's 140's. R groin with sm ooze. Sheath pulled using minx closure device. diastal pulses are palapble.\n\nResp: Lungs CTA. O2 sats >94% on 2l.\n\nNeuro: Pt is alert and oriented x's 3. PERRL. Bilateral hand grasp. Able to MAE. Denies headache. Pt has h/o restless leg syndrome. Takes Mirapex. Bedrest x's 3hrs. OOB at 6pm.\n\nGI/GU: Appetite is good. Abd is soft with bowel sounds present. Foley draining CYU. IV 1/2 NS at 75cc/hr x's 1 liter.\n\nSocial Pt lives alone husband died of sudden cardiac death in . She has 3 daughters 2 are with pt and have spoken with Dr .\n\nA&P: 71 yo women admitted for carotid angio s/p PCI to R ICA. Hemodynamically stable. Cont to hold antihypertensives. Monitor BP. Bedrest until 6pm. Post cath fluids MD.\n" }, { "category": "Nursing/other", "chartdate": "2195-05-15 00:00:00.000", "description": "Report", "row_id": 1631233, "text": "CCU NPN 1900-0700\nS: \" I might go home today \"\nO: s/p right carotid stent. overnight, HR 49-50's SB. PAC's. BP 120-130's/\nback to bed late eve, stable on feet ambulating. no CP/SOB.\nright fem. cath site D/I/soft. pulses +. extrem. warm.\nslept til ~ 0400, then dozing off/on. no c/o pain.\nfoley d/c'd this morning. DTV. foley drained >1L overnight.\nIVF x1L completed.\ntaking water with meds and at bedside.\nLS clear. sats on RA 96% when awake...dipping to 90% overnight- placed on 2lnc while asleep.\n\nplan; d/c to home today...Dr. making plan for meds at home. OOB and ambulate today.\n" }, { "category": "Nursing/other", "chartdate": "2195-05-15 00:00:00.000", "description": "Report", "row_id": 1631234, "text": "CCU Nursing progress note 7am-4pm\nS: I was really scared about the proceedure.\n\nO: CV - HR 47-71 sb/sr w/ occ pac's. BP 98-150/40-50's. r groin dsd removed. Cath site intact w/ bandaid. Pulses +2/+2 bilat. Feet warm\n\nNeuro - alert and oriented x3, speech nl, MAE,\n\nResp - ls clear on RA w/ sats 96-100%.\n\nGU- voiding on commode without difficulty\n\nGI - Appetite good for meals. Abd soft w/ +bs. No stool\n\nActivity - Amb while pushing wheelchair without difficulty. BP up to 130-150/ w/ ambulation, otherwise 98-110/\n\nDischarge instructions given and pt was discharged from CCU at 3:45pm.\n" }, { "category": "ECG", "chartdate": "2195-05-15 00:00:00.000", "description": "Report", "row_id": 142912, "text": "Probable ectopic atrial rhythm. Compared to tracing #1 low atrial rhythm\nversus ectopic atrial rhythm is present with absence of atrial ectopy.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2195-05-14 00:00:00.000", "description": "Report", "row_id": 142913, "text": "Sinus rhythm with frequent atrial premature beats. Compared to the previous\ntracing of frequent atrial ectopy is now present.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2167-08-03 00:00:00.000", "description": "Report", "row_id": 1373472, "text": "Addendum\n\nPt with sudden decrease in SBP down to 70's, MAP's down to 50's. No change in HR. CT o/p unchanged. MD . Pt given 400cc NS with slight improvement in BP. Restarted a pacing at rate of 90 with improved SBP to 90-100's, MAP's 60-70's. Pt otherwise unchanged. O2 sats 98% or greater on CPAP. Tidal volumes 500's, rr 20's. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-04 00:00:00.000", "description": "Report", "row_id": 1373473, "text": "CSRU PROGRESS\nAWAKE, ALERT, O X 3. EXTUBATED AT . SWITCHED FROM FACE MASK TO NP'S WITH GOOD SATS. HR HIGH 90'S SR. A-PACED AT 9O. SBP ~ 100. ONE EPISODE OF HYPOTENSION - SBP 70'S. CONFIRMED W/ CUFF. ~ 400 CC LR GIVEN W/ IMPROVEMENT. GOOD PAIN CONTROL W/ TORADOL. K, MG, IoCA AND GLUCOSE LEVELS TREATED. DOING WELL. TO BE TRANSFERRED TO THE FLOOR THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-04 00:00:00.000", "description": "Report", "row_id": 1373474, "text": "CSRU TRANSFER NOTE\n\nMr. is a 62 year old man with known CAD who was experiencing increasing SOB w/ exertion. He had CP for which he was admitted to - where he r/o for MI. Cardiac cath with 3VD, EF 55%. He went to OR for CABG x 4 with LIMA to LAD. OR course stable. CSRU course stable: initially on/off NTG gtt then required a pacing for low BP. Extubated last night without difficulty.\n\nAllergy: Contrast dye.\n\nPMH: BPH, Htn, elevated cholesterol, GERD, s/p repair of dupryten contractions.\n\nNeuro: Alert and oriented x 3. MAE with equal strength. Seems slightly anxious and frequently asking questions as to \"what is going to happen next\". Does better with reassurance and explanations of plans.\n\nCV: HR 90's NSR, no ectopy noted. BP 90-low 100's/50's. OOB to chair with c/o slight dizziness this morning. Skin warm, dry. + pp bilat. Up approx 8 kg from pre op. Hct 28. Ct's d/ by NP this morning. DLCL removed without difficulty.\n\nResp: BS initially rhonchorous throughout which cleared with coughing and deep breathing. Currently with diminished BS at bases. Clearing thick yellow sputum in small amts with good cough. O2 sats 96% or greater on 4l NP.\n\nGI/GU: + BS. Abd soft, ND. Denies nausea. Not interested in taking in much po. Is currently taking ice chips to ease dryness. u/o 60-80cc/hr this morning. BUN/Cr wnl.\n\nID: Low grade temp last night treated w/ tylenol. Afebrile this morning.\n\nEndo: Glucose control per protocol. Receiving SC insulin prn.\n\nSkin: Sternal incision w/ steristrips intact, OTA. Right leg incision with acewrap in place, no dng noted. Right groin site with steristrips, scant amt serousang dng, DSD changed. No breakdown noted.\n\nComfort/Activity: Med with SC MSO4 4 mg with good effect for \"discomfort\" at incisions. OOB to chair w/ 2 assist-tolerated well.\n\nSocial: Son's in visiting.\n\nA/P Hemodynamically stable. Assess readiness for lopressor given SBP 90-100's. Monitor lytes and replace prn. Cont with pulmonary hygiene and wean O2 as tolerated. Begin diuresis. Med for pain prn. Increase activity as tolerated. Transfer to 6 today.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-04 00:00:00.000", "description": "Report", "row_id": 1373475, "text": "ADDENDUM\n\nSBP in 90's with HR in 90's. Pt asymptomatic. NP. Lopressor dose held. Ok for transfer to 6 NP.\n" }, { "category": "Nursing/other", "chartdate": "2167-08-03 00:00:00.000", "description": "Report", "row_id": 1373471, "text": "NSG ACCEPTANCE NOTE\n\nMr. is a 62 year old man with known CAD who started to have increased anginal symptoms. w/u revealed 3vd w/ ef of 55%. Went to OR today for CABG x 4 with LIMA to LAD. OR course stable.\n\nAllergies: IV contrast dye.\n\nNeuro: Initially sedated on propofol at 30 mcg/kg/min. Weaned to off. Currently is sleepy but easily arousable to voice. Able to MAE with equal strength to request. PERRL.\n\nCV: Arrived a paced at rate of 88. A pacing turned off with underlying rhythm of normal sinus at rate in 70's. No ectopy noted. BP labile at times. On/off NTG to maintain MAP's 60-80. See careview for details. CVP initially 9--> up to 14-16 after 1l NS. CT's with decreasing o/p-did have dump with turning. Hct 32. K+ 3.3 repleted. Repeat K+ pnd.\n\nResp: Rhonchorous upon arrival. Suctioned for scant amt thin clear secretions. Lots of oral secretions. PaO2 116 on SIMV 10x900, 100%. NP-Peep increased to 8 FiO2 decreased to 70%. Repeat ABG 208. Decreased to 40% FiO2 with O2 sats 99% or greater.\n\nGI/GU: OGT w/ mod amt lt brown o/p. No BS noted. Large u/o.\n\nEndo: Received amp D50 for glucose 68--> repeat 185 rx'd w/ IV insulin.\n\nID: Initially warm at 96 po then decreased to 95.7 po. Rewarmed up to greater than 96 po. Vanco q 12 hours ordered.\n\nComfort: Facial grimaces and mouthing he was in a lot of pain upon awakening. Rx'd w/ MsO4 and Toradol with good effect.\n\nSkin: Intact to back/buttocks. Dsgs to sternum, right groin, CT's, and right leg dry and intact.\n\nA/P Sleepy but easily arousable to voice and MAE. BP currently stable off NTG. Monitor electrolytes closely and replete prn. To attempt CPAP ventilation and plan to wean if patient awake enough. Monitor CT o/p. Glucose control per protocol. Med for pain prn.\n" }, { "category": "ECG", "chartdate": "2167-08-03 00:00:00.000", "description": "Report", "row_id": 108457, "text": "Sinus rhythm, rate 81\nProbably normal Early transition, but should Consider posterior infardt\nAnterior ST segment elevation - Consider acute injury\nConsider prior inferior myocardial infarct\nSince last ECG, further QRS & ST-T changes present\nAbnormal ECG\n\n" }, { "category": "ECG", "chartdate": "2167-07-31 00:00:00.000", "description": "Report", "row_id": 108458, "text": "Normal sinus rhythm, rate 85\nEarly transition\nDiffuse nonspecific T wave abnormalities\nAbnormal ECG\n\n" }, { "category": "Radiology", "chartdate": "2167-08-02 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 740891, "text": " 1:52 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: preop cabg. cough, r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cad awaiting cabg with cough\n REASON FOR THIS EXAMINATION:\n preop cabg. cough\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Preop cabg. R/O infiltrate.\n\n CHEST, THREE VIEWS: There is mild hyperinflation. The heart is not enlarged\n and there is no CHF, focal infiltrate or effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741038, "text": " 10:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Temp spike.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p CABG.\n REASON FOR THIS EXAMINATION:\n Temp spike.\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE FILM.\n\n HISTORY: CABG and fever.\n\n S/P CABG. There are low lung volumes. There is obscuration of the left\n hemidiaphragm, likely due to atelectasis/consolidation in the left lower lobe.\n The left CPA is coned off the film and a small left pleural effusion cannot\n be ruled out. Appearances are essentially unchanged since the prior study of\n the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2167-08-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 741029, "text": " 4:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG, need CXR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG, need CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n CHEST, SINGLE VIEW\n\n Comparison is made to study of .\n\n Patient is status post CABG surgery. There are expected post CABG surgery\n changes including small left effusion and left lower lobe collapse. No\n pneumothorax is seen. There are low lung volumes.\n\n IMPRESSION: Post op changes with no acute disease process identified.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2112-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 514466, "text": "Briefly, 80 year old Mandarin speaking female patient of Dr\n \ns, presenting with symptomatic bradycardia in setting of\n multiple nodal agents and dronaderone taken for recent PAF episodes. Pt\n speaks Manarin but understands English.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU. Temp wire placed via R IJ. pt\n converted to sinus rhythm minimal need for pacing.\n Bradycardia\n Assessment:\n Tele sinus rhythm 60\n Backup rate of pacer decreased to 50.\n Pacer sensing & pacing appropriately.\n Denies chest pain. Lungs few scattered rales.\n INR 2.0 this am.\n Conts with brisk diuresis from lasix .\n Action:\n Nodal agents remain on hold.\n Response:\n Sinus rhythm with periods of AF. Team aware.\n Rate 60-100\n Plan:\n To EP lab for PPM.\n To hold off on restarting meds for now.\n" }, { "category": "Nursing", "chartdate": "2112-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 514468, "text": "Briefly, 80 year old Mandarin speaking female patient of Dr\n \ns, presenting with symptomatic bradycardia in setting of\n multiple nodal agents and dronaderone taken for recent PAF episodes. Pt\n speaks Manarin but understands English.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU. Temp wire placed via R IJ. pt\n converted to sinus rhythm minimal need for pacing.\n Bradycardia\n Assessment:\n Tele sinus rhythm 60\n Backup rate of pacer decreased to 50.\n Pacer sensing & pacing appropriately.\n Denies chest pain. Lungs few scattered rales.\n INR 2.0 this am.\n Conts with brisk diuresis from lasix .\n Action:\n Nodal agents remain on hold.\n Response:\n Sinus rhythm with periods of AF. Team aware.\n Rate 60-100\n Plan:\n To EP lab for PPM.\n To hold off on restarting meds for now.\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n BRADYCARDIA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 57.5 kg\n Daily weight:\n 55.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Arrhythmias, CAD, Hypertension\n Additional history: s/p nephrectomy\n Surgery / Procedure and date: Admitted to ED last pm with RVR tx'd with\n diltiazem IV/po and discharged at 430am. Pt returned at aprrox 1030\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:141\n D:61\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 110 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 58 mL\n 24h total out:\n 3,930 mL\n Pacer Data\n Temporary pacemaker type:\n Transvenous\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 40 bpm\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 10 mV\n Temporary ventricular sensitivity setting:\n 5 mV\n Temporary ventricular stimulation threshold :\n 2 mA\n Temporary ventricular stimulation setting :\n 10 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires ventricular:\n 1\n Transcutaneous pacemaker placement:\n Not applicable\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:03 AM\n Potassium:\n 3.8 mEq/L\n 04:03 AM\n Chloride:\n 104 mEq/L\n 04:03 AM\n CO2:\n 23 mEq/L\n 04:03 AM\n BUN:\n 18 mg/dL\n 04:03 AM\n Creatinine:\n 1.0 mg/dL\n 04:03 AM\n Glucose:\n 82 mg/dL\n 04:03 AM\n Hematocrit:\n 27.9 %\n 04:03 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 3 via EP lab.\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514248, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2112-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514464, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:54 PM\n NASAL SWAB - At 08:15 PM\n Routine MRSA Swab\n Temp pacing wire placed via RIJ cordis\n Lasix IV 20mg given for crackles on lung exam, put out close to 3L\n overnight\n Dopamine weaned off\n HR 60s all night, her own rhythm, not dependent on pacer\n Converted back Afib this morning during rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.8\nC (98.3\n HR: 62 (38 - 70) bpm\n BP: 122/53(69) {95/33(48) - 124/58(72)} mmHg\n RR: 12 (12 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,701 mL\n 8 mL\n PO:\n TF:\n IVF:\n 165 mL\n 8 mL\n Blood products:\n 536 mL\n Total out:\n 708 mL\n 2,890 mL\n Urine:\n 708 mL\n 2,890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,993 mL\n -2,882 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n GENERAL: NAD. Mood, affect appropriate. Oriented x 3\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. II/VI SM at apex. No thrills, lifts. No S3 or S4.\n LUNGS: bibasilar crackles, no wheezing\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Labs / Radiology\n 231 K/uL\n 9.7 g/dL\n 82 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 104 mEq/L\n 136 mEq/L\n 27.9 %\n 7.6 K/uL\n [image002.jpg]\n 07:18 PM\n 04:03 AM\n WBC\n 9.4\n 7.6\n Hct\n 31.8\n 27.9\n Plt\n 284\n 231\n Cr\n 1.2\n 1.0\n Glucose\n 137\n 82\n Other labs:\n PT / PTT / INR:21.8/36.0/2.0, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n CXR :\n No evidence of pneumothorax. Status post right IJ approach pacing wire\n pacement in RV. Lungs with bibasilar atelectasis. Mild pulmonary\n interstitial edema.\n TTE : The left atrium is normal in size. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. Trace aortic regurgitation is seen. The mitral\n valve leaflets are structurally normal. Mild to moderate (+) mitral\n regurgitation is seen. There is moderate pulmonary artery systolic\n hypertension. There is an anterior space which most likely represents a\n fat pad.\n Compared with the prior study (images reviewed) of , the\n bradycardia is more profound and the estimated PA systolic pressure is\n higher. The severity of mitral and aortic regurgitation are similar.\n Assessment and Plan\n 80 y/o F with pAF and hypertension presenting with bradycardia, likely\n manifestation of sick sinus syndrome.\n .\n # RHYTHM: Patient presented with bradycardia. Presentation ECG\n consistent with junctional bradycardia; however subsequent ECG with\n likely AV dissociation. Given history of pAF, likely has Sick sinus\n syndrome and will require PPM. On admission, temp wire was placed is\n currently VVI paced at 60 BPM. Was given 2u FFP to reverse\n anticoagulation on . Overnight on , patient's intrinsic heart\n rate was around 60-70s, not requiring pacing. BP improved as well.\n Patient was initially on dopamine 10, was weaned off overnight. During\n the rounds this morning, patient went back to Afib, HR around 100.\n - plan for PPM this morning, pt is on call to the EP lab\n - Hold Anticoagulation for now, will restart after PPM placement\n - monitor on tele\n - can restart AV nodal blockers after the PPM placement\n .\n # PUMP: Patient received 4L NS bolus in ED. Volume overloaded on exam\n with signs of L sided heart failure from aggressive fluid\n resusitation. Patient was on 6L NC on admission, weaned down to 3L\n this am. Echo with preserved systolic function. Patient took\n a significant number of antihypertensive medications this AM, which is\n also contributing to her hypotention. MAP improved on Dopamine and as\n BP medications are wearing off. Patient was initially on dopamine 10,\n was weaned off overnight. As patient sounded crackly on lung exam, she\n was given 20mg IV lasix overnight on . She put out close to 3L\n overnight to the 20mg IV lasix. This AM, lung exam better but still\n has bibasilar crackles.\n - hold off on further diuresis as she is going to be NPO today, and she\n will also likely self-diurese the rest of the fluid. She is able to\n tolerate lying flat for the EP procedure\n - wean oxygen as tolerated\n .\n # CORONARIES: No known history of CAD.\n - Monitor sx\n .\n # CKD: Patient s/p L nephrectomy for RCC three years ago. Basline Cr\n ~1.0. Admission Cr 1.2, likely pre-renal etiology secondary to\n hypotension. Cr back to baseline 1.0 this AM.\n - Trend renal function\n .\n # Hepatitis B: Diagnosed > 10 years ago, unclear mode of\n transmission. HepBSAg Pos, EAb Pos, EAg Neg, Viral load ~3000 .\n Patient seen in Liver Clinic in , and recommended against liver Bx\n and treatment given low viral load and lack of clinical symptoms.\n - Monitor LFTs and sx\n ICU Care\n Nutrition:\n Cardiac healthy diet\n Glycemic Control: not on insulin\n Lines:\n 18 Gauge - 02:27 PM\n 16 Gauge - 02:28 PM\n Cordis/Introducer - 05:54 PM\n Prophylaxis:\n DVT: coumadin held currently, will restart after PPM placement today\n Stress ulcer: not indicated\n VAP: not indicated\n Comments:\n Communication: Comments: to be contact person \n (), (office)\n Code status: Full code\n Disposition: can transfer to floor after PPM placement if everything\n goes well\n" }, { "category": "Nursing", "chartdate": "2112-02-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 514465, "text": "Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2112-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514414, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:54 PM\n NASAL SWAB - At 08:15 PM\n Routine MRSA Swab\n Temp pacing wire placed via RIJ cordis\n Lasix IV 20mg given\n Dopamine weaned off\n HR 60s all night, her own rhythm, not dependent on pacer\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.8\nC (98.3\n HR: 62 (38 - 70) bpm\n BP: 122/53(69) {95/33(48) - 124/58(72)} mmHg\n RR: 12 (12 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,701 mL\n 8 mL\n PO:\n TF:\n IVF:\n 165 mL\n 8 mL\n Blood products:\n 536 mL\n Total out:\n 708 mL\n 2,890 mL\n Urine:\n 708 mL\n 2,890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,993 mL\n -2,882 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n GENERAL: NAD. Mood, affect appropriate. Oriented x 3\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. II/VI SM at apex. No thrills, lifts. No S3 or S4.\n LUNGS: Crackles 1/3 up bilaterally\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Labs / Radiology\n 231 K/uL\n 9.7 g/dL\n 82 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 104 mEq/L\n 136 mEq/L\n 27.9 %\n 7.6 K/uL\n [image002.jpg]\n 07:18 PM\n 04:03 AM\n WBC\n 9.4\n 7.6\n Hct\n 31.8\n 27.9\n Plt\n 284\n 231\n Cr\n 1.2\n 1.0\n Glucose\n 137\n 82\n Other labs:\n PT / PTT / INR:21.8/36.0/2.0, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n CXR :\n No evidence of pneumothorax. Status post right IJ approach pacing wire\n pacement in RV. Lungs with bibasilar atelectasis. Mild pulmonary\n interstitial edema.\n TTE : The left atrium is normal in size. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. Trace aortic regurgitation is seen. The mitral\n valve leaflets are structurally normal. Mild to moderate (+) mitral\n regurgitation is seen. There is moderate pulmonary artery systolic\n hypertension. There is an anterior space which most likely represents a\n fat pad.\n Compared with the prior study (images reviewed) of , the\n bradycardia is more profound and the estimated PA systolic pressure is\n higher. The severity of mitral and aortic regurgitation are similar.\n Assessment and Plan\n 80 y/o F with pAF and hypertension presenting with bradycardia, likely\n manifestation of sick sinus syndrome.\n .\n # RHYTHM: Patient presented with bradycardia. Presentation ECG\n consistent with junctional bradycardia; however subsequent ECG with\n likely AV dissociation. Given history of pAF, likely has Sick sinus\n syndrome and will require PPM. On admission, temp wire was placed is\n currently VVI paced at 60 BPM. Was given 2u FFP to reverse\n anticoagulation on . Overnight on , patient's intrinsic heart\n rate was around 60-70s, not requiring pacing. BP improved as well.\n Patient was initially on dopamine 10, was weaned off overnight.\n - plan for PPM today\n - Hold Anticoagulation for now, will restart after PPM placement\n - monitor on tele\n - hold all AV nodal blockers for now\n .\n # PUMP: Patient received 4L NS bolus in ED. Volume overloaded on exam\n with signs of L sided heart failure from aggressive fluid\n resusitation. Patient was on 6L NC on admission, weaned down to 3L\n this am. Echo with preserved systolic function. Patient took\n a significant number of antihypertensive medications this AM, which is\n also contributing to her hypotention. MAP improved on Dopamine and as\n BP medications are wearing off. Patient was initially on dopamine 10,\n was weaned off overnight. As patient sounded crackly on lung exam, she\n was given 20mg IV lasix overnight on . She put out close to 3L\n overnight to the 20mg IV lasix.\n - wean oxygen as tolerated\n - keep I/O even today\n .\n # CORONARIES: No known history of CAD.\n - Monitor sx\n .\n # CKD: Patient s/p L nephrectomy for RCC three years ago. Basline Cr\n ~1.0. Admission Cr 1.2, likely pre-renal etiology secondary to\n hypotension. Cr back to baseline 1.0 this AM.\n - Trend renal function\n .\n # Hepatitis B: Diagnosed > 10 years ago, unclear mode of\n transmission. HepBSAg Pos, EAb Pos, EAg Neg, Viral load ~3000 .\n Patient seen in Liver Clinic in , and recommended against liver Bx\n and treatment given low viral load and lack of clinical symptoms.\n - Monitor LFTs and sx\n ICU Care\n Nutrition:\n Cardiac healthy diet\n Glycemic Control: not on insulin\n Lines:\n 18 Gauge - 02:27 PM\n 16 Gauge - 02:28 PM\n Cordis/Introducer - 05:54 PM\n Prophylaxis:\n DVT: coumadin held currently, will restart after PPM placement today\n Stress ulcer: not indicated\n VAP: not indicated\n Comments:\n Communication: Comments: to be contact person \n (), (office)\n Code status: Full code\n Disposition: can transfer to floor after PPM placement\n" }, { "category": "Nursing", "chartdate": "2112-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514418, "text": "Bradycardia/ fluid overload\n Assessment:\n Temp wire in place, on peripheral dopamine. Crackles at bases.\n Action:\n Sense and stim thresholds tested, tele monitored\n Dopa weaned\n 20mg IV lasix given\n Response:\n Stable off Dopa, Hr 60s SR, occas V-paced beats. Excellent response to\n diuresis. K+ 3.8, Mg+ 1.9. L arm PIV where Dopa infusing WNL. INR 2.0.\n Plan:\n To EP for PPM today.\n Replete lytes\n OF NOTE: HCT down to 27.9 (31.8\n35.3\n40.6) . No stool. T&S active til\n Thursday 23:59. Continue to monitor, Guiac stools.\n ------ Protected Section ------\n Alarms ringing for asystole. Pacer not appropriately sensing intrinsic\n beats. Sensitivity decreased to make pacer sense intrictic beats. Rate\n set at 60, occas requiring PCM\n ------ Protected Section Addendum Entered By: , RN\n on: 07:15 ------\n" }, { "category": "Physician ", "chartdate": "2112-02-16 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514419, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:54 PM\n NASAL SWAB - At 08:15 PM\n Routine MRSA Swab\n Temp pacing wire placed via RIJ cordis\n Lasix IV 20mg given\n Dopamine weaned off\n HR 60s all night, her own rhythm, not dependent on pacer\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.8\nC (98.3\n HR: 62 (38 - 70) bpm\n BP: 122/53(69) {95/33(48) - 124/58(72)} mmHg\n RR: 12 (12 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,701 mL\n 8 mL\n PO:\n TF:\n IVF:\n 165 mL\n 8 mL\n Blood products:\n 536 mL\n Total out:\n 708 mL\n 2,890 mL\n Urine:\n 708 mL\n 2,890 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,993 mL\n -2,882 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n GENERAL: NAD. Mood, affect appropriate. Oriented x 3\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. II/VI SM at apex. No thrills, lifts. No S3 or S4.\n LUNGS: bibasilar crackles 1/3 up bilaterally\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Labs / Radiology\n 231 K/uL\n 9.7 g/dL\n 82 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 104 mEq/L\n 136 mEq/L\n 27.9 %\n 7.6 K/uL\n [image002.jpg]\n 07:18 PM\n 04:03 AM\n WBC\n 9.4\n 7.6\n Hct\n 31.8\n 27.9\n Plt\n 284\n 231\n Cr\n 1.2\n 1.0\n Glucose\n 137\n 82\n Other labs:\n PT / PTT / INR:21.8/36.0/2.0, Albumin:3.5 g/dL, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n CXR :\n No evidence of pneumothorax. Status post right IJ approach pacing wire\n pacement in RV. Lungs with bibasilar atelectasis. Mild pulmonary\n interstitial edema.\n TTE : The left atrium is normal in size. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened but aortic\n stenosis is not present. Trace aortic regurgitation is seen. The mitral\n valve leaflets are structurally normal. Mild to moderate (+) mitral\n regurgitation is seen. There is moderate pulmonary artery systolic\n hypertension. There is an anterior space which most likely represents a\n fat pad.\n Compared with the prior study (images reviewed) of , the\n bradycardia is more profound and the estimated PA systolic pressure is\n higher. The severity of mitral and aortic regurgitation are similar.\n Assessment and Plan\n 80 y/o F with pAF and hypertension presenting with bradycardia, likely\n manifestation of sick sinus syndrome.\n .\n # RHYTHM: Patient presented with bradycardia. Presentation ECG\n consistent with junctional bradycardia; however subsequent ECG with\n likely AV dissociation. Given history of pAF, likely has Sick sinus\n syndrome and will require PPM. On admission, temp wire was placed is\n currently VVI paced at 60 BPM. Was given 2u FFP to reverse\n anticoagulation on . Overnight on , patient's intrinsic heart\n rate was around 60-70s, not requiring pacing. BP improved as well.\n Patient was initially on dopamine 10, was weaned off overnight.\n - plan for PPM today\n - Hold Anticoagulation for now, will restart after PPM placement\n - monitor on tele\n - hold all AV nodal blockers for now\n .\n # PUMP: Patient received 4L NS bolus in ED. Volume overloaded on exam\n with signs of L sided heart failure from aggressive fluid\n resusitation. Patient was on 6L NC on admission, weaned down to 3L\n this am. Echo with preserved systolic function. Patient took\n a significant number of antihypertensive medications this AM, which is\n also contributing to her hypotention. MAP improved on Dopamine and as\n BP medications are wearing off. Patient was initially on dopamine 10,\n was weaned off overnight. As patient sounded crackly on lung exam, she\n was given 20mg IV lasix overnight on . She put out close to 3L\n overnight to the 20mg IV lasix. This AM, lung exam better but still\n has bibasilar crackles.\n - hold off on further diuresis as she is going to be NPO today, and she\n will also likely self-diurese the rest of the fluid. She is able to\n tolerate lying flat for the EP procedure\n - wean oxygen as tolerated\n .\n # CORONARIES: No known history of CAD.\n - Monitor sx\n .\n # CKD: Patient s/p L nephrectomy for RCC three years ago. Basline Cr\n ~1.0. Admission Cr 1.2, likely pre-renal etiology secondary to\n hypotension. Cr back to baseline 1.0 this AM.\n - Trend renal function\n .\n # Hepatitis B: Diagnosed > 10 years ago, unclear mode of\n transmission. HepBSAg Pos, EAb Pos, EAg Neg, Viral load ~3000 .\n Patient seen in Liver Clinic in , and recommended against liver Bx\n and treatment given low viral load and lack of clinical symptoms.\n - Monitor LFTs and sx\n ICU Care\n Nutrition:\n Cardiac healthy diet\n Glycemic Control: not on insulin\n Lines:\n 18 Gauge - 02:27 PM\n 16 Gauge - 02:28 PM\n Cordis/Introducer - 05:54 PM\n Prophylaxis:\n DVT: coumadin held currently, will restart after PPM placement today\n Stress ulcer: not indicated\n VAP: not indicated\n Comments:\n Communication: Comments: to be contact person \n (), (office)\n Code status: Full code\n Disposition: can transfer to floor after PPM placement\n" }, { "category": "Nursing", "chartdate": "2112-02-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514399, "text": "Bradycardia/ fluid overload\n Assessment:\n Temp wire in place, on peripheral dopamine. Crackles at bases.\n Action:\n Sense and stim thresholds tested, tele monitored\n Dopa weaned\n 20mg IV lasix given\n Response:\n Stable off Dopa, Hr 60s SR, occas V-paced beats. Excellent response to\n diuresis. K+ 3.8, Mg+ 1.9. L arm PIV where Dopa infusing WNL. INR 2.0.\n Plan:\n To EP for PPM today.\n Replete lytes\n OF NOTE: HCT down to 27.9 (31.8\n35.3\n40.6) . No stool. T&S active til\n Thursday 23:59. Continue to monitor, Guiac stools.\n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514284, "text": "Briefly, 80 year old Mandarin speaking female patient of Dr\n \ns, presenting with symptomatic bradycardia in setting of\n multiple nodal agents and dronaderone taken for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received from ED on dopamine at 10mcgs/kg/min.\n Tele sinus brady 40\ns alternating with junctional rhythm.\n SBP 90\ns-100\n Pt c/o feeling dizzy.\n INR 2.6 from 2pm.\n Rales in bases.\n O2 sats 95%.\n Denies chest pain.\n Action:\n Meds on hold.\n Given 2units of FFP.\n Trans venous pacer placed at bedside.\n Response:\n Plan:\n PPM once INR is < 2.2\n Hold all nodal agents.\n Wean dopamine as BP tolerates.\n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514279, "text": "Briefly, 80 year old Mandarin speaking female patient of Dr\n \ns, presenting with symptomatic bradycardia in setting of\n multiple nodal agents and dronaderone taken for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received from ED on dopamine at 10mcgs/kg/min.\n Tele sinus brady 40\ns alternating with junctional rhythm.\n SBP 90\ns-100\n Pt c/o feeling dizzy.\n INR 2.6 from 2pm.\n Rales in bases.\n O2 sats 95%.\n Denies chest pain.\n Action:\n Meds on hold.\n Given 2units of FFP.\n Trans venous pacer placed at bedside.\n Response:\n Plan:\n PPM once INR is < 1.8.\n Hold BB.\n Wean dopamine as BP tolerates.\n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514272, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514274, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2112-02-15 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 514340, "text": "TITLE:\n Chief Complaint: Bradycardia\n HPI:\n 80yoF w/ a h/o pAF (on Dronedarone) and hypertension, recently\n discharged from , represented to the ED this morning with general\n malaise, chest heaviness, and self-reported bradycardia.\n .\n The patient had been hospitalized from for new onset atrial\n fibrillation and was started on dronedarone for rhythm control. The\n patient was also started on warfarin in addition to her home\n metoprolol succinate and norvasc. The patient was discharged home\n without complication.\n .\n The patient represented to the ED early in the AM of with Atrial\n fibrillation with RVR (120s). Patient was rate controlled in the ED\n with 10mg IV dilt then 60mg po dilt and 5mg IV dilt and was ultimately\n discharged home on diltiazem XR 120mg daily. Once she got home, she\n took her home medications (metoprolol, norvasc, dronedarone) and\n developed generalized fatigue and noted her pulse to be in the 30s,\n prompting her to return to the ED.\n .\n In the ED, she presented with an inital heart rate in the 40s, with her\n systolic blood pressure in the 80s. She complained of fatigue,\n malaise, and chest discomfort. She received ASA, calcium, glucagon and\n zofran. Pacer pads were placed in the ER. She was started on\n peripheral dopamine at 10mcg. Pt continued to feel nauseated and was\n transferred to CCU.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n cough, hemoptysis, black stools or red stools. S/he denies recent\n fevers, chills or rigors. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n syncope or presyncope. ROS positive as above.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 6.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n HOME MEDS:\n Toprol 50mg daily\n Dronedarone\n Norvasc 5mg daily\n Diltiazem 120mg XL daily ***Started in ED, script not filled\n Protonix\n Warfarin 5mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: Hypertension\n 2. CARDIAC HISTORY:\n -CABG: none\n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD:none\n 3. OTHER PAST MEDICAL HISTORY:\n mild AR and mild MR.\n Palpitations associated with atypical CP.\n HTN\n GERD\n Hepatitis B\n CKD\n s/p L nephrectomy \n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory.\n Worked as ob/gyn in , lives with husband, daughter very\n involved.\n -Tobacco history:none\n -ETOH: none\n -Illicit drugs:none\n Review of systems:\n Flowsheet Data as of 11:24 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 60 (38 - 60) bpm\n BP: 109/47(58) {95/33(48) - 124/58(70)} mmHg\n RR: 18 (14 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 4,697 mL\n PO:\n TF:\n IVF:\n 161 mL\n Blood products:\n 536 mL\n Total out:\n 0 mL\n 608 mL\n Urine:\n 608 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,089 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD. Mood, affect appropriate. Oriented x 3\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: JVP of 12cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. II/VI SM at apex. No thrills, lifts. No S3 or S4.\n LUNGS: Crackles 2/3 up bilaterally\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation. No abdominial bruits.\n EXTREMITIES: No c/c/e.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Labs / Radiology\n 284 K/uL\n 10.6 g/dL\n 137 mg/dL\n 1.2 mg/dL\n 20 mg/dL\n 21 mEq/L\n 106 mEq/L\n 5.1 mEq/L\n 137 mEq/L\n 31.8 %\n 9.4 K/uL\n [image002.jpg]\n \n 2:33 A1/25/ 07:18 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.4\n Hct\n 31.8\n Plt\n 284\n Cr\n 1.2\n Glucose\n 137\n Other labs: PT / PTT / INR:18.5/37.8/1.7, Ca++:7.8 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n 2D-ECHOCARDIOGRAM:\n \n The left atrium is normal in size. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). Right ventricular chamber size and free wall motion are normal.\n The aortic valve leaflets (3) are mildly thickened but aortic stenosis\n is not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild to moderate (+) mitral\n regurgitation is seen. There is moderate pulmonary artery systolic\n hypertension. There is an anterior space which most likely represents a\n fat pad.\n .\n Compared with the prior study (images reviewed) of , the\n bradycardia is more profound and the estimated PA systolic pressure is\n higher. The severity of mitral and aortic regurgitation are similar.\n Assessment and Plan\n 80 y/o F with pAF and hypertension presenting with bradycardia, likely\n manifestation of sick sinus syndrome.\n .\n # RHYTHM: Patient presented with bradycardia. Presentation ECG\n consistent with junctional bradycardia; however subsequent ECG with\n likely AV dissociation. Given history of pAF, likely has Sick sinus\n syndrome and will require PPM. On admission, temp wire was placed is\n currently VVI paced at 60 BPM. Given INR of 2.6, will recheck in AM\n and if < 2.2, plan for PPM on afternoon of .\n - Recheck INR in AM. If > 2.2, can give PO Vita K\n - NPO after MN\n - VVI Pacing @ 60\n - Hold Anticoagulation for now\n .\n # PUMP: Patient is s/p 4L NS bolus in ED. Volume overloaded on exam\n with signs of L sided heart failure from aggressive fluid\n resusitation. Patient on 6L NC. Echo with preserved systolic\n function. Patient took a significant number of antihypertensive\n medications this AM, which is also contributing to her hypotention.\n MAP is improving on Dopamine and as BP medications are wearing off.\n - Diuresis as necessary\n - Wean Dopamine as tolerated\n .\n # CORONARIES: No known history of CAD.\n - Monitor\n .\n # CKD: Patient s/p L nephrectomy for RCC three years ago. Basline Cr\n ~1.0. Admission Cr 1.2, likely pre-renal etiology secondary to\n hypotension.\n - Trend renal function\n - Renally dose medications\n .\n # Hepatitis B: Diagnosed > 10 years ago, unclear mode of\n transmission. HepBSAg Pos, EAb Pos, EAg Neg, Viral load ~3000 .\n Patient seen in Liver Clinic in , and recommended against liver Bx\n and treatment given low viral load and lack of clinical symptoms.\n - Monitor\n .\n FEN: NPO after MN\n .\n ACCESS: RIJ Cordis\n .\n PROPHYLAXIS:\n -DVT ppx: Therapeutically anticoagulated\n .\n CODE: Full\n .\n COMM: to be contact person (home), \n (office)\n .\n DISPO: PPM tomorrrow, then likely to Floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:27 PM\n 16 Gauge - 02:28 PM\n Cordis/Introducer - 05:54 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2112-02-15 00:00:00.000", "description": "Brief EP Admit Note", "row_id": 514265, "text": "TITLE: EP Fellow Brief Admit Note\n Please see resident H+P for full details. Briefly, 80 year old Mandarin\n speaking female patient of Dr \ns, presenting with symptomatic\n bradycardia in setting of multiple nodal agents and dronaderone taken\n for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Currently on IV dopamine 10, s/p 5L IVF, BP 100/35, HR 45-50 sinus\n Cool peripheries\n S1S2\n Lungs CTA\n LABS: Cr 1.2, baseline 1.0, INR 2.6\n ECG: sinus brady, rates 40-50, intermittent junctional rhythm rate 30\n with some dissociated P waves seen.\n IMP/PLAN\n Sick sinus syndrome\n Symptomatic bradycardia\n Unmasked by medications\n Symptomatic PAF\n - Difficult to rate control\n - Will need PPM\n - Cont IVF\n - Wean off dopamine as tolerated, MAP >55\n - Consider temp pacemaker if continues to be hypotensive\n despite fluid\n - Hold coumadin. consider FFP or vit K.\n" }, { "category": "Nursing", "chartdate": "2112-02-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514325, "text": "Briefly, 80 year old Mandarin speaking female patient of Dr\n \ns, presenting with symptomatic bradycardia in setting of\n multiple nodal agents and dronaderone taken for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received from ED on dopamine at 10mcgs/kg/min.\n Tele sinus brady 40\ns alternating with junctional rhythm.\n SBP 90\ns-100\n Pt c/o feeling dizzy.\n INR 2.6 from 2pm.\n Rales in bases.\n O2 sats 95%.\n Denies chest pain.\n Action:\n Meds on hold.\n Given 2units of FFP.\n Trans venous pacer placed at bedside.\n Response:\n Pacer rate set at 60. MA 20 pacer sensing and capturing.\n SBP >100.\n Dopamine decreased to 8mcgs/kg/min.\n Plan:\n PPM once INR is < 2.2\n Hold all nodal agents.\n Wean dopamine as BP tolerates.\n" }, { "category": "Physician ", "chartdate": "2112-02-15 00:00:00.000", "description": "Brief EP Admit Note", "row_id": 514298, "text": "TITLE: EP Fellow Brief Admit Note\n Please see resident H+P for full details. Briefly, 80 year old Mandarin\n speaking female patient of Dr \ns, presenting with symptomatic\n bradycardia in setting of multiple nodal agents and dronaderone taken\n for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Currently on IV dopamine 10, s/p 5L IVF, BP 100/35, HR 45-50 sinus\n Cool peripheries\n S1S2\n Lungs CTA\n LABS: Cr 1.2, baseline 1.0, INR 2.6\n ECG: sinus brady, rates 40-50, intermittent junctional rhythm rate 30\n with some dissociated P waves seen.\n IMP/PLAN\n Sick sinus syndrome\n Symptomatic bradycardia\n Unmasked by medications\n Symptomatic PAF\n - Difficult to rate control\n - Will need PPM\n - Cont IVF\n - Wean off dopamine as tolerated, MAP >55\n - Consider temp pacemaker if continues to be hypotensive\n despite fluid\n - Hold coumadin. consider FFP or vit K.\n ------ Protected Section ------\n Attending\ns Note:17.00hrs\n Reviewed data and agreewith Dr.\ns note\n Would place Temp pacer until P.Pacer and for elimination of Sinus\n depressant meds.\n \n Spent 45 mins on case.\n ------ Protected Section Addendum Entered By: \n on: 17:41 ------\n" }, { "category": "Physician ", "chartdate": "2112-02-15 00:00:00.000", "description": "Brief EP Admit Note", "row_id": 514299, "text": "TITLE: EP Fellow Brief Admit Note\n Please see resident H+P for full details. Briefly, 80 year old Mandarin\n speaking female patient of Dr \ns, presenting with symptomatic\n bradycardia in setting of multiple nodal agents and dronaderone taken\n for recent PAF episodes.\n PMH\n - HTN, on metoprolol and norvasc.\n - PAF first documented . Presented with palpitations\n and chest pressure. Found to have AF/RVR. Rate controlled with IV\n diltiazem, self converted. Started dronedarone and coumadin and\n discharged .\n Readmitted with recurrent PAF/RVR. Given IV diltiazem in ED +\n 30mg PO diltiazem. Converted to SR, discharged from ED. Took\n metoprolol 50mg SR and usual dronaderone this morning. At 10am, felt\n faint, flushed, pulse 30s. Daughter took her to ED. Found to have\n junctional escape HR 30-40. No CHF. SBP in 70-80s. Given 4L IVF, IV Ca\n gluconate, IV glucagon with no effect. Started IV dopamine and\n transferred to CCU.\n Currently on IV dopamine 10, s/p 5L IVF, BP 100/35, HR 45-50 sinus\n Cool peripheries\n S1S2\n Lungs CTA\n LABS: Cr 1.2, baseline 1.0, INR 2.6\n ECG: sinus brady, rates 40-50, intermittent junctional rhythm rate 30\n with some dissociated P waves seen.\n IMP/PLAN\n Sick sinus syndrome\n Symptomatic bradycardia\n Unmasked by medications\n Symptomatic PAF\n - Difficult to rate control\n - Will need PPM\n - Cont IVF\n - Wean off dopamine as tolerated, MAP >55\n - Consider temp pacemaker if continues to be hypotensive\n despite fluid\n - Hold coumadin. consider FFP or vit K.\n ------ Protected Section ------\n Attending\ns Note:17.00hrs\n Reviewed data and agreewith Dr.\ns note\n Would place Temp pacer until P.Pacer and for elimination of Sinus\n depressant meds.\n \n Spent 45 mins on case.\n ------ Protected Section Addendum Entered By: \n on: 17:41 ------\n ------ Protected Section Addendum Entered By: \n on: 17:43 ------\n" }, { "category": "Echo", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 63059, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 118\nBSA (m2): 1.49 m2\nBP (mm Hg): 93/40\nHR (bpm): 40\nStatus: Inpatient\nDate/Time: at 15:22\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Resting bradycardia (HR<60bpm). Ascites.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Mild to moderate (+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is an anterior space\nwhich most likely represents a fat pad.\n\nCompared with the prior study (images reviewed) of , the bradycardia\nis more profound and the estimated PA systolic pressure is higher. The\nseverity of mitral and aortic regurgitation are similar.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119845, "text": "Atrial fibrillation, average ventricular rate 65. Compared to tracing #1 the\nventricular rate has decreased from 114 to 65. The non-specific T wave changes\nnoted on tracing #1 have largely regressed and are present but mild at this\ntime, seen mainly in leads III, aVF and V4-V6. This is consistent with\nrate-related ischemic changes on the prior tracing that have regressed with\nimprovement in the ventricular rate.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119846, "text": "Atrial fibrillation with rapid ventricular response at a rate of 114 beats per\nminute. Non-specific ST-T wave changes. Compared to the previous tracing\nof the patient remains in atrial fibrillation with a more rapid\nventricular response. The previously noted marked T wave inversions in\nleads V2-V6 have largely regressed in the right precordial leads and are much\nless prominent in leads V4-V6. These T wave changes are non-specific but may be\ndue to myocardial ischemia.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2112-02-17 00:00:00.000", "description": "Report", "row_id": 119671, "text": "Ectopic atrial rhythm. ST-T wave abnormalities with borderline prolonged/upper\nlimits of normal QTc interval are non-specific but clinical correlation is\nsuggested. Since the previous tracing of probable ectopic atrial rhythm\nhas replaced sinus rhythm and T wave changes appear slightly less prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-02-16 00:00:00.000", "description": "Report", "row_id": 119672, "text": "Sinus rhythm. Low limb lead QRS voltage. Diffuse T wave abnormalities with\nborderline prolonged/upper limits of normal QTc interval are non-specific but\ncannot exclude possible myocardial ischemia. Clinical correlation is suggested.\nSince the previous tracing of ectopic atrial bradycardia is absent and\nT wave changes appear more prominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119673, "text": "Probable ectopic atrial rhythm. Low limb lead QRS voltage. Delayed R wave\nprogression. Prolonged QTc interval. Diffuse T wave changes. Findings are\nnon-specific but clinical correlation is suggested. Since the previous tracing\nof same date probable ectopic atrial rhythm is now present, right axis\ndeviation is absent and limb lead QRS voltage is lower.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119674, "text": "Probable junctional rhythm with atrial mechanism that appears to be independent\nmarked sinus bradycardia at a slower rate with intermittent capture beats.\nRight axis deviation may be left posterior fascicular block. ST-T wave\nabnormalities are non-specific. Clinical correlation is suggested. Since the\nprevious tracing of same date ST-T wave changes appear slightly less prominent\nbut there may be no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119675, "text": "Junctional rhythm with atrial mechanism that appears to be independent sinus at\na slower rate with intermittent capture beats. Right axis deviation could be\nleft posterior fascicular block. Delayed R wave progression. ST-T wave\nabnormalities are non-specific but cannot exclude myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of same date the rhythm as\noutlined is now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2112-02-15 00:00:00.000", "description": "Report", "row_id": 119676, "text": "Sinus bradycardia. Consider left atrial abnormality. Delayed R wave\nprogression. Diffuse T wave abnormalities. Findings are non-specific but\nclinical correlation is suggested. Since the previous tracing of same date\natrial fibrillation is now absent and findings as outlined are now seen.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2112-02-15 00:00:00.000", "description": "O CHEST (SINGLE VIEW) IN O.R.", "row_id": 1118089, "text": " 5:59 PM\n CHEST (SINGLE VIEW) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n CHEST FLUORO WITHOUT RADIOLOGIST\n Reason: TEMPERARY PEACEMACKER\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n WET READ: DLrc MON 6:11 PM\n Spot flouroscopic intraoperative radiographs demonstrate extensive overlying\n wires and advancement of the pacing wire.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, , 6:18 P.M.\n\n HISTORY: Temporary pacemaker.\n\n Frontal spot radiograph centered over the left T11 costovertebral junction is\n submitted to document an invasive procedure performed under fluoroscopic\n guidance without a radiologist in attendance.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-02-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1118024, "text": " 11:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with chest pain, bradycardia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: Chest pain, bradycardia, question interval change.\n\n FINDINGS: AP portable view of the chest obtained. Multiple overlying wires\n limit the evaluation. There is no definite change from prior study with\n grossly clear lungs bilaterally. Cardiomediastinal silhouette appears\n essentially stable. No pneumothorax or pleural effusion is seen.\n\n IMPRESSION: No acute interval change. Somewhat limited evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2112-02-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1118342, "text": " 8:39 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with tachy-brady syndrome s/p PPM. Asess lead placement\n REASON FOR THIS EXAMINATION:\n lead placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year-old woman with bradycardia post pacer placement.\n\n COMPARISON: Multiple radiographs including at 19:40\n\n PA AND LATERAL CHEST RADIOGRAPH: A dual-lead pacer with leads overlying the\n the right atrium and right ventricle is new since 2 days prior. A right IJ\n pacing wire has been removed. There is bibasilar atelectasis. The left\n inferior lung projects lower than 2 days prior and may represent a deep sulcus\n sign which raises concern for pneumothorax post-ICD placement. There is no\n consolidation or effusion in either lung. The imaged upper abdomen is\n unremarkable.\n\n IMPRESSION: Recommend repeat chest radiograph in four hours to determine\n stability of new left deep sulcus which raises possibility of pneumothorax\n post ICD placement.\n\n Findings were discussed with CCU resident by phone at the time of dictation.\n\n" }, { "category": "Radiology", "chartdate": "2112-02-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1118096, "text": " 7:20 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? Post procedural\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with temp wire, s/p cordis placement\n REASON FOR THIS EXAMINATION:\n ? Post procedural\n ______________________________________________________________________________\n WET READ: DLrc MON 8:35 PM\n No evidence of pneumothorax. Status post right IJ approach pacing wire\n pacement in RV. Lungs with bibasilar atelectasis. Mild pulmonary\n interstitial edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n HISTORY: Status post Cordis placement.\n\n The following preliminary report was provided by the radiology resident. No\n evidence of pneumothorax. Status post right IJ approach pacing wire placement\n and RV. Lungs with bibasilar atelectasis. Mild pulmonary interstitial edema.\n D. Li .\n\n COMPARISON: Chest x-ray performed and 11:30 a.m.\n\n Compared to the prior study a right-sided catheter has been placed, the tip of\n which projects over the right ventricle. Compared to the prior study, the\n degree of pulmonary vascular re-distribution is unchanged. There is bibasilar\n opacity consistent with atelectasis. There is no pneumothorax.\n\n IMPRESSION: Status post placement of catheter with tip projecting over the\n right ventricle. Otherwise, no interval change from prior study.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2164-01-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1171541, "text": " 9:29 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 44 cm Picc placed in right basilic vein, needs Picc tip plac\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 44 cm Picc placed in right basilic vein, needs Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:44 A.M., \n\n HISTORY: New PIC line, check placement.\n\n IMPRESSION: AP chest compared to :\n\n Right PIC line turns up into the neck, but extends only 15 mm above the\n clavicle. Severe enlargement of the cardiac silhouette has been present since\n at least , the earliest chest radiographic study here. How much of\n it is heart and how much pericardial effusion is radiographically\n indeterminate. Pulmonary vascular congestion and mild edema; however, have\n improved since earlier in the day. Left lower lobe is obscured by the large\n cardiac silhouette. No pneumothorax.\n\n Dr. discussed the PIC position with nurse at 10:40 a.m.\n today.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171509, "text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval volume status, infiltrates\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with chf and copd with new afib.\n REASON FOR THIS EXAMINATION:\n eval volume status, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:23 A.M. ON \n\n HISTORY: CHF and COPD. New AFib.\n\n IMPRESSION: AP chest compared to through 7:\n\n The hugely enlarged cardiac silhouette has not changed, and pulmonary vascular\n engorgement which worsened between and 7 is stable, now accompanied\n by increasing small bilateral pleural effusions. The lower lungs are largely\n obscured by the cardiac silhouette. There is no evidence of pneumonia in the\n upper lungs. Given the widening of the upper mediastinum, there is an\n increase in central venous pressure and/or volume which could be due to\n hemodynamically significant pericardial effusion or right ventricular\n decompensation. Presumably these possibilities have been investigated by\n echocardiography.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-25 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1171132, "text": " 9:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n Additional information has been obtained from CareWeb Clinical Lookup since\n the approval of the original report. Reason for exam should also state\n weakness.\n\n\n 9:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with fall\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg WED 10:47 PM\n Motion limits study. no ICH, or mass effect. No large territorial infarct.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 58-year-old female status post fall, question\n intracranial process.\n\n COMPARISON: None available.\n\n TECHNIQUE: Axial images were acquired of the head without contrast. Due to\n motion, these were repeated. Images were reformatted in the coronal and\n sagittal planes.\n\n FINDINGS: Within the limitations of a motion degraded study, there is no\n evidence of infarction, hemorrhage, extraaxial collection, or mass effect.\n -white differentiation appears preserved, though the evaluation of this is\n also severely limited by motion artifact. The ventricles and sulci are normal\n in size and configuration.\n\n The orbits and parapharyngeal soft tissues are unremarkable. Incidental note\n is made of hyperostosis frontalis which is a normal variant. There is no\n fracture.\n\n IMPRESSION: No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2164-01-28 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1171585, "text": " 2:37 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT, bilateral\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58F acute onset hypoxia and new AF/RVR\n REASON FOR THIS EXAMINATION:\n ? DVT, bilateral\n ______________________________________________________________________________\n WET READ: KKgc SAT 11:05 PM\n No evidence for an occlusive thrombus in both common femoral, superficial\n femoral, and popliteal veins. However, a small non-occlusive thrombus cannot\n entirely be excluded based on this study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old female patient with acute-onset hypoxia and new\n atrial fibrillation, to rule out DVT.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and Doppler son of bilateral common femoral,\n superficial femoral, and popliteal veins were performed. The assessment of the\n calf veins is limited due to the patient's body habitus.\n\n RIGHT LOWER EXTREMITY: There is normal compressibility and flow within the\n right common femoral, proximal and mid portions of the superficial femoral\n vein. The distal portion of the superficial femoral vein was difficult to\n assess given the patient's body habitus. The right popliteal vein\n demonstrates normal flow, with respiratory variation.\n\n LEFT LOWER EXTREMITY: There is normal compressibility and flow within the\n left common femoral and superficial femoral in the proximal portion. The\n distal portion of the superficial femoral vein was difficult to assess. The\n left popliteal vein demonstrates normal flow with respiratory variation.\n\n IMPRESSION: Limited study due to patient's habitus. No evidence for an\n occlusive thrombus in the common femoral, superficial femoral, and popliteal\n veins. However, a small non-occlusive thrombus cannot entirely be excluded\n based on this study.\n\n" }, { "category": "Radiology", "chartdate": "2164-02-08 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1173120, "text": " 11:04 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for ascites\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n diastolic CHF, abdominal distension\n REASON FOR THIS EXAMINATION:\n evaluate for ascites\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NATg WED 1:06 PM\n No ascites.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 58-year-old female with CHF and abdominal distention,\n question presence of ascites.\n\n TECHNIQUE AND FINDINGS: Four-quadrant survey of the abdomen demonstrates no\n ascites.\n\n IMPRESSION: No ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-02-08 00:00:00.000", "description": "US ABD LIMIT, SINGLE ORGAN", "row_id": 1173121, "text": ", P. MED 5S 11:04 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for ascites\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n diastolic CHF, abdominal distension\n REASON FOR THIS EXAMINATION:\n evaluate for ascites\n ______________________________________________________________________________\n PFI REPORT\n No ascites.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171322, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Monitor for progressive changes\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD ++ and CHF wiht resp decompensation and fluid\n overload. No fevers.\n REASON FOR THIS EXAMINATION:\n Monitor for progressive changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:26 A.M. \n\n HISTORY: COPD and CHF. Respiratory decompensation with volume overload.\n\n IMPRESSION: AP chest compared to and 6:\n\n Cardiomegaly is severe and mediastinal veins have been incorporation since\n , but small right pleural effusion has increased and borderline\n interstitial edema is new since . Bibasilar opacification could be\n attributed to a combination of atelectasis and dependent edema. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171917, "text": " 5:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change in CHF\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with CHF and COPD\n REASON FOR THIS EXAMINATION:\n ? interval change in CHF\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chronic heart failure and COPD, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly with mild overhydration. Retrocardiac\n atelectasis. Potential minimal left pleural effusion. No focal parenchymal\n opacity suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171635, "text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with respiratory failure, now improved\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Respiratory failure.\n\n Portable AP chest radiograph was compared to and .\n\n Severe cardiomegaly is unchanged. The patient continues to be in mild\n interstitial pulmonary edema but minimally improved since the prior\n radiograph. The right PICC line catheter has been removed, not seen on the\n current study. Bilateral pleural effusions are most likely present. There is\n no evidence of pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2164-01-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171156, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with CHF, COPD presents with hypoxia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chronic heart failure, COPD. Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is massive unchanged\n cardiomegaly without evidence of overhydration. No pleural effusions, no\n focal parenchymal opacity suggesting pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171384, "text": " 11:33 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: patient acutely hypoxic, eval for change in CXR\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD, CHF acutely hypoxic\n REASON FOR THIS EXAMINATION:\n patient acutely hypoxic, eval for change in CXR\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:53 A.M., \n\n HISTORY: COPD and CHF. Acutely hypoxic.\n\n IMPRESSION:\n\n AP chest compared to through at 6:26 a.m.:\n\n Pulmonary edema developed between and 7 and may have improved\n slightly since, but the cardiac silhouette is huge and mediastinal veins\n severely distended. Small right pleural effusion is stable. No collapse or\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-28 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1171557, "text": " 11:07 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat xray for repositioned Picc\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with repositioned Picc\n REASON FOR THIS EXAMINATION:\n repeat xray for repositioned Picc\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:17 A.M. ON \n\n HISTORY: PICC re-positioned.\n\n IMPRESSION: AP chest compared to 9:44 a.m. today:\n\n Radiographically the PICC is in the same place it was earlier, heading up\n about 15 mm above the upper margin of the right clavicle. Despite the severe\n enlargement of the cardiac silhouette pulmonary vasculature is no longer\n engorged, and there is no good evidence for substantial pleural effusion.\n Some atelectasis is presumed at the left lung base. Whether the patient has\n pericardial effusion or cardiomegaly alone is radiographically indeterminate.\n\n Findings were discussed with nurse Hopper at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1171118, "text": " 7:14 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pulm path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with SOB\n REASON FOR THIS EXAMINATION:\n ? pulm path\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old woman with shortness of breath.\n\n COMPARISON: None available.\n\n TWO VIEWS OF THE CHEST: The lungs are low in volume and evaluation is limited\n due to body habitus/underpenetrated technique. Allowing for this, there is\n cardiomegaly which appears stable. There is no focal consolidation to suggest\n pneurmonia and no over CHF. Mild congestion cannot be excluded given the\n underpenetrated technique. There are small bilateral pleural effusions.\n\n IMPRESSION: Mild cardiomegaly with small bilateral effusions and possible mild\n pulmonary congestion.\n\n" }, { "category": "Radiology", "chartdate": "2164-01-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1171736, "text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD and CHF presents with SOB\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:16 A.M. \n\n HISTORY: COPD and CHF. Shortness of breath.\n\n IMPRESSION: AP chest compared to through 9:\n\n Mild pulmonary edema and mediastinal vascular engorgement have worsened. Left\n lower lobe is poorly aerated and could be substantially atelectatic. Severe\n cardiomegaly is longstanding. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2164-01-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1171772, "text": " 9:07 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE, pt with history of nausea to contrast\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD, CHF presents with acute hypoxia\n REASON FOR THIS EXAMINATION:\n eval for PE, pt with history of nausea to contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MBue MON 12:02 PM\n PFI:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Bilateral pleural effusions, moderate on the left and small on the right\n with associated compressive atelectasis. No definite parenchymal\n abnormalities identified.\n\n 3. Cardiomegaly and atherosclerotic calcification of the coronary arteries.\n\n 4. Small hiatal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 58-year-old female with COPD and CHF, presents with acute hypoxia,\n evaluate for PE.\n\n COMPARISON: Chest x-ray dated .\n\n TECHNIQUE: Contiguous helical acquisition of the chest was acquired with and\n without intravenous contrast. Reformatted images in the coronal, sagittal,\n and oblique planes were created.\n\n FINDINGS: The heart is enlarged. Atherosclerotic calcification of the\n coronary arteries is noted. There are increased number of mediastinal lymph\n nodes which are not increased in size. Following contrast administration the\n central, lobar, segmental, and subsegmental pulmonary arteries opacify\n normally without evidence of intraluminal thrombus. The tracheobronchial tree\n is patent to level of the subsegmental bronchi bilaterally.\n\n There are bilateral pleural effusions, moderate on the left greater and small\n on the right, with adjacent compressive bibasilar atelectasis. Motion\n artifact limits evaluation of subtle parenchymal abnormalities. However, no\n focal consolidations, pulmonary nodules, or masses are identified.\n\n The osseous structures are intact. No suspicious lytic or sclerotic lesions\n are identified.\n\n Although the study was not designed for subdiaphragmatic evaluation, the\n visualized liver and spleen are normal in appearance. Post-surgical changes\n are noted in the region of the stomach. There is a small hiatal hernia.\n (Over)\n\n 9:07 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE, pt with history of nausea to contrast\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Bilateral pleural effusions, moderate on the left and small on the right\n with associated compressive atelectasis. No definite parenchymal\n abnormalities identified.\n\n 3. Cardiomegaly and atherosclerotic calcification of the coronary arteries.\n\n 4. Small hiatal hernia.\n\n" }, { "category": "Radiology", "chartdate": "2164-01-30 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1171773, "text": ", F. MED 9:07 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE, pt with history of nausea to contrast\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with COPD, CHF presents with acute hypoxia\n REASON FOR THIS EXAMINATION:\n eval for PE, pt with history of nausea to contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Bilateral pleural effusions, moderate on the left and small on the right\n with associated compressive atelectasis. No definite parenchymal\n abnormalities identified.\n\n 3. Cardiomegaly and atherosclerotic calcification of the coronary arteries.\n\n 4. Small hiatal hernia.\n\n" }, { "category": "Echo", "chartdate": "2164-02-07 00:00:00.000", "description": "Report", "row_id": 92919, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 330\nBSA (m2): 2.31 m2\nBP (mm Hg): 147/61\nHR (bpm): 80\nStatus: Outpatient\nDate/Time: at 11:39\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion echo dense, c/w\nblood, inflammation or other cellular elements. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size is normal. with\nnormal free wall contractility. There is a small to moderate sized pericardial\neffusion. The effusion is echo dense, consistent with blood, inflammation or\nother cellular elements. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion appears similar.\n\n\n" }, { "category": "Echo", "chartdate": "2164-01-26 00:00:00.000", "description": "Report", "row_id": 92887, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 60\nWeight (lb): 330\nBSA (m2): 2.31 m2\nBP (mm Hg): 146/65\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 10:29\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nTechnically difficult study to interpret in the setting of sub-optimal image\nquality.\nLEFT VENTRICLE: Normal LV wall thickness. Suboptimal technical quality, a\nfocal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Aortic valve not well seen. No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nEffusion echo dense, c/w blood, inflammation or other cellular elements. No RA\ndiastolic collapse. No RV diastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Suboptimal image quality - patient unable to\ncooperate. Echocardiographic results were reviewed by telephone with the\nhouseofficer caring for the patient.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%). The aortic valve is\nnot well seen. There is no valvular aortic stenosis. The increased transaortic\nvelocity is likely related to high cardiac output. No aortic regurgitation is\nseen. The mitral valve leaflets are not well seen. Physiologic mitral\nregurgitation is seen (within normal limits). The pulmonary artery systolic\npressure could not be determined. There is a small to moderate sized,\ncircumferential pericardial effusion, measuring 1.8 centimeters in greatest\ndimension. The effusion is echo dense, consistent with blood, inflammation or\nother cellular elements. No right atrial diastolic collapse is seen. No right\nventricular diastolic collapse is seen.\n\nIMPRESSION: Small to moderate sized, circumferential pericardial effusion,\nmeasuring 1.8 centimeters in greatest dimension. Echo dense effusion,\nconsistent with blood, inflammation or other cellular elements. No\nechocardiographic evidence of pericardial tamponade.\n\nDr. was notified by telephone on at 6:45 p.m.\n\n\n" }, { "category": "ECG", "chartdate": "2164-02-06 00:00:00.000", "description": "Report", "row_id": 256029, "text": "Sinus rhythm. Wandering baseline. Diffuse non-specific ST-T wave flattening and\nappearance of sinus rhythm as compared to the previous tracing of and\nslowing of the rate. Otherwise, no apparent diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2164-01-27 00:00:00.000", "description": "Report", "row_id": 256030, "text": "Atrial fibrillation with rapid ventricular response. Compared to the previous\ntracing of the rate has increased.\n\n" }, { "category": "ECG", "chartdate": "2164-01-25 00:00:00.000", "description": "Report", "row_id": 256031, "text": "Moderate baseline artifact. The rhythm appears to be a narrow complex\ntachycardia at a rate of 109. P waves are seen in some of the leads and it\nappears to be sinus tachycardia with occasional atrial premature beats.\nThere are non-specific ST-T wave changes noted in leads II, III and aVF. No\nother diagnostic abnormality. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2166-12-11 00:00:00.000", "description": "Report", "row_id": 107732, "text": "Irregular supraventricular rhythm at upper limits of normal rate with some\nbursts early in the tracing of faster rates, possible multifocal atrial\ntachycardia. Left anterior fascicular block. Right bundle-branch block. Since\nthe previous tracing of the rhythm is more variable.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2166-12-12 00:00:00.000", "description": "Report", "row_id": 107731, "text": "Sinus rhythm atrial premature beats. Since the previous tracing of \nthe rate is slower, the axis is less leftward and Q-T interval prolongation\npersists.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2166-12-10 00:00:00.000", "description": "Report", "row_id": 110517, "text": "Sinus rhythm\nFirst degree A-V delay\nAtrial premature complexes\nLeft atrial abnormality\nRight bundle branch block\nSince previous tracing of , T wave changes more prominent\n\n" }, { "category": "ECG", "chartdate": "2166-12-10 00:00:00.000", "description": "Report", "row_id": 110518, "text": "Sinus rhythm\nAtrial premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nLow limb lead QRS voltages - is nonspecific\nRight bundle branch block\nSince previous tracing of , tachycardia absent, intraventricular\nconduction delay decreased, left anterior fascicular block not seen and T waves\nless prominent\n\n\n" }, { "category": "ECG", "chartdate": "2166-12-09 00:00:00.000", "description": "Report", "row_id": 110519, "text": "Regular rhythm - mechanism uncertain - may be atrial tachycardia with 2:1 block\nRight bundle branch block\nLeft anterior fascicular block\nSince previous tracing of the same date, markedly wide complex tachycardia with\nleft bundle branch block type morphology now absent\n\n" }, { "category": "ECG", "chartdate": "2166-12-09 00:00:00.000", "description": "Report", "row_id": 110520, "text": "Mostly regular wide complex tachycardia with period of irregularity - mechanism\nuncertain - probably accelerate idioventricular rhythm\nClinical correlation is suggested\nSince previous tracing of , rhythm as described now present\n\n" }, { "category": "Radiology", "chartdate": "2166-12-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937849, "text": " 1:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval: tube, line, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with bradycardia s/p intub, R IJ\n REASON FOR THIS EXAMINATION:\n eval: tube, line, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with bradycardia status post intubation, right IJ\n line placement.\n\n COMPARISON: Report from .\n\n FRONTAL SUPINE CHEST RADIOGRAPH: An endotracheal tube terminates 6.0 cm above\n the carina. A nasogastric tube tip is not visualized but extends below the\n diaphragm. A right internal jugular central venous catheter tip overlies the\n superior vena cava. The thoracic aorta is tortuous. The heart is at the\n upper limits of normal. There is elevation of the left hemidiaphragm. In the\n right upper lobe is a 7 mm calcified nodule, which was also reported . The\n pulmonary vascularity is within normal limits. No pneumothoraces or pleural\n effusions are identified on this supine study; the right costophrenic angle\n blunting appears old.\n\n IMPRESSION: Lines and tubes as described above. No evidence of\n consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2166-12-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937902, "text": " 8:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls evaluate for bleed, acute infarct\n Admitting Diagnosis: HYPERKALEMIA/BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p Cardiac arrest, bradycardia, hyptension, Hyperkalemia--per\n family found down\n REASON FOR THIS EXAMINATION:\n pls evaluate for bleed, acute infarct\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: MMBn TUE 9:43 PM\n No ICH. No major infarct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man found down. Evaluate for acute intracranial\n hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift\n of normally midline structures. There is no major vascular territorial\n infarction. A low attenuation lesion within the area of the right caudate\n likely represents a lacunar infarct. Low attenuation in periventricular white\n matter is consistent with small vessel ischemic disease. There are bilateral\n basal ganglia calcifications.\n\n The cavernous carotid arteries are densely calcified. The right middle\n cerebral artery appears slightly ectatic.\n\n Small mucosal polyps are seen within bilateral maxillary sinuses. The\n remaining imaged paranasal sinuses and mastoid air cells are appropriately\n aerated.\n\n IMPRESSION: No intracranial hemorrhage.\n\n NOTE ADDED AT ATTENDING REVIEW: The gyri over the right frontal convexity do\n not appose the inner table of the skull, and there is suspicion for a small\n chronic subdural hematoma. There is no acute blood.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-12-12 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 938259, "text": " 10:42 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n Admitting Diagnosis: HYPERKALEMIA/BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with hyperkalemia, mild hypoxia, s/p extubation\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mild hypoxia status post extubation.\n\n COMPARISON: CXR .\n\n FINDINGS: PA and lateral chest radiograph. The patient has been extubated\n and an NG tube has been removed. Right-sided internal jugular line has also\n been removed.\n\n Cardiomediastinal silhouette appears stable with tortuous appearance of aortic\n and mild cardiomegaly again seen. Blunting of right costophrenic angle is\n stable. A small left-sided pleural effusion is evident. Increased prominence\n of the interstitium is noted bilaterally, which may represent some worsening\n edema. Calcified right upper lobe nodule, is stable since . No\n pneumothorax.\n\n IMPRESSION: Some increase in prominence of the interstitium bilaterally\n suggesting some mild worsening of pulmonary edema. Small left-sided pleural\n effusion. No evidence of focal consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2166-12-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 938194, "text": " 7:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Assess for cirhhosis. assess with dopplers please.\n Admitting Diagnosis: HYPERKALEMIA/BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with asthma, MMP, s/p extubation with RUQ pain. Liver 5 cm\n below costal margin\n REASON FOR THIS EXAMINATION:\n Assess for cirhhosis. assess with dopplers please.\n ______________________________________________________________________________\n WET READ: 7:58 PM\n consistent with CT, polycystic liver dz (likely accounts for\n hepatomegaly) & polycystic kidney dz, cysts make eval of parenchyma for\n cirrhosis nearly impossible, nl color doppler in PV and HVs, no GB seen, CBD\n WNL for age\n ______________________________________________________________________________\n FINAL REPORT\n LIVER ULTRASOUND, at 7:22 p.m.\n\n HISTORY: Liver 5 cm below costal margin (hepatomegaly). Assess for\n cirrhosis.\n\n COMPARISON: No prior imaging available for direct comparison. The report of\n a CT scan completed in has been reviewed.\n\n FINDINGS: Consistent with the prior report, there is extensive cystic\n son throughout the liver and included right kidney parenchyma,\n consistent with polycystic liver and kidney disease, respectively. This\n likely accounts for the hepatomegaly noted clinically. There is little\n intervening hepatic parenchyma available for evaluation. Grossly, no lesions\n are identified, although the presence of innumerable cysts makes evaluation\n limited. Normal color Doppler signal was obtained in the portal and hepatic\n veins. Hepatic artery was not discretely identified. No gallbladder is seen.\n The common bile duct measures 7 mm, which is within normal limits for stated\n age.\n\n IMPRESSION: Polycystic liver and kidney disease consistent with report of\n prior CT from . This likely accounts for hepatomegaly detected\n clinically.\n\n" }, { "category": "Nursing/other", "chartdate": "2166-12-11 00:00:00.000", "description": "Report", "row_id": 1425963, "text": "Micu nursing note 7am-2pm\nS: No c/o\n\nO: ID -T max 98.7 po.\n\nCV - HR 80-100's nsr with freq apc's and rare pvc's. BP 90-135/68\n\nResp - Resp is non labored on 3ln/p. ls have crackles l base and exp wheezes on l and r base. Tolerating inhalers without difficulty.\n\nGU - has not voided this shift. Awaiting HD\n\nGI - No stool this shift, but multiple .\n\nActivity - oob to chair with supervision only. Tolerated well\n\nA: Stable resp and cv status, awaiting HD today\n\nP: HD today then c/o to med floor. Ultrasound of gb and liver post HD. Continue to monitor lytes .\n\n" }, { "category": "Nursing/other", "chartdate": "2166-12-10 00:00:00.000", "description": "Report", "row_id": 1425961, "text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: AAOx3 - Russian-speaking, but knows some English. Follows all commands, OOB to chair w/ minimal assistance. Moves self well in bed.\n\nCV: HR=90s, NER w/ freq PACs and PVCs. This am, K was down to 4.2 and he wasn't dialyzed per renal, but this afternoon, K up to 6.7 - EKG done, Ca glu 2gms, 1amp D50, Insulin 10 units IV, 30gm KExylate po and biscodyl 10mg po given. Repeat K to be obtained after pt has BM. BP 120-130s/70s by NIPB, 20 points lower than S-line that was in the same arm. A-line d/c'd. +periph pulses, extrems cool, + edema in L hand.\n\nResp: Extubated at 12 noon to 50% CMM and then changed to n/p - currently on 4 l and 02sat 97-98%. Lungs clear bilat - occ wheeze, pt is asthmatic - gets inhalers. RR=14-20.\n\nGI/GU: abd soft, +BS, no BM as of yet. Taking regular cardiac/renal diet w/o problems. cath w/ clear yellow urine - 10-30cc/hr. Probable dialysis tomorrow as it's his scheduled day (Tu/TH/Sat).\n\nSkin: Abrasion over L eye, hematoma L forearm w/ +edema. Otherwise intact - buttocks and heels ok.\n\nID: afebrile - no antibx\n\nPain: denies any discomfort.\n\nAccess: RIJ cordis, #18 PIV R antecub. L forearm dialysis fistula - +thrill/+bruit.\n\n\nSocial: Wife and friends in today. Wife speaks better English than pt, and friends were helpful, too. Russian interpreter at bedside when pt was extubated to explain everything to him.\n\nPlan: ?TX to floor tomorrow. Probable dialysis tomorrow. Monitor cardiac/resp/neuro status.\n" }, { "category": "Nursing/other", "chartdate": "2166-12-11 00:00:00.000", "description": "Report", "row_id": 1425962, "text": "NPN 1900-0700:\n\nPt continues to make good progress and will likely go to floor today.\n\nNEURO: A&O X 3, pleasant and cooperative; communication somewhat limited by language barrier. He is able to make his needs known and utilizes an electronic translator. OOB to chair till MN; able to transfer to bed/chair/commode with minimal assist/supervision. Denies any discomfort x brief episode L calf pain upon standing which resolved quickly when he massaged it (no swelling noted; HO aware). Recieved Ambien for sleep with good effect.\nRESP: O2 3l NC with sats mostly in mid-90's; occ dip to high 80's while sleeping. Attempted to D/C O2, but sats dropped to 80's while awake. RR teens, non-labored; LS w/scattered exp wheezes; alb/atr MDI's given by RT.\nC-V: Remains hemodynamically stable. Lytes WNL (most notably K of 3.5-3.9).\nGI: Belly softly distended with hyperactive BS. He's had several small loose stools and is passing a lot of gas. c/o abd discomfort (\"gassy\") during the evening, but better as the night has progressed.\nGU: Foley D/C'd at 2200. Pt has not voided, but he generally does not make much urine. BUN/creat elevated per baseline. TFB +2300 for LOS.\nID: No active issues.\nHEME: No active issues.\nENDO: No active issues.\nSKIN: L temple and forehead abrasions; L arm hematoma (all unchanged).\nACCESS: R arm PIV, RIJ Cordis.\nSOCIAL: Pt spoke with his wife by phone several times; no other calls or visits.\n\nA: continues to make good progress.\n\nP: HD today (regular schedule); monitor GI sx; labs ordered for 1500; anticipate tx to floor today.\n" }, { "category": "Nursing/other", "chartdate": "2166-12-09 00:00:00.000", "description": "Report", "row_id": 1425957, "text": "72yr gentleman found down at home. Has had recent hx of multiple falls. Has ESRD due to polycystic kidney disease and enters with K+>8.\nIntubated for airway protection (7.5 ET, 24 @ lip) and started on hemodyalysis. One inhaled albuterol MDI rx for hyperkalemia. Wean sedation and wean to extubate when electrolytes normalyzed. BS few fine crackles.\n" }, { "category": "Nursing/other", "chartdate": "2166-12-09 00:00:00.000", "description": "Report", "row_id": 1425958, "text": "Nursing Progress Note:\n\n(History obtained via pt's wife who has limited English (Russian speaking) so hx is vague)\n\nPt. is 72 yo dialysis pt. who presented to ED via ambulance after having several falls in last couple days. Prior to today, pt. returned to baseline after falling but today family was unable to arouse pt. so ambulance was called. Upon arrival to pt. was awake but had BP 60/40 and HR of 22. He also had a K+ of 8.4. Pt. was due for dialysis today. In pt. was given a total of 2mg Atropine with no effect on HR and pacing was tried as well without capture. Pt. then received 1mg epinephrine which was effective in raising HR. He received an additional 1mg of epi later. Pt. was also given Bicarb,Insulin, Dextrose,Kayexelate, and Calcium chloride fro High K+ and was intubated for airway protection and placed on Propofol gtt. On arrival to MICU K+ was 7.3.\n\nNeuro: Pt. sedated initially on 60mcg/kg/min Propofol but this was reduced to 50mcg/kg/min. Attempted to go down to 40mcg/kg/min but started becoming tachycardic and looked uncomfortable.Pt. responds to pain, but does not follow commands. Pt. does not seem to be uncomfortable.Due to hx of falls a CT head is ordered when dialysis is finished.\n\nCV: HR 80s-100s initially in junctional rhythm but now in NSR with frequent PACs. Arterial line placed and ABP has been 140s-150s/70s. Pt. has R IJ Cordiss catheter and one PIV all of which are WNL.\n\nResp: Pt. intubated with vent settings AC 600X14/40%/5. Pt. initially on 100% Fi02 but p02 came back as 398 so this was reduced to 50% and then 40%. Last ABG 7.49/39/195 before reducing fi02 to 40%. RR teens, 02 sats 100%, lungs clear to all lobes.\n\nGI: PT. is NPO, BSX4, OG tube in place.\n\nGU: Pt. dialyzed with last K+ off ABG 2.8 taken while being dialyzed so should be repeated in hours. Pt. does make small amounts of clear, yellow urine.\n\nSkin: Pt. has small abrasion with hematoma to L temple and hematoma to L U arm.\n\nSocial: Wife in to see pt., grandson also in and wants to be contact to help with translation and updates and if any decisions need to be made. Wife is spokesperson.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2166-12-10 00:00:00.000", "description": "Report", "row_id": 1425959, "text": "NPN 1900-0700:\n\nEVENTS: Head CT done. Hemodynamically stable post-HD.\n\nROS:\nNEURO: Pt adequately sedated on Propofol which was weaned a bit to 40mcg/kg/min. Responds to stimuli, does not f/c or make purposeful movements. When Propofol was turned off to attempt , pt became tremulous and bronchospastic, and was attempting to sit up, but did not respond to us or open his eyes (unclear how mch the language barrier is contributing).\nRESP: No vent changes. Most recent ABG 7.52/39/151/33/8 on CMV .4/600/14/5; taking 0-4 breaths over set rate. Sats 99-100%. Minimal secretions; LS mostly CTA.\nC-V: HR 60's-70's, NSR, frequent PAC's and occ PVC's. BP 120's-160's (higher when sedation off). Lytes corrected to WNL after HD and Mg repletion. Trop elevated; CK's flat.\nGI: Belly benign, no stool. NPO x meds. ALT/AST slightly elevated.\nGU: UO 5-50cc/hr, clear yellow. BUN/creat elevated per baseline.\nID: Afebrile, WBC WNL, all cx NGTD.\nHEME: No active issues.\nENDO: No acive issues.\nSKIN: Intact.\nACCESS: PIV, Cordis, a-line.\nSOCIAL: Family called for update.\n\nA: stable night\n\nP: Anticipate quick wean/extubation; ? repeat HD today; EKG ordered; follow hemodynamics, lab values; continue supportive care.\n" }, { "category": "Nursing/other", "chartdate": "2166-12-10 00:00:00.000", "description": "Report", "row_id": 1425960, "text": "Resp Care: Pt continues on AC 600x14 40%+5. Pt occassionally over- breathing vent. LS clear and diminished bilaterally. Sxn'd for scant to small amounts of clear/white secretions. MDI's given per . attempted this am: when sedation turned off pt became agitated, bronchospastic, and was sitting up in bed. During this time pt did not open his eyes or respond to us. PLAN: wean vent as tolerated, quick extubation.\n" } ]

[ { "category": "Radiology", "chartdate": "2110-08-20 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 874215, "text": " 8:24 AM\n PORTABLE ABDOMEN Clip # \n Reason: r/o ileus\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p RUL\n REASON FOR THIS EXAMINATION:\n r/o ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female status post right upper lobe resection. Now\n presenting with ileus.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: AP supine single view of the abdomen.\n\n FINDINGS: There is air distributed through the GI tract in a nonspecific\n distribution. No definite without evidence of small bowel obstruction is\n seen. There is severe right convex scoliosis of the lumbar spine with marked\n degenerative changes. No abnormal calcifications are seen.\n\n IMPRESSION: Nonspecific small bowel gas pattern.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 875053, "text": " 12:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate R lung re-expansion s/p 1.5L thoracentesis\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p RUL lobectomy now s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n evaluate R lung re-expansion s/p 1.5L thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobe lobectomy. Evaluate for right lung\n reexpansion.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: The tip of the left IJ catheter appears to be going into the azygos\n vein. There is decrease in the right-sided pleural effusion. Moderate left\n effusion persists. Left basilar atelectasis is seen. Vague patchy\n parenchymal opacities appear to be decreasing as compared to the prior film.\n\n IMPRESSION:\n 1. Decrease in the right-sided pleural effusion.\n 2. Persistent left effusion with left basilar atelectasis.\n 3. Tip of the left IJ catheter still remains in the azygos vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 874835, "text": " 4:16 PM\n CHEST (PA & LAT) Clip # \n Reason: now w/ desat w/ amb -please obtain chest x-ray as soon as po\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with RULobectomy\n\n REASON FOR THIS EXAMINATION:\n now w/ desat w/ amb -please obtain chest x-ray as soon as possible\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper lobectomy with decreasing sats.\n\n X-RAY CHEST AP AND LATERAL VIEWS.\n\n COMPARISON: and .\n\n FINDINGS: Mediastinal and hilar contours are stable. There is a new moderate\n right pleural effusion. There is persistent left pleural effusion with left\n lower lobe atelectasis/consolidation. There is no pneumothorax. The tip of\n the left central venous catheter is unchanged and is in the azygos vein. No\n bony abnormality is seen.\n\n IMPRESSION:\n 1. New moderate right pleural effusion.\n\n 2. Persistent left pleural effusion with left basal\n atelectasis/consolidation.\n\n 3. Left IJ catheter tip in the azygos vein. Since its prior to insertion on\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873436, "text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ru Lobectomy\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p ru Lobectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobectomy.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination of , the 2 right-sided\n chest tubes are again seen in similar position. A left internal jugular\n venous access catheter is again seen to curve on itself, possibly curving\n within the vessel or alternatively terminating in the azygous vein. The heart\n size and mediastinal contours are within normal limits. A right apical\n pneumothorax is present, with interval decrease in pleural fluid previously\n layering at the right apex. There is decrease in subcutaneous emphysema at\n the right lateral chest wall.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873725, "text": " 12:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx, acute/interval change; r/o PE\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p RUL lobectomy ; now w/ 'd O2 sat, r/o PE\n\n REASON FOR THIS EXAMINATION:\n eval for ptx, acute/interval change; r/o PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobectomy with decreased oxygen\n saturation. Evaluate for pneumothorax or pulmonary embolus.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination of , the 2 right-sided chest\n tubes appear in unchanged position and a small right apical pneumothorax is\n again visualized. A left internal jugular venous access catheter appears in\n unchanged position. There is increase in size of a small left pleural\n effusion and increase in adjacent atelectasis within the left lower lobe. The\n heart size and mediastinal contours are unchanged allowing for patient\n positioning. Gaseous distention of the colon is noted.\n\n IMPRESSION:\n 1. Stable small right apical pneumothorax with 2 right-sided chest tubes in\n place.\n 2. Increase in left pleural effusion and adjacent left lower lobe\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 875345, "text": " 10:07 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change in PTX/acute lung process/pleural effusion\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with RULobectomy s/p pleural tap\n\n REASON FOR THIS EXAMINATION:\n interval change in PTX/acute lung process/pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right upper lobectomy. Following pleural tap.\n\n IMPRESSION: PA and lateral chest compared to and prior films since\n :\n\n There has been no change since . Considerable consolidation is still\n present at both lung bases, small-to-moderate right and left pleural effusions\n are stable and there is no pneumothorax. The heart is top normal size. The\n left internal jugular catheter cannulates the azygous vein as it has for more\n than a week.\n\n The persistent abnormality in the lower lungs has been attributed to\n asymmetric edema, but the chronicity now begins to suggest pulmonary\n hemorrhage, less likely pneumonia because both areas were atelectatic when\n larger pleural effusions were present.\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2110-08-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873774, "text": " 8:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p RUL lobectomy\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p RUL lobectomy ; now w/ 'd O2 sat, r/o PE\n\n REASON FOR THIS EXAMINATION:\n s/p RUL lobectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female status post right upper lobectomy.\n\n AP CHEST RADIOGRAPH: Comparison made to prior examinations from and\n .\n\n Two right-sided chest tubes terminating at the right lung apex are unchanged\n in position. A left IJ central venous line again noted with its tip curved in\n a cephalad direction abutting the right border of the SVC. The heart size and\n mediastinal contours are unchanged. There is again seen a left-sided pleural\n effusion. Post-surgical change in the right hilum related to the patient's\n right upper lobectomy is unchanged. No significant pneumothorax is\n identified. There is again seen scoliosis of the thoracolumbar spine (convex\n right). There is no evidence of failure or new areas of pulmonary parenchymal\n consolidation.\n\n IMPRESSION:\n 1. The tip of the left IJ central venous line is curved and positioned in a\n cephalad direction abutting the right border of the SVC.\n\n 2. Unchanged small left-sided effusion and left lower lobe volume loss.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-26 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 874894, "text": " 9:09 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with RULobectomy conts to require high amts of O2\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right upper lobectomy, requiring high oxygen.\n\n PA AND LATERAL CHEST: Comparison is made . Left internal\n jugular central venous line tip remains in the azygos vein. Cardiac size\n remains within normal limits. The loculated moderate right pleural effusion\n and predominantly freely layering small left pleural effusion are unchanged.\n Vague areas of parenchymal opacity in the aerated portions of the right lung\n are unchanged.\n\n IMPRESSION: Moderate loculated right effusion and small predominantly freely\n layering left effusion stable since one day earlier, but have increased\n compared to older studies.\n\n" }, { "category": "Radiology", "chartdate": "2110-08-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873897, "text": " 11:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p RUL lobectomy ; now w/ 'd O2 sat, r/o PE\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Removal of chest tubes.\n\n CHEST PORTABLE, AP UPRIGHT: Comparison study .\n\n There has been removal of the two right-sided chest tubes. There is a small\n inferior pneumothorax seen at the right lung base. Bullous disease is noted\n at the right apex. There is a persistent left pleural effusion. The left\n lung is unchanged. Again, noted is a left central line, which has its tip in\n the SVC. Pulmonary sutures are noted along the right superior mediastinum.\n There is postoperative shift of the mediastinum from left to right.\n\n IMPRESSION: Removal of the right chest tubes with small inferior\n pneumothorax.\n\n\n" }, { "category": "Echo", "chartdate": "2110-08-19 00:00:00.000", "description": "Report", "row_id": 98877, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Hypertension.\nHeight: (in) 60\nWeight (lb): 110\nBSA (m2): 1.45 m2\nBP (mm Hg): 118/60\nHR (bpm): 130\nStatus: Inpatient\nDate/Time: at 09:03\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild to moderate\n(+) MR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Resting\ntachycardia (HR>100bpm). Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, mitral regurgitation is now more prominent and estimated pulmonary\nartery systolic pressure is now higher.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 875212, "text": " 1:10 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change after pleural tap\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with RULobectomy s/p pleural tap\n REASON FOR THIS EXAMINATION:\n interval change after pleural tap\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman with right upper lobectomy following pleural tap.\n\n IMPRESSION: AP chest compared to chest radiographs since , most\n recently at hours.\n\n Heterogeneous opacification, which appeared at the base of the left lung\n following left thoracentesis, probably post-reexpansion edema, has not\n resolved. Nevertheless re-expansion edema is still the leading explanation.\n Given the patient's underlying emphysema and new edema in the right lower lobe\n this is probably the cause for considerable hypoxia. There is no pneumothorax\n and only a small volume of left pleural fluid remains. Small to moderate\n right pleural effusion has recurred.\n\n Heart size is top normal. The course of the left internal jugular line\n suggests the tip has been in the azygous vein since at least . A small\n volume of pleural air persists at the right apex.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2110-08-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 873383, "text": " 5:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ru Lobectomy\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p ru Lobectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right upper lobectomy.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: A left internal jugular venous access catheter has been placed in\n the interval, and appears to coil upon itself, either coiling within the\n brachiocephalic vein or entering the azygos vein and terminating posteriorly.\n There has been interval placement of two right-sided chest tubes. Probable\n small right apical pneumothorax as well as pleural fluid layering adjacent to\n the right apex. The heart size and mediastinal contours are within normal\n limits allowing for positioning. The lungs are well inflated and otherwise\n clear. The osseous structures appear unchanged. There is subcutaneous\n emphysema within the right lateral chest wall.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 875119, "text": " 7:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please do upright cxr looking for ptx\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p RUL lobectomy now s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n please do upright cxr looking for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for pneumothorax.\n\n TECHNIQUE: AP upright chest radiograph from is compared to AP\n upright chest radiograph from 11 hours prior.\n\n The tip of the left subclavian catheter is in the azygous vein and unchanged\n from prior study. There is unchanged underlying emphysema, predominantly in\n the left lung. There is an increase in pulmonary edema bilaterally in an\n asymmetric pattern, right greater than left. There is left lower lobe\n consolidation that could be due to asymmetric pulmonary edema or pneumonia.\n There are bilateral pleural effusions. The heart size is normal, the\n mediastinal and hilar contours are unremarkable. The pulmonary vasculature is\n normal. There is a tortuous descending aorta that is unchanged from prior\n exam.\n\n IMPRESSION: 1) Worsening pulmonary edema. 2) Left lower lobe atelectasis or\n pneumonia. 3) Stable underlying emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-08-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 873825, "text": " 3:46 PM\n CHEST (PA & LAT) Clip # \n Reason: eval change in ptx, s/p chest tubes to water seal\n Admitting Diagnosis: RIGHT UPPER LOBE NODULE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with RULobectomy\n REASON FOR THIS EXAMINATION:\n eval change in ptx, s/p chest tubes to water seal\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS ON .\n\n HISTORY: Chest tubes to water seal.\n\n REFERENCE EXAM: .\n\n FINDINGS: There has been no significant change in the two right-sided chest\n tubes. There is lucency at the right apex but it is difficult to identify a\n pneumothorax. Again seen is a left IJ line with its tip curved abutting the\n border of the superior vena cava. The heart size and mediastinal contours are\n unchanged although evaluation is difficult due to the slight rotation of this\n film. Again seen is a left pleural effusion. There is no new infiltrate.\n\n\n" }, { "category": "ECG", "chartdate": "2110-08-15 00:00:00.000", "description": "Report", "row_id": 279575, "text": "Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave\nchanges. Compared to tracing #1 atrial fibrillation is present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2110-08-15 00:00:00.000", "description": "Report", "row_id": 279576, "text": "Sinus rhythm. Compared to the previous tracing of atrial premature beats\nand ventricular premature beats are absent.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2142-03-14 00:00:00.000", "description": "Report", "row_id": 67636, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease, dilated ascending aorta, intraop for Ascending aortic replacement\nStatus: Inpatient\nDate/Time: at 12:07\nTest: TEE (Complete)\n: Full and color \nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor .\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Markedly dilated ascending aorta. Normal\naortic arch diameter. Mildly dilated descending aorta. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure.\n\nConclusions:\nPre bypass: No atrial septal defect is seen by 2D or color . Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Regional left ventricular wall motion is normal.\nThe ascending aorta is markedly dilated. The descending thoracic aorta is\nmildly dilated. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation\nis seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nno pericardial effusion.\n\nPost bypass: Perserved biventricular function lvef >55% no wall motion\nabnormalities. Trace AI. Proximal portion of ascending aortic graft visualized\nin good position. Remaining exam unchanged from baseline. Findings discussed\nwith surgeons at time of exam.\n\n\n" }, { "category": "ECG", "chartdate": "2142-03-14 00:00:00.000", "description": "Report", "row_id": 143596, "text": "Baseline artifact. Sinus rhythm. Low QRS voltage - clinical correlation is\nsuggested. Since the previous tracing of sinus bradycardia is absent and\nlow QRS voltage is seen but baseline artifact makes comparison difficult.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 901787, "text": " 1:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTALL PROCEDURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with Asc. Aortic Aneurysm s/p Asc. Aorta and Hemi-Arch\n Replacement. Please call ordering PA with abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ascending aortic aneurysm repair.\n\n COMPARISON: Preoperative study of .\n PORTABLE SUPINE CHEST RADIOGRAPH: Endotracheal tube tip and NG tube tips in\n satisfactory position. Right IJ introducer with Swan-Ganz catheter with its\n tip in the main pulmonary artery. Two mediastinal drains, and one left lower\n chest tube is seen. Minimal atelectasis in the right mid lung. No pleural\n effusions or focal consolidations. Linear gas projecting over the soft\n tissues of the left neck are probably artifactual.\n\n IMPRESSION: Lines and tubes in satisfactory position.\n\n" }, { "category": "Radiology", "chartdate": "2142-03-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 902091, "text": " 4:23 PM\n CHEST (PA & LAT) Clip # \n Reason: post-pull film. assess for pneumothorax.\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTALL PROCEDURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p ascending aorta replacement now s/p removal of chest\n tubes\n REASON FOR THIS EXAMINATION:\n post-pull film. assess for pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST \n\n COMPARISON: .\n\n INDICATION: Chest tube removal.\n\n There has been interval removal of various lines and tubes. No pneumothorax\n is evident. Cardiac and mediastinal contours are within normal limits for the\n postoperative status of the patient and allowing for relatively low lung\n volumes. There are bibasilar atelectatic changes as well as small bilateral\n pleural effusions, with worsening atelectasis and increasing effusions since\n the recent radiograph.\n\n IMPRESSION:\n 1. No pneumothorax.\n\n 2. Bibasilar atelectasis and small effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2142-03-20 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 902571, "text": " 6:04 PM\n CHEST (PA & LAT) Clip # \n Reason: asess for effusions\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\BENTALL PROCEDURE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman s/p Asc Ao repair\n REASON FOR THIS EXAMINATION:\n asess for effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ascending aortic repair, evaluate for effusions.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median\n sternotomy with several clips noted overlying the right suprahilar region.\n Heart is enlarged, which is new in the interval, and there is mild upper zone\n vascular redistribution without evidence of overt heart failure. There is\n interval worsening of bibasilar opacities consistent with worsening\n atelectasis. Small bilateral pleural effusions persist. There is no\n pneumothorax. Changes are again seen within the thoracic spine.\n\n IMPRESSION:\n\n 1. Cardiomegaly, which is new in the interval. Upper zone vascular\n redistribution without evidence of frank pulmonary edema. These findings may\n be secondary to early congestive heart failure and volume overload, however, a\n pericardial effusion is also a possibility. Clinical correlation is\n recommended.\n\n 2. Interval worsening of bibasilar atelectasis. Stable small bilateral\n pleural effusions.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-03-15 00:00:00.000", "description": "Report", "row_id": 1477572, "text": "Neuro:\nAlert and oriented x3. MAE without difficulty.\nResp:\nPt weaned from face tent to NC. Currently at 4L maintaining Sat 98%. Lungs diminshed at bases. Encouraging coughing and deep breathing. IS when awake.\nCV:\nNS rhythm with rare PVC. Co/CI low but FICK 5.7 PT had drop in ABP requiring NEO to maintain MAPS above 60. Currently at .2 but unable to wean at present. Monitoring via Femoral and Radial A-lines. Filling pressures WNL. Mixed Venous in low 60's. Pedial pulses via doppler. CT with minimal sersang drainage.\nGI: ABD soft and distended, non tender. Hypoactive BS. Started on clear liquids. NO N/v\nGU: Foley with clear, yellow urine QS.\nENDO:\nInsulin as per protocol.\nPAin: C/o intermitant incisional pain. Morphine given as needed. Using ABD pillow to splint as needed.\nFamily:\nDaughter visited in pm. Will return in am. Very supportive.\nPlan:\nWean NEo as tolerated. Wean O2. Monitor CO/CI and FICK. Pain control. Monitor Mixed Venous.\n\n" }, { "category": "Nursing/other", "chartdate": "2142-03-15 00:00:00.000", "description": "Report", "row_id": 1477573, "text": "Addendium:\nIncrease in CO to 4 and CI over 2. Weaning NEO as tolerated.\nNC 2L maintaining Sat above 95%.\nDrop in urine output less than 30cc x2 hours. Notifed Dr . Bolus of 250cc given. Increase urine output to 30cc/hr.\nDC'D femerol A-line.\n" }, { "category": "Nursing/other", "chartdate": "2142-03-15 00:00:00.000", "description": "Report", "row_id": 1477574, "text": "500cc IV Fluid bolus given at 0600 r/t downward trending urine output. NEO off. MAPS in low 60's. PA line DC'D. Pt had episode of nausea lasting 30 seconds. No vomiting. Denies any increase in pain. States,\"I feel better now.\" Cool compress applied to forehead.\n" }, { "category": "Nursing/other", "chartdate": "2142-03-15 00:00:00.000", "description": "Report", "row_id": 1477575, "text": "7A-7P\nSEE CAREVIEW FOR COMPLETE ASSESSMENT.\n\nPT AWAITING TX TO 2, SEE TRANSFER NOTE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2142-03-14 00:00:00.000", "description": "Report", "row_id": 1477570, "text": "~1300 PATIENT ADMITTED FROM OR S/P ASCENDING ARCH AND HEMI ARCH REPLACEMENT WITH GRAFT. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. NO GTTS INFUSING. PATIENT BEING A PACED WITH SR UNDER. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. OG IN PLACE, PLACEMENT CHECKED. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE. DOPPLERABLE PULSES PRESENT. DAUGHTER IN.\n" }, { "category": "Nursing/other", "chartdate": "2142-03-14 00:00:00.000", "description": "Report", "row_id": 1477571, "text": "NEURO: REMAINS SLEEPY BUT SMILED WHEN I TOLD HER THAT OR WAS ALL OVER, HAD THAT SURPRISED LOOK ON HER FACE, MAE, FOLLOWING COMMANDS.\n\nCARDIAC: MP SR WITHOUT ECTOPY. CCO SWAN IN PLACE, CO/CI POOR BUT GOOD BY FICK. HO AWARE. IV NTG/NEO FOR SB/P SUPPORT. CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. DOPPPLERABLE PULSES.\n\nRESP: CS DIMINISHED IN BASES. WEANING TO EXTUBATE, SLOW TO WAKE, ABG;S PENDING.\n\nGI: OG IN PLACE, PATENT FOR BILIOUS DRAINAGE.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT ^, FOLLOWING PROTOCOL.\n\nPAIN: MEDICATED X 2 WITH IV MS WITH EFFECT, WILL ADD TORIDOL.\n\nDAUGHTER IN, EXPLAINED WHAT WAS DONE IN OR AND OUR PLAN OF CARE FOR OVERNIGHT, VISIT AGAIN LATER. ANOTHER DAUGHTER IN EUROPE. MRS. IS DIVORCED.\n\nPLAN: WEAN TO EXTUBATE, MONITOR HEMODYNAMICS, DO CCO/CI BY FICK'S Q4-6. MEDICATE AS NEEDED.\n" } ]

[ { "category": "Radiology", "chartdate": "2168-07-21 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1150594, "text": " 9:00 AM\n CHEST (PA & LAT) Clip # \n Reason: lead position\n Admitting Diagnosis: POLYMORPHIC VENTRICULAR TACHYCARDIA\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with dual chamber icd\n REASON FOR THIS EXAMINATION:\n lead position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dual-chamber ICD, check lead position.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEW, CHEST: A left chest wall ICD with right atrial and\n ventricular leads in standard location is noted. No pneumothorax, pleural\n effusion, pulmonary edema is present. Lungs are largely clear without focal\n consolidation. Note made of low lung volumes with mild crowding of\n bronchovascular markings, particularly at the bases.\n\n IMPRESSION: Dual-chamber ICD with right atrial and ventricular leads in\n standard location.\n\n\n" }, { "category": "Echo", "chartdate": "2168-07-20 00:00:00.000", "description": "Report", "row_id": 90331, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Syncope.\nHeight: (in) 63\nWeight (lb): 165\nBSA (m2): 1.78 m2\nBP (mm Hg): 148/74\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 10:24\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Doppler parameters are most consistent with\nGrade I (mild) LV diastolic dysfunction. No resting or Valsalva inducible LVOT\ngradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. LV\ninflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - body habitus.\nSuboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). Doppler parameters\nare most consistent with Grade I (mild) left ventricular diastolic\ndysfunction. There is no left ventricular outflow obstruction at rest or with\nValsalva. There is no ventricular septal defect. Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation. The estimated pulmonary artery systolic pressure is normal. There\nis no pericardial effusion.\n\nIMPRESSION: No structural cardiac cause of syncope identified. Preserved\nglobal and regional biventricular systolic function. No significant valvular\nabnormality seen. No resting or inducible outflow tract obstruction.\n\n\n" }, { "category": "ECG", "chartdate": "2168-07-19 00:00:00.000", "description": "Report", "row_id": 238505, "text": "Sinus rhythm with polymorphic ventricular premature beats including couplets\nincomplete right bundle-branch block. Right axis deviation may be due to left\nposterior fascicular block. Consider left ventricular hypertrophy. Prominent\ninferolateral lead Q waves raise the consideration of possible prior\ninferolateral myocardial infarction although are non-diagnostic. Diffuse\nST-T wave changes with prolonged QTc interval. Clinical correlation is\nsuggested. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2168-07-19 00:00:00.000", "description": "Report", "row_id": 238503, "text": "Sinus bradycardia. Right bundle-branch block. Right axis deviation may be due\nto left posterior fascicular block. Consider left ventricular hypertrophy.\nProminent inferolateral lead Q waves raise the consideration of possible prior\nlateral myocardial infarction although are non-diagnostic. Diffuse ST-T wave\nchanges with prolonged QTc interval and what appear to be prominent U waves.\nClinical correlation is suggested. Since the previous tracing of same date no\nsignificant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2168-07-19 00:00:00.000", "description": "Report", "row_id": 238504, "text": "Sinus rhythm with borderline sinus bradycardia. Incomplete right bundle-branch\nblock. Right axis deviation may be due to left posterior fascicular block.\nConsider left ventricular hypertrophy. Prominent inferolateral lead Q waves\nraise the consideration of prior lateral myocardial infarction although are\nnon-diagnostic. Diffuse ST-T wave changes with prolonged QTc interval and what\nappear to be prominent U waves. Clinical correlation is suggested. Since the\nprevious tracing of same date ventricular ectopy is absent.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2120-03-13 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 957329, "text": " 7:05 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: FOLLOW UP PREVIOUS STUDIES SHOWING IVH AND DANDY \n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with dandy- cyst\n REASON FOR THIS EXAMINATION:\n FOLLOW UP PREVIOUS STUDIES SHOWING IVH AND DANDY MALFORMATION\n ______________________________________________________________________________\n FINAL REPORT\n HEAD ULTRASOUND\n\n This child was born on of this year. She had an ultrasound\n performed on and then another on . Her last examination showed\n stable dysgenesis of the corpus callosum with inferior vermian hypoplasia.\n Note was made at the time of new bilateral germinal matrix hemorrhage.\n\n In the interim since her last exam, the ventricles have increased in size.\n The dilatation appears to be limited to the lateral ventricular system. They\n are now mildly dilated. They continue to be dysmorphic that is laterally\n displaced secondary to the stable hypoplastic corpus callosum. Note is also\n made of stable vermian hypoplasia. The germinal matrix hemorrhages appear\n stable. That on the right is slightly larger than that on the left.\n\n IMPRESSION: Interval slight increase in ventricular size. The examination is\n otherwise stable with bilateral germinal matrix hemorrhage and cerebellar and\n corpus callosum dysgenesis.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-03-12 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 957176, "text": " 8:39 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: 44 day old severe growth restriction, requiring oxygen.\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with IUGR,Dandy and triple x chromosome with ongoing oxygen\n requirement.\n REASON FOR THIS EXAMINATION:\n 44 day old severe growth restriction, requiring oxygen.\n ______________________________________________________________________________\n FINAL REPORT\n Infant with intrauterine growth retardation. Comparison and .\n The study is limited as the low lung volumes are extremely low. Technically,\n the right costophrenic angle was not included on the study. The heart is in\n the upper limits of normal. There is ground-glass opacity throughout the\n lungs and bibasilar atelectasis most likely secondary to the very low lung\n volumes. There are no pleural effusions. Feeding tube is in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2120-01-30 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 951714, "text": " 5:53 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # \n Reason: where is the UVC tip?\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress and UVC in heart on ECHO, repositioned.\n REASON FOR THIS EXAMINATION:\n where is the UVC tip?\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM\n\n Date of exam . Time of exam is 18:04.\n\n CLINICAL HISTORY: This is a two-day-old, preterm infant having her UVC\n repositioned.\n\n FINDINGS: A single, portable view of the chest and abdomen was obtained and\n is compared to the previous film dated at 17:40.\n\n The UV catheter has been removed slightly so that its tip is now at the\n junction between the right atrium and IVC. The remainder of the film is\n unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2120-02-03 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 952213, "text": " 11:48 PM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: picc line adjusted\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with picc line adjusted\n REASON FOR THIS EXAMINATION:\n picc line adjusted\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST, .\n\n HISTORY: Infant with PICC line adjusted.\n\n FINDINGS: Comparison is made to the examination performed earlier the same\n day. The right PICC has been pulled back yet its tip still crosses the\n midline. This location was discussed with the ICU team at morning rounds. The\n nasogastric tube tip projects over the air distended stomach. The umbilical\n catheter tip projects between the T8/9 interspace in the midline. The lung\n volumes are lower, and there is still scattered atelectasis bilaterally. The\n heart size appears mildly enlarged. The mediastinal contour is unchanged.\n Pleural effusion is not seen.\n DFDok\n\n" }, { "category": "Radiology", "chartdate": "2120-01-30 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 951711, "text": " 5:23 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: where is the UVC?\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress and UVC in heart on ECHO\n REASON FOR THIS EXAMINATION:\n where is the UVC?\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM AT 17:40\n\n CLINICAL HISTORY: This is a two-day-old preterm infant with respiratory\n distress.\n\n FINDINGS: A single, portable view of the chest and abdomen was obtained and\n is compared to the previous film dated at 17:58.\n\n FINDINGS: The ET tube has been removed. The NG tube tip is in the left-sided\n stomach. The UV catheter is in the mid right atrium.\n\n The heart may be very slightly enlarged. The pulmonary vascularity is a bit\n decreased. There may be a subtle, bilateral ground-glass opacification of the\n lungs, but there is no focal lung opacity.\n\n The bowel gas pattern is within range of normal limits.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-03 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 952208, "text": " 10:35 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: New PICC line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with new PICC line\n REASON FOR THIS EXAMINATION:\n New PICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST, .\n\n HISTORY: Infant with new PICC. Line placement.\n\n FINDINGS: The heart is enlarged and appears similar to the examination dated\n . This finding was discussed with the ICU team at morning rounds. The\n mediastinal contour is unchanged. The new right PICC tip projects over the\n expected position of the mid right subclavian vessel. The lungs are only\n moderately well inflated and there is scattered atelectasis present. There is\n no focal airspace consolidation. A pleural effusion is not seen. The patient\n is rotated on this radiograph. The umbilical catheter tip now projects over\n the left side of T9-10. The nasogastric tube tip projects just over the\n gastric bubble. The visualized bowel in the upper abdomen appears\n nonobstructive.\n DFDok\n\n" }, { "category": "Radiology", "chartdate": "2120-02-05 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 952298, "text": " 7:20 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: EVALUATE BRAIN, VENTRICLES\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with DANDY-WALKER CYST\n REASON FOR THIS EXAMINATION:\n EVALUATE BRAIN, VENTRICLES\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE HEAD ULTRASOUND, \n\n CLINICAL HISTORY: Infant with Dandy-Walker variant.\n\n Unchanged since last examination dated . The lateral ventricles and\n third ventricle are normal in size and configuration. Fourth ventricle is top\n normal in size with widely patent foramen of Magendie. The cisterna magna is\n normal in size and configuration. Foramen magnum and mastoid views confirm\n mild hypoplasia of the cerebellar vermis. No parenchymal abnormalities are\n identified. The extraaxial fluid spaces are normal.\n\n IMPRESSION: Mild hypoplasia of the cerebellar vermis, unchanged since last\n examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-03 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 952211, "text": " 11:14 PM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: picc line repositioned\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with repositioned PICC\n REASON FOR THIS EXAMINATION:\n picc line repositioned\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST, \n\n HISTORY: Infant with reposition PICC. Line reposition.\n\n FINDINGS: Comparison is made to the examination performed earlier the same\n day. The right PICC now crosses the midline and its tip projects over the\n expected position of the left subclavian vessel at its mid portion. The\n nasogastric tube and umbilical venous catheter are in similar locations. The\n patient is markedly rotated. The lungs are slightly better aerated. The\n enlarged heart and the mediastinal contour appear unchanged. A pleural\n effusion is not seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2120-02-22 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 954536, "text": " 6:51 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o hydrocephalus\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with dandy-walker cyst\n REASON FOR THIS EXAMINATION:\n r/o hydrocephalus\n ______________________________________________________________________________\n FINAL REPORT\n AT 8:03 A.M., COMPARED TO AT 6:59 A.M.\n\n FINDINGS: Examination of the cranium through the anterior fontanelle and the\n left mastoid foramen demonstrates dysgenesis of the corpus callosum with a\n truncated genu which causes the frontal horns to be more lateral than normal.\n Again noted is inferior vermian hypoplasia. There is a new finding of\n bilateral germinal matrix hemorrhages, without ventricular dilatation.\n\n IMPRESSION: Stable dysgenesis of the corpus callosum and inferior vermian\n hypoplasia. New bilateral germinal matrix hemorrhages.\n\n" }, { "category": "Radiology", "chartdate": "2120-01-28 00:00:00.000", "description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT", "row_id": 951427, "text": " 5:49 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: evaluate lung fields, et-tube placement and line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress\n REASON FOR THIS EXAMINATION:\n evaluate lung fields, et-tube placement and line placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable Babygram.\n\n DATE OF EXAMINATION: .\n\n TIME: 17:58.\n\n CLINICAL HISTORY: The patient is a newborn baby with respiratory distress.\n\n COMPARISON: There is no prior examination available for comparison.\n\n FINDINGS: Mild opacity is seen in both lungs, which may represent a small\n amount of residual surfactant deficiency syndrome. No focal consolidation,\n pleural effusion, or pneumothorax is seen. Heart size and mediastinal\n contours are within normal limits given the patient's rotation to the right\n side. Mildly prominent bowel loops are seen in the abdomen with a paucity of\n bowel gas in the region of the rectum. No evidence of pneumatosis, abnormal\n calcification or portal venous gas is seen. The visualized osseous structures\n are normal in appearance.\n\n IMPRESSION:\n\n 1. Mild opacity in both lungs which may represent mild surfactant deficiency\n syndrome.\n\n 2. Endotracheal tube with its tip located above carina.\n\n 3. Nonspecific but non-obstructive bowel gas pattern. Clinical correlation\n and close interval radiological followup study will be helpful.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2120-01-29 00:00:00.000", "description": "NEONATAL HEAD PORTABLE", "row_id": 951482, "text": " 7:16 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: follow up prenatal findings consistent with Dandy-walker mal\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n follow up prenatal findings consistent with Dandy-walker malformation\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable head ultrasound.\n\n TIME: 8:51.\n\n CLINICAL HISTORY: The patient is newborn baby with a history of \n malformation seen on prenatal MRI examination.\n\n COMPARISON: None.\n\n FINDINGS: Hypoplasia of the cerebellar vermis associated with top normal sized\n fourth ventricle with widely patent forament of Megendie are seen. There is no\n significant enlargement of the posterior fossa. These findins are compatible\n with Dandy- Walker variant. Mid to distal portion of the corpus callosum\n appears to be somewhat hypoplastic. There is no evidence of acute germinal\n matrix, intraventricular, or intraparenchymal hemorrhage. Gyri and sulci\n formation is somewhat less developed. No abnormal extra-axial fluid\n collection is seen.\n\n IMPRESSION:\n\n 1. Hypoplasia of cerebellar vermis associated with widely patent forament of\n Megendie without significant enlargement of the posterior fossa compatible\n with Dandy-Walker variant.\n\n 2. Hypoplasia of the mid to distal portion of corpus callosum.\n\n 3. The findings were discussed with the clinician taking care of this patient\n at the time of dictation. MRI of the brain examination will be helpful for\n further evaluation as well as further characterization of Dandy-Walker variant\n and associated intracranial abnormality.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917682, "text": "Bandaid removed from left arm ant to elbow, at site of previous blood draw on .Looks erythematous and raised.\nWill watch over next few hours and start antibiotics if no improvement.Left word for mother on phone message re this and general update.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917683, "text": "Bandaid removed from left arm ant to elbow, at site of previous blood draw on .Looks erythematous and raised.\nWill watch over next few hours and start antibiotics if no improvement.Left word for mother on phone message re this and general update.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917684, "text": "/NEON DOL 22 CGA 35\nNC 13 cc's > RA, RR 50-70, HR 150-170, 5 bradys, prob PPS m\nWt 885 up 28 on 160 cc/kg with 138 BM 30 over 2.5 hrs, IV at 22 cc/kg, least PICC line can run. With Dex in 80's will wean to D7.5 with 2Na/1KCL, and try and maintain sugars> 55.\nHct 36.6 and Na 138 K 4.9 on .\nMom Breastfeeding when she comes in.\nEye exam today.\nLeft phone message to update mom.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917685, "text": "NPN\n\n\n#2Resp O- Infant placed in room air this am and sats have\nbeen above 87. RR 30-60. Lungs clear. Mild retractions\nnoted. Color pale. Hct 36.6 Infant noted to have3-4 episodes\nof bradycardia today.(see flow sheet) She was noted to have\nsome drifting in O2 sat after 1800 and she was placed on\ncannula for short period. Sats 99-100%. A-Continues with\noccassional spell/has blood culture pending/on oxacillin P-\nContinue to follow closely.\n#3F/N O-Infant continues on feeds of BM30cal with BP at\n138cc/kg. Dextrose conc. decreased today to D7.5W with lytes\nvia PICC line at.8cc/hour (20cc/kg) D-sticks today 110/94.\nAbdomen is soft and full with + bowel sounds. Girth\n18.5-19cm. Infant voiding and passing soft yellow stool. No\nspits/aspirates noted. A-Tol. feeds Stable blood glucose\ntoday P- Check glucose/wts.\n#4Family O- in to visit and updated at bedside by\nthis RN. Family shown left arm and are aware infant started\non IV oxacillin for presumed cellulitis. MD called family at\n home to update them. Mom held infant briefly. A-Family\nupdated P-Family to have CPR class per their request / \nhad taken the day off from work.\n#5Dev. O- Infant has stable temp in servo heated isolette.\nShe is alert with cares. Infant sucking on pacifier when\noffered. Eye exam done this Am (eyes immature zone 3).\nA- AGA now 35 weeks P- Support dev.\n#6 Alt. skin O- Infant noted to have red raised rashy/weepy\narea on left arm when bandaid removed from antecub area\nthis am. MD aware at this time and area cleaned/left open to\n air. Infant had blood culture sent at 0130 and oxacillin\nstarted at 1430 because area continued to look\nreddened/cellulitic. Redness has not increased in size or\nspread. A-alt. skin/cellulitis P- Continue to follow\nclosely. check blood culture/continue antibiotics per team.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917686, "text": "CPR instruction\n here at 6pm to take CPR class. practiced breaths, compressions and choking manuevers. viewed the video in Spanish and stated they understood. Mom translated the class for in . were given the CPR poster to take home.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917687, "text": "Nsg Addendum\nBlood culture sent at 1330 not 0130 as stated in previos note.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-07 00:00:00.000", "description": "Report", "row_id": 1917751, "text": "Labs: Total T4, Free T4, TSH and thyroglobulin and State ScrState screen results remain with elevated TSH but normal T4.\nI have called endocrine consult, who will come tomorrow.\nLaeen.bs drawn are: repeat State Screen, \r TTotal T44\nFree T4, TSH and thyroglobulin levels.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-07 00:00:00.000", "description": "Report", "row_id": 1917752, "text": "Labs: Total T4, Free T4, TSH and thyroglobulin and State ScrState screen results remain with elevated TSH but normal T4.\nI have called endocrine consult, who will come tomorrow.\nLaeen.bs drawn are: repeat State Screen, \r TTotal T44\nFree T4, TSH and thyroglobulin levels.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-07 00:00:00.000", "description": "Report", "row_id": 1917753, "text": "NPN 0700-1900\n\n#2 Alt. in Resp. Function\nO: Infant in NC 100% mainly 25-50cc at rest, 75-200cc for PO feeding. Sats 91-98 with occasional brief drifts to 80's but no HR drops or prolonged desats. Did have choking spells with desats to 60's X 2 with PO feeding requiring increased 02 to recover. RR 50's-50's with mild SC retractions. Breath sounds are clear but with upper airway congestion. Saline gtts and suction X 1 for lg. amts yellow secretions and decreased upper airway congestion noted.\nA: 02 requirement continues with some nasal congestion\nP: Continue close observation and monitoring. Wean 02 as able. Document all spells.\n\n#3 Alt. in Nutrition\nO: TF=160cc/kg=28cc BM30/BP Q 3 hrs. Abd. is round, soft with + BS, no loops. Girth stable at 24cm. 1-3.4cc residuals. No spits. Voiding and stooling guaiac -. D/S=60. PO fed X 2. Did well X 1, taking 20cc w/o choking or desats. PO fed poorly X 1 taking only 8cc with choking and desats X 2.\nA: Tolerating feeds, learning to PO, still with some difficulty\nP: Continue with present feeding plan, (alt. PO/PG) with close observation of feeding skills. Follow daily wts.\n\n#4 Alt. in Parenting\nO: Mom in for 1100 feeding. Updated and questions answered. Held and bottle fed w/o assistance. CH endocrinology team here and spoke with mom.\nA: Involved mom\nP: informed and support.\n\n#5 Alt. in Development\nO: Maintaining temp in off isolette, swaddled and positioned supine. Not waking for feeds but alert with cares. Sucks well on pacifier but some choking and desats with POs. Fontanells open and full, sutures spread. Blood work for Total T4, Free T4, TSH and thyroglobulin level drawn. Repeat state screen also drawn. Endocrinology team from CH here to see infant. Spoke with mother at the bedside.\nA: Infant at 37 1/2 weeks still with immature behaviors, ? hypothyroid\nP: Continue to support developmental needs. Await bloodwork results.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-08 00:00:00.000", "description": "Report", "row_id": 1917754, "text": "Nursing\n\n\n#2O: In nasal cannula 100% 25 - 50cc, increased with bottle\nfeed up to 75cc. Br. sounds clear but does have nasal\ncongestion and was sx x 1 for a mod. amt. yellow secretions.\n\n#3O: Wt up 30g on 160cc/kg, BM30 with beneprotein, q 3 hr.\nfeeds. Belly soft, voids qs, no stool. Sm. asp. and 1 sm.\nspit. Bottle attempted x 2, did not do well, uncoordinated.\n Gav. fed.\n#4O: No contact.\n#5O: In off isolette, stable temp. Had a . Active,\nslightly irritable, calms with pacifier and swaddling.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917618, "text": "Neonatology Attending Procedure Note\n\nProcedure: PICC line insertion\nIndication: Need for IVFs as advancing in enteral feedings\nSedation: 1 mcg/kg Fentanyl x 1\n\nTime-out, patient identified. PICC line cut in advance at 10 cm mark. Right arm prepped in usual sterile fashion. Right antecub vein entered with 26 gauge introducer and 1.9 Fr PICC line advanced to 7 cm mark. Line sterily dressed.\n\nAdjustments:\n-- CXR 1 with line at first half of right clavicle, sterile field maintained and with assistance from , line advanced 2 cm to 9 cm mark. Area redressed in sterile fashion.\n-- CXR 2 line crossing midline to left clavicular region, again while maintaining sterile field, PICC line pulled back 1 cm, to 8 cm mark.\n-- CXR 3 line at midline, likely well within subclavian vein. Occlusive dressing again applied in sterile fashion.\n\nInfant tolerated procedure well w/o complication.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917619, "text": "Nursing\n\n\n#2O: In room air with O2 sats > 98% with no noted desats or\nspells. br. sounds clear with very mild retractions.\n#3O: Wt. up 14g on 150cc/kg. Enteral feeds are @ 30cc/kg,\nBM q 3 hrs. Belly soft +BS, Min. asp. and no spits. Central\nPIC (confirmed by x-ray) placed in right arm tonite. Thru\nthis D15W with 1/2 u Heparin/cc infusing @ KVO until new PN\nis able to be hung. Double lumen UVC has PN of D13 with\nlipids that is infusing without incident and will be pulled\nwhen new PN is going thru PIC. IV total fluids @ 120cc/kg.\nUrine out for 2cc/kg, and for tonite 1.6cc/kg. Very\nsm. mec passed. D-s 55 and 65.\n#4O: Dad daughter briefly for 1st time. Mom,\nsister, and uncle also into visit. Updated at the bedside.\n#5O: Nested on servo in heated isolette, stable temp.\nActive, feisty with cares.\n#6O: Under Neoblue phototherapy with eyes covered. Color\nsl. jaundiced. Will check bili level tonite.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917620, "text": "Neonatology Attending\nDOL 7 / PMA 32-6/7 weeks\n\nInfant remains in room air with no apneas/bradycardias. On vit A.\n\nNo murmur. BP 69/33 (46).\n\nWt 656 (+14) on TFI 150 ml/kg/day including enteral feeds BM20 at 30 ml/kg/day, tolerating well with only mild abdominal distention, likely secondary to fentanyl. Voiding and stooling normally (guiac negative). PICC placed last night. D-stick 91.\n\nRemains under phototherapy with bilirubin < 4.\n\nTemp stable in servo isolette. OFC stable.\n\nA&P\n32-6/7 week GA infant with Dandy-Walker malformation, severe IUGR, feeding and respiratory immaturity\n-Cranial ultrasound tomorrow\n-Genetics and neurology involved\n-Chromosomes pending\n-Advance enteral intake to 40 ml/kg/day and monitor tolerance and abdominal examination closely\n-Repeat lytes and bilirubin tomorrow; continue phototherapy in the interim\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917621, "text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. She is pale pink, well perfused, no murmur auscultated. She is comfortable in room air, breath sounds clear and equal. She is tolerating slow advance of enteral feeds. Abd soft, soft bowel sounds. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-22 00:00:00.000", "description": "Report", "row_id": 1917817, "text": "NPN\n\n\n#2 Resp O- continues in NC 25-50cc's 100% to\nmaintain O2 sats above 90. RR 50-70's. Lungs clear. No\nbradycardia noted. occassional quick drift in\nsat/self-resolved. A- Stable in low flow NC P- Discharge\nhome late next week in NC if she continues to do well.\n#3F/N O- was switched to 28cal Bm with Neosure\npowder at 1700. Infant bottling every 4 hours and taking\n35-60cc's with bottle. Infant voiding and passing\nstool. abdomen benign. A-Bottling improving P- Follow wts.\nad lib amounts every 4 hours.\n#4Family Mom in to visit and independent with cares. Mom\nupdated at bedside with plan of care for next week. Mom\nshown how to give meds and aware discharge packet made for\n.Mom aware that home care rep. will be in Tuesday \n for O2 home discharge teaching. Mom requesting portuguese\ninterpreter for Tuesday. Mom very /dedicated\npreparing for discharge. P- teach/support as needed.\n#5Dev. O- Infant with low ax temp this am although rectal\ntemp 99.2. Infant double swaddled and ax temp improved.\nInfant active/alert. A-AGA /Triple X /Dandy Walker\nMalformation P-Immunizations to be given next week.(60day)\n Family has handouts. Mom aware infant may not fit properly\nin carseat and may need carbed. Infant needs hearing screen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-22 00:00:00.000", "description": "Report", "row_id": 1917818, "text": "Nursing addendum\nInfant noted to have yellow eye drainage from left eye this am and during night shift. Eye culture sent. Erythromycin ointment started at 0900. Eye care done prn. Family aware.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-23 00:00:00.000", "description": "Report", "row_id": 1917819, "text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf, sagital sutures split, large AF\nminimal subcostal retractions in NCO2, lungs clear/=\nll/lV holosystolic murmur across precordium, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nsmall amount of white drainage from left eye, no erythema\noverall increased tone upper extremities > lower\n" }, { "category": "Nursing/other", "chartdate": "2120-03-23 00:00:00.000", "description": "Report", "row_id": 1917820, "text": "Nursing\n\n\n#2O: In nasal cannula mostly 50cc 100%, increased @ x's to\n75cc. Br. sounds clear with mild retractions.\n#3O: Wt. up 35g, taking in 2111cc/kg, BM28. Belly soft,\nvoiding and, 1 sm. stool. Plan is to keep on 4 hr. schedule\nbut infant needed a snack, 3 hrs. after feed. Bottles well\nwith bottle with # 1 nipple.\n#4O: No contact.\n#5O: Temp stable in crib. Awake for many hours tonite,\nwanting to be held, calmed somewhat with pacifier.\nErythromycin applied to both eyes, left eye has yellow\ndrainage, eye cleansed, and duct massaged.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-23 00:00:00.000", "description": "Report", "row_id": 1917821, "text": "Neonatology Attending Progress Note:\nDOl #55\nPMA 39 5/7 weeks\nremains in NC oxygen 25-50cc (inc to 75 cc with feeding) RR=40-80s, mild/mod ic/sc retx\nno spells overnight\nmurmur (c/w PPS), HR+150-160's, BP mean=55\nwt=1755g (inc 35g), TF=160cc/kg/d BM 28 with neosure\npoing well took 198cc/kg/d\nvoiding, stooling\nerythromycin ophthalmic\nImp/Plan: premie infant with CLD, feeding well\n--monitor weight\n--HC tomorrow\n--encourage po feeding\n--d/c teaching (aiming for late next week)\n--will get immunizations this week\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1917678, "text": "Neonatology NP Note\nPE\nnested in isolette\nAF full and tense, sagital and coronal sutures widely split, lamboidal sutures approximated(all findings baseline)\nminimal subcostal/intercostal retractions in room air, lungs clear/=\nsoft systolic murmur at LSb, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nPICC insertion site with occlusive dressing,no erythema or edema at site\nactive with good tone\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1917679, "text": "Neonatology Attending Note\nDOL# 21, CGA 34 \n\nIn NC O2, 25 cc, FIO2 100%\nClear BS\nRR 40-60s\nMild retractions\nNo spells\n\nLoud murmur (PPS)\nP 150-180s\nPale\nMBP 44\n\nWt 857 (up 26 gm)\nTF 160 cc/kg\nIV KVO with D10 and lytes via PICC\nEnteral feeds at 140 cc/kg BM 28 with beneprotein\nStable D-sticks\n\nSmall aspirates\nVoiding and stooling\n\nOn Vit E and Fe\nHC 26.5 (up 0.25 cm)\n\nA/P:\nPremature SGA infant with mild CLD, feeding immaturity, Dandy-Walker malformation\nRESP: Continue on NC O2 and monitor sats\nCV: Stable\nFEN: Adjust enteral feeds to 30 cals and continue to try to wean IVF for D-sticks.\nSOC: Plan to update on plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1917680, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25cc flow, 100% FiO2.\nInfant's lung sounds cl/=. Mild IC/SC retractions noted. No\nspells thus far this shift. O2 sats stable. A: Infant\nbreathing comfortably w/ resp. support. P: Continue to\nsupport infant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day. IV fluids @\n22cc/kg/day (KVO). D10 w/ 2NaCl + 1KCl + 1/2U hep/cc\ninfusing w/out incident through central PICC in R arm.\nDstick of 86 this afternoon. Enteral feedings remain @\n138cc/kg/day, BM 30 w/ BP. Q 3hr feedings, PG, gavaged over\n2hrs 30min. Infant also breastfed today for about 10min.\nLatched and sucked intermittantly. Minimal aspirates, no\nspits.Infant's abdomen is soft, active BS, no loops. Infant\nvoiding, stooling well (neg. heme). Continues on vit. E and\niron. A: Infant tolerating feedings well. P: Continue to\nsupport infant's nutritional needs.\n\n#4 : O: Mom and in for 1100 cares. \nparticipated in cares. Mom held and breastfed infant.\n updated at bedside by this RN. A: very\nloving, invested. P: Continue to update, support and teach\n.\n\n#4 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. Fontanels remain full/soft. Sutures spread. A: Alt. in\nG&D. P: Continue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-19 00:00:00.000", "description": "Report", "row_id": 1917681, "text": "Nursing\n\n\n#2O: In nasal cannula 100% 13cc to Keep O2 sats > 87%. Br.\nsounds clear with very mild retractions. Has had 2 quick\nspells tonite.\n#3O: Wt. up 28g on total fluids @ 160cc/kg. IV of D10 with\nlytes and heparin infusing @ 0.8cc/hr. thru central PIC for\ntotal 22cc/kg. Enteral feeds of BM30 with beneprotein @\n138cc/kg. Feeds are every 3 hrs. being given over 2 hr. 30\nmin. D-s 81. Belly soft, voiding and stooling. Min.asp.\nand no spits.\n#4O: No contact.\n#5O: Nested on servo in heated covered isolette, stable\ntemp. Active with cares. Likes pacifier. Scheduled for\n1st eye exam today. HC 26.75cm (^.25cm). Fontanelles are\nflat, widely spaced.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-03 00:00:00.000", "description": "Report", "row_id": 1917613, "text": "2. Resp: O: Infant is in RA w/ RR 30-50s, clear ls, and no\nspells so far this shift. She has retractions because she is\nvery little. A: Stable in RA. P: Continue w/ plan. Monitor.\n\n3. F/N: O: Infant is on TF = 150cc/k/d, consisting of TPN\nand lipids infusing via a DUV and pg feeds of BM at\n20cc/k/d, fed q 3 hours via gavage. Abd is benign. She had a\none time asp of 1cc of clear secretions w/ brown flecks and\nhas had min asps since. A/g is stable at 15cm. D/s are 108\nand 78. She gained 27g. Lytes were sent and are pnd at this\nwriting. A: Tol feeds so far. P: Continue as per plan. Check\nresults of labs.\n\n4. : O: and the other sibling were in to\nvisit just after this infant's cares were done. Mom did\ncares on the other infant. They were updated. A: Loving,\ninvolved . P: Continue to support.\n\n5. G/d: O: Infant's temp is stable on servo in a heated\nisolette under phototx. She is active w/ cares and sucks\nvigorously on a pacifier. A/P: Continue to support infant\nneeds.\n\n6. Bili: O: Infant is under the neoblue phototx. A bili was\nsent and results are pnd. A: Hyperbilirubinemia. P: Continue\nas per plan. Check results of labs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-03 00:00:00.000", "description": "Report", "row_id": 1917614, "text": "Neonatology on call note\nPE:\n\nNEURO: infant nested in isolette, active on exam, AFOS, sutures , x4.\n\nRESP: infant in r/a, breath sounds =clear with mild intercostal/subcostal retractions.\n\nCARDIAC: color pink/sl jaundice well perfused, no audible murmur on exam, pulses palpable =x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: intact, no lesions, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam\n\nGU: voiding in diapers, normal preterm female genitalia.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-03 00:00:00.000", "description": "Report", "row_id": 1917615, "text": "Neonatology Attending Note\nDay 6, PMA 32 5\n\nRA. RR30-60s. Vit A. No caffeine. No A&Bs.\nNo murmur. HR 140-160s. BP 59/31, 40.\nWt 642, up 27 gms. TF 150 = PN/IL @130 + enteral @20. Tol well.\nVoiding 3.8 and passing mec.\nd/s this AM 71\n137/4.2/110/17\nBili 3.0/0.9 - under photo.\nServo isolette.\n\nA/P:\nRDS - resolving transitioning to RA, no AOP\nFEN - cont feeding adv, d/s appear stable with current GIR\nBIL - cont photot\nAccess - discuss w family PICC consent\nLabs - lytes, TG, bili Monday\nHUS - scheduled for Monday\n" }, { "category": "Nursing/other", "chartdate": "2120-02-03 00:00:00.000", "description": "Report", "row_id": 1917616, "text": "NPN\n\n\n#2Resp remains in room air with O2 sats 100% RR\n50-60. Breath sounds clear. Mild retractions noted. Color\npink. No murmur audible. No spells noted. A- Stable P_\ncontinue to follow.\n#3F/N O- Enteral feeds increased to 30cc/kg. PN13% and\nlipids at 110cc/kg With D10W at 10cc/kg. D-sticks 71/74.\nAbdomen is full and soft with + BS. Girth 16cm. Infant\nvoiding and passing meconium stool. A- Stable blood glucose\nP-PN 13% as ordered. Check labs on monday .\n#4Family No contact this shift.\n#5Dev. O- Temp stable in servo heated isolette. Infant sucks\nwell on pacifier when offered. Active/alert with cares.\nA-AGA now 32 5/7 weeks IUGR P- on Monday. Daily HC.\n#6Bili Remains under double neoblue . Bili to be checked\nMonday.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-03 00:00:00.000", "description": "Report", "row_id": 1917617, "text": " Physical Exam\nAwake and alert in isolette under phototherapy. AFOF with good activity. BSC and equal on RA with mild retractions. No audible murmur, well perfused, but mottled with exam, normal pulses. ABD soft and rounded with active BS, no masses. Normal GU.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-06 00:00:00.000", "description": "Report", "row_id": 1917745, "text": "/NEON DOL 38 CGA 37 \nNC att 25-50 cc liter flow, RR 50-80, HR 170-180 PPS m, no bradys\nWt 1335 up 35 on 150 cc/kg BM 30 Beneprotein\nTook 2 whole bottles overnite\nMom to come in this am for breastfeeding consult.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-06 00:00:00.000", "description": "Report", "row_id": 1917746, "text": "Called and left message for mo m.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-06 00:00:00.000", "description": "Report", "row_id": 1917747, "text": "Lactation Consult\nMet w/ mom today to assist w/ latch. Infant placed cross cradle on a nursing support pillow. Infant latched very well using a small sized nipple shield. Unable to latch w/o shield due to infant's small size. Infant had strong sucking and some audible swallows. Milk present in shield. Mom pleased w/ session. Will check in w/ family by next Weds.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-06 00:00:00.000", "description": "Report", "row_id": 1917748, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 100% FiO2, 25-50cc flow.\nLung sounds cl/=. Mild SC retractions noted. O2 sats >90%.\nNo spells thus far this shift. A: Infant breathing\ncomfortably w/ resp. support. P: Continue to support\ninfant's resp. needs. Wean flow as tolerated.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 3hr feedings, PO/PG, gavaged over 1hr. Infant breastfed x1\nthis AM for about 10min w/ lactation consult. Minimal\naspirates, no spits. Infant's abdomen is soft, active BS, no\nloops. Voiding, stooling well (neg. heme). Continues on iron\nand Vit. E. A: Infant tolerating feedings well. P: Continue\nto encourage PO feedings. Continue to support infant's\nnutritional needs.\n\n#4 Family: O: Mom in this morning for 1100 cares and\nfeeding. Updated at bedside by this RN. Supported w/\nbreastfeeding by lactation consultant. A: Mom seems very\nloving, invested. Asking appropriate questions. Comortable\ncaring for infant. P: Continue to update, support and teach\n.\n\n#5 DEV: O: Infant remains swaddled in an off isolette.\nMaintaining stable temps. Infant sleeps well between cares.\nWakes w/ cares and remains A/A throughout. MAE. Fontanels\nfull/soft. Sutures remain spread. A: Alt. in G&D. P:\nContinue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-07 00:00:00.000", "description": "Report", "row_id": 1917749, "text": "NPN 1900-0700\n\n\n#2RDS: Pt remains in NC 25-50cc flow, 100% FiO2. RR\n30's-70's. Lung sounds clear and equal bilaterally. Mild\nsubcostal retractions. No spells so far this shift. P: Cont\nto monitor resp status.\n\n#3FEN: Wt 1385 (^50gms). TF 160cc/kg/day of BM30 with\nbeneprotein, Q 3 hrs alternating PO/PG. Full feeding given\nover 60 mins, when gavaged. Pt bottled 15cc at 2300 care\ntime, using yellow nipple. Pt is poorly coordinated with\nPO's and tires easily. Tolerating feedings well, no spits,\nmin asp, AG stable. Abd soft and round, no loops, +BS.\nVoiding & only trace amts of stool. Pt cont on iron and vit\nE. P: Cont with current feeding plan. Encourage PO's.\n\n#4FAM: No contact from so far this shift. P: Cont to\nsupport, educate and update .\n\n#5DEV: Temps stable, pt swaddled in off-isolette. Alert and\nactive. Settles and sleeps well in between care times. Sucks\non pacifier. MAE. Fontanels soft/full. Sutures remain\nspread. P: Cont to support dev needs. Measure head\ncircumference 2x/wk.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-07 00:00:00.000", "description": "Report", "row_id": 1917750, "text": "/NEON CGA 37 DOL 39\nNC at 25-50 cc's l flow, RR 30-70, lungs clear\nHR 150-180 PPS m sounds softer today\nWt 1385 up 50 grams on 160 cc's/kg BM30 Beneprotein\nStarting to PO a bit more.\nWill call mom and give update.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 1917676, "text": "NUrsing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. O2 sats stable. Lung\nsounds cl/=. Mild IC/SC retractions noted. Infant continues\non Vit. A injections. Spell x1 thus far this shift, at rest,\nQSR, no O2 desaturation. Desat x1 to 74% requiring mod. stim\nand BBO2 after breastfeeding. Please refer to flowsheet for\nfurther details. A: Infant breathing comfortably in RA. P:\nContinue to support infant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day. IV fluid\nremains @ 22cc/kg/day (0.8cc/hr). D10 w/ 2NaCl + 1KCl + hep\ninfusing through central PICC in R arm. Dstick this\nafternoon of 89. Enteral feedings remain @ 138cc/kg/day,\nBM28 w/ BP. Q 3hr feedings, PG, gavaged over 2hrs 30min.\nMinimal aspirates, no spits. Infant also breastfed for about\n10min this AM. Latched well, sucked intermittantly. Infant's\nabdomen is soft, + BS, no loops. Infant voiding well.\nStooling (neg. heme). Continues on vit E and iron. A: Infant\ntolerating feedings well. P: Continue to support infant's\nnutritional needs.\n\n#4 Family: O: Mom, and big sister in this morning for\ncares. Mom held and breastfed infant. updated at\nbedside by this RN. Infant's sibling noted to have cough.\n intructed that children are not permitted in NICU if\nsick. instructed to remove sibling from NICU during\nthis visit for persistant cough. A: very loving,\nunderstanding of NICU policy. P: Continue to update, support\nand teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. Fontanels full/soft. Sutures spread. A: Alt. in G&D. P:\nContinue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-18 00:00:00.000", "description": "Report", "row_id": 1917677, "text": "2. Resp: O: Infant is in RA w/ RR 40-60s, clear ls, no\nspells so far this shift. Color is pink and she is active\nand vigorous. A: Stable in RA. P: Monitor.\n\n3. F/N: O: Infant is on TF = 160cc/k/d. She has D10W w/\nlytes running at KVO via a pic line. She also has her feeds\nof BM 28 + protein, at 138cc/k/d (160 - KVO) fed via gavage,\nq three hours over 2.5 hours each feed. D/s at 11p was 106.\nAbd is benign. She is voiding and stooling, g- stools. No\nspits, min asps. She gained 26g. A: Tol feeds, maintaining\nher d/s w/ much support. Gaining some wt. P: Continue w/\nplan. Monitor d/s.\n\n4. : No contact so far this shift.\n\n5. G/d: O: Temp is stable on servo in a heated isolette.\nInfant is nested in a sheepskin w/ bounderies and has a gel\npillow. She sucks vigorously on a binkie. A/P: Continue to\nsupport infant needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-21 00:00:00.000", "description": "Report", "row_id": 1917813, "text": "/NEON DOL 53\nNC at 25 cc's up to 50-75 for feeds. RR 40-70, HR 150-170 PPS m\nWt 1695 up 10 grms, took 179 cc/kg of BM 30 now all PO\nWill discuss with nutrition next week re cals and Neosure powder as will be getting ready for discharge.\nAs per endocrine have changed to alternating daily doses of 12.5 mcg and 25 mcg of synthroid. To repeat thyroid studies prior to discharge.\nHct 30.4 on iron\nTo start teaching for discharge home on oxygen mid to end of next week.\nSpoke with mother yesterday and she will be ready and eager to take home on oxygen as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-21 00:00:00.000", "description": "Report", "row_id": 1917814, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 100% FiO2, 25cc flow\n(increased to 50cc w/ feedings). O2 sats WNL. Lung sounds\ncl/=. Mild SC retractions noted. No spells thus far this\nshift. A: Infant breathing comfortably w/ resp. support. P:\nContinue to support infant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nInfant waking for feedings q 4hrs. PO intake ~ 50cc/feeding\nusing bottle. No spits. Infant's abdomen is soft,\nactive BS, no loops. Infant voiding, stooling well.\nContinues on iron, Vit. E and synthroid. A: Infant\ntolerating feedings well. P: Continue to support infant's\nnutritional needs.\n\n#4 Family: O: Mom in for 1300 cares. Mom w/\ncares. Held infant throughout the afternoon. Updated at\nbedside by this RN. A: Mom very , comfortable caring\nfor infant. P: Continue to update, support and teach\n.\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. Sutures spread. A: Alt. in G&D. P: Continue to\nsupport infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-22 00:00:00.000", "description": "Report", "row_id": 1917815, "text": "Nursing\n\n\n#2O: Remains in nasal cannula 100% 25 - 50cc @ rest and\nincreased up to 75cc with feeds. br. sounds clear with mild\nretractions.\n#3O: Wt. up 25g on BM 30 with beneprotein, q 4 hr. feeds;\nordered for 160cc/kg but is all bottles and took in\n198cc/kg, . Bottles well with bottle. Belly\nsoft, voiding and passing sm. amt. stool.\n#4O: No contact.\n#5O: Temp stable in crib, active with cares, likes binky.\nHad a .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-22 00:00:00.000", "description": "Report", "row_id": 1917816, "text": "/NEON DOL 54 CGA 39 \nNC at 25 cc'c up to 50-75 for feeds. RR 40-80, HR 150-160 PPS m\nWt 1720 up 25, starting to take excellent volumes, took 198 cc/kg.\nWill switch her to MM28 cals/ounce.\nHaving L eye drainage, to culture and start on erythromycin eye ointment.\nTo begin discharge teaching.\nWould like to discharge her on Fri/Sat, give immunizations on Wed and recheck Thyroid functions next Tues.\n\nNeon to cover \n" }, { "category": "Nursing/other", "chartdate": "2120-03-05 00:00:00.000", "description": "Report", "row_id": 1917740, "text": "NPN 7p-7a\n\n\n#2: remains in NC 100%, 25-50cc flow. At rest mostly\n25cc, but needing increase to 50cc with cares and end of\nfeeds. Occ drift to mid 80's- QSR. No apnea/brady spells\nnoted. RR 40-80, mildly tachypnic at times- stable. BBS\ncl/=. Sx'ed x1 for sm-mod white secrestions from bilateral\nnares. A: stable in low flow NC P:Cont to monitor and\nprovide support as needed.\n\n#3: TF: 160cc/k/d. Conts on Bm30 with Beneprotein, 26cc\nq3hrs PG'ed over 1hr. No spits. Min benign asps. Abd soft\nand full with +, no loops. AG stable. Voiding qs. Trace\nyellow stools. A: tol'ing PG feeds. P:Cont with current\nfeeding schedule. Follow wt and exam.\n\n#4: No contact with thus far in shift.\n\n#5: is maintaining stable temps while swaddled in an\noff isolette. She sleeps comfortably in btw cares, nested\nwithin boundaries. She is alert/active with cares. MAE.\nFonts full/soft with spread sutures. Strawberry hemangioma\nnoted on right butt cheek- slightly raised. A: AGA P:Cont\nto monitor and provide support as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-05 00:00:00.000", "description": "Report", "row_id": 1917741, "text": "NPN 7p-7a\nAdd: wt 1300gms, down 5gms.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-05 00:00:00.000", "description": "Report", "row_id": 1917742, "text": "/NEON DOL 37 CGA 37 \nNC at 25-50 cc's l flow RR 40-80, lungs clear, HR 160-180 PPS m\nWt 1300 down 5 in isollete on 160 cc/kg BM 30\nMinimal PO\nHC 29 appropriate growth, no change re sutures and soft but full fontanell. Will f/u HUS next week.\nNeuro: Baby is quite but alert, am starting to be concerned re minimal bottling at this GA. I am starting to wonder whether comb of Dandy Walker/IUGR and triple x chromosomes are starting to demonstrate their ultimate poorer outcome. I will recall Neuro next week and have them look at her again. The G1 bleed should not be having any effect.I will have the repeat HUS at that time.\nHad spoken in past to mom about unknown outcome, but that baby is at high risk. Mom seems not to really want to recognize this aspect yet.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-05 00:00:00.000", "description": "Report", "row_id": 1917743, "text": "NPN\n\n\n#2RESP NO CHANGE. NO SPELLS NOTED.\n#3F/N O- SHE CONTINUES ON BM 30CAL WITH BP AT 160CC/KG.\nMAKING SOME SUCKING ATTEMPTS AT BREAST/ONLY BOTTLED 3CC'S\nWITH BOTTLE. VOIDING AND STOOLING. A-POOR FEEDER\nP-CONTINUE TO OFFER BREAST/BOTTLE WHEN AWAKE.\n#4FAMILY NO CHANGES.\n#5DEV. O- TEMPS STABLE IN OFF ISOLETE. INFANT WAKING FOR\nSOME FEEDS. INFANT NOT LATCHING WELL AT BREAST/OR BOTTLING\nWELL. A-NOW 37 1/7WEEKS NOT READY TO FEED /P- SUPPORT DEV.\n EYE EXAM NEXT WEEK. KEEP IN ISOLETTE UNTIL CONTINUED WT.\nGAIN THEN MOVE TO OPEN CRIB.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-06 00:00:00.000", "description": "Report", "row_id": 1917744, "text": "Nursing\n\n\n#2O: In nasal cannula 100% 25 - 50cc, no spells. Br.\nsounds clear with mild retractions.\n#3O: Wt. up35g on 160cc/kg, BM30 with beneprotein, q 3 hr.\nfeeds. belly soft, min. asp. no spits. Voiding and passing\nsm. amt. stool. Bottled x 2 doing fairly well with yellow\nnipple, sloppy. Gav. other fdgs. over 1 hr.\n#4O: No contact.\n#5O: Temp stable in off isolette, swaddled with hat on.\nVery alert with most cares and awake alot of the nite.\nLikes pacifier. Head circ. 29cm, fontanelle full, sutures\nsplit.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917581, "text": "NPN\n\n\n#1Sepsis Continues on antibiotics. Blood culture neg. to\ndate. CBC benign. A- R/O sepsis P- Continue to follow.\n#2Resp O- Received infant on vent settings of 22/5 X\n24.Second dose of surfactant given at 2300. She was weaned\nduring night with current settings of 17/5 X 17 21% O2 with\nsats above 95.(see flow sheet) RR 50-70. last v. gas at 0300\n7.38/33/46/20/-4. A- Stable P- Wean as tolerated.\n#3F/N O- Infant continues NPO with total fluids at 80cc/kg.\nPN10% and D10W infusing via DLUV line. D-stick improved\nafter bolus at .(58/91/68/67). U/O 1.8cc/kg/hr over last\n12 hours. abdomen soft and round with + bowel sounds. No\nstool passed.Lytes and bili sent at 12 hours. A-Blood sugar\nimproved P- Check labs.\n#4Family O- Parents in to visit with sibling. Family asking\nappropriate questions. A-Updated with status P- Support as\nneeded.\n#5Dev. O- Set point weaned x2 for elevated ax temps. (see\nflow sheet) Infant active and alert with cares. Sleeping\nbetween care times. A-IUGR 31 week infant/Dandy Walker\nsyndrome P- Support dev. To have today.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917582, "text": "Respiratory Care Note\nPt. began shift on IMV 22/5 R 24. pt. has weaned overnight and is currently on 16/5 R 16 and 21%. pt. did receive a second dose of Beractant at 2330, in the amt. of 2.6cc. Last vbg was on 19/5 R19 7.38/33/46/20/-4. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917583, "text": "Attending Note\nDay of life 1 PMA 32 0/7\nsevere IUGR\nintubated surf X2 on 16/5 rate 14 FiO2 21% VBC 7.40/31 RR 50-60\nwill get vit A\nHR 130-160\nweight 646 grams on 80 cc/kg/day NPO getting PN and lipid and D 10 W\nUO 1.8 cc/kg/hr but no stool so far\nOG tube in place\nDstick 58-91 and 104 this am\nBcx NGTD on amp/gent\nhct 54.3\non warmer stable temp\nHUS-showed agenesis of corpus callosum and Dandy-Walkter malformation\nHC last night 24 cm\n\nIMP-Infant with severe IUGR now in stable condition\nRESP-will plan to extubate today. Will consider CPAP\nCV-will consider ECHO on tomorrow to look for midline defect\nFEN-will check lytes, BUN/Cr with 24 hour labs\nGenetics-because of her growth restriction will have a genetic evaluation\nHEME-will plan to recheck plt count today\nNEURO-will have neurology follow up becasue of abnormal HUS. She will likely need a MRI in the future.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917605, "text": "Attending Note\nDay of life 4 PMA 32 3/7\nCPAP 5 RA RR 30-60 on vit A no spells\nHR 130-150's BP 60/47 mean 50\nweight 623 down 2 grams on 140 cc/kg/day enteral at 10 cc/kg/day\ngetting PN D 15 and IL at 100 cc/kg/day and D15 W at 30 cc/kg/day\nlowest d-stick 50, 70, 58, 136, 105\nsome soft loops present no aspirate no spits\nUO 2.7 cc/kg/day passing mec stools\non neoblue bili 4.4/0.5 on yesterday\nKaryotype pending\nstable temp in isolette\nHC 24 cm no change\n\nIMP-infant making progress still growth restricted\nRESP-will continue CPAP for now.\nCV-stable currently\nFEN-will continue TF at 140 cc/kg/day. Will continue enteral at 10 cc/kg/day. Will have 20 cc/kg/day of other fluid to adjust as needed. Will have PN at 100 cc/kg/day.\nNEURO-will have a HUS next week\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917606, "text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .21, bs clear, rr 40-60 with mild retractions. No spells noted thus far this shift. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-02 00:00:00.000", "description": "Report", "row_id": 1917611, "text": "Attending Note\nDay of life 5 PMA 32 \noff CPAP last night in room air RR 30-70 no spells\non vit A\nHR 140-160 BP 59/35 mean 40\nhct 52 plt 138\nweight 615 down 8 grams on 140 cc/kg/day enteral feeds at 10 cc/kg/day Q3 hour IVF at 130 cc/kg/day of PN and Il\nd stick 248, 185, and 154\nsoft abodomen no loops\nstable girth\nno spits normal aspirats\nUO 3 cc/kg/hr\nNa 137 K 4.3 Cl 113 CO2 15 TG 112\non neoblue photo bili 3.0/0.8\nin servoisolette\nHC unchanged\n\nIMP-infant making good progress\nRESP-will monitor for spells\nFEN-will increase to 150 cc/kg/day. Will increase enterals 10 cc/kg/day. Will check lytes tomorrow.\nGI-will check a bili in am. Will continue phototherapy\n" }, { "category": "Nursing/other", "chartdate": "2120-02-02 00:00:00.000", "description": "Report", "row_id": 1917612, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. O2 sats stable. Lung\nsounds cl/=. Mild IC/SC retractions noted. Infant continues\non Vit. A injections. No episodes of apnea or bradycardia\nthus far this shift. A: Infant breathing comfortably in RA.\nP: Continue to monitor infant's resp. status closely.\n\n#3 FEN: O: Total fluids currently @ 140cc/kg/day. Enteral\nfeedings of BM 20 remain @ 10cc/kg/day, q 3hrs. IV fluids of\nPN D 15 and IL infusing @ 100cc/kg/day through DLUVC w/out\nincident. D10 w/ U hep/cc also infusing w/out incident\nthrough DLUVC @30cc/kg/day. Team aware. Dstick this AM of\n175. Infant's abdomen is soft, active BS, no loops. Minimal\naspirates, no spits. Infant voiding well. Stooling mec.\nstools. A: Infant tolerating feedings well. Blood glucose\nstable. P: W/ new PN, increase TF to 150cc/kg/day. Increase\nenteral feedings to 20cc/kg/day. Hang D10 w/ U hep/cc @\n20cc/kg/day. Continue to monitor infant's blood glucose\nclosely.\n\n#4 Family: O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. Sutures slightly spread. Fontanels soft/flat. A: Alt.\nin G&D. P: Continue to support infant's developmental needs.\n\n#6 Jaundice: O: Infant remains pink, slightly jaundiced.\nContinues under neoblue bank double phototherapy. Eye\nshields in place. P: Continue w/ phototherapy. Plan to draw\nbili and electrolyte levels tomorrow AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-16 00:00:00.000", "description": "Report", "row_id": 1917672, "text": "NPN \n\n\n\n #2. Remains in RA. RR 40-70 LS cl/=. Mild SC/IC\nretractions. 1 A/b thus far today QSR. Sating >94%. P: cont\nto monitor for AOP and document.\n\n #3. TF 160cc/k/d IVF D10W w/lytesa and heparing infusing\[email protected]/k (~22cc/k/hr). Enteral feeds are @138cc/k/h (14cc\npg'd over 2hrs) BM28 made w/4 HMF,2 MCT and 2 Polycose. DS\ntoday done q6hrs have been 95 then 62. Team aware. Abd\nbenign. No spits. V+trace yellow stool. P: Increase pg time\nto 2.5hrs and recheck DS @next set of cares (@).\n\n #4. mom in @100. and BF infant. Updated by MD and this\nRN on infant's plan of care. Approp concerned about DS\nissues. P: cont support, keep updated and educate.\n\n #5. Temp stable nested in sheepskin boundaries in servo\ncontrol isolette. A+A w/cares. Wakes before some feeds. Good\ntone AF soft and full. HC stable. P: cont to support G+D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-20 00:00:00.000", "description": "Report", "row_id": 1917809, "text": "#2Resp\nLungs clear with sc retractions. Increase work of breath\nwith feeds. RR 40-60's. Sat in mid to high 90's. Baby in\nnasal cannula 100% 25cc at rest but required up to 75cc with\nfeeds due to drifts to 80's and at 2130 drift to 78. No true\nspells. Color pale\nA. Cont to require O2\nP. Cont to monitor\n#3FEN\nWt 1.685 up 40g. TF at 160cc/kg. Min of 45 q4.Baby bottling\n50cc q4 with bottle. Void and stooling, heme neg Abd\nround but soft. Active bowel sounds. Cont to receive BM30\nwith BP\nA. Tol feed and gaining weight\nP. Cont to monitor.tol to feed and weight gain.\n#4Parent\nNo contact\n#5Dev\nWaking for some feeds. Cont to bottle all feeds. Active and\nalert with cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-20 00:00:00.000", "description": "Report", "row_id": 1917810, "text": "/NEONN DOL 52, CGA 39 \nRR 40-70, NC at 25 cc's and increasing to 50-75 with feeds, HR 150-180\nPPS m.\nWt 1685 up 40 on 160 cc/kg now all PO of MM30 cals/ounce\nOn synthroid, iron and vit E.\nOn her TSH was0.63, T4 13.3 and Free T4 2.8, called endocrine and they will get back to us re new decreased dose.\nCalled and left message for mother. to page me when mom is in.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-20 00:00:00.000", "description": "Report", "row_id": 1917811, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in NC, 25cc flow, 100% FiO2. Flow\nincreased to 50cc w/ feedings. Lung sounds cl/=. Mild SC\nretractions noted. O2 sats WNL. No spells thus far this\nshift. Hematocrit of 30.4 today. A: Infant breathing\ncomfortably w/ resp, support. P: Continue to support\ninfant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 4hr feedings, all PO, using bottle. No spits.\nInfant's abdomen is soft, active BS, no loops. Infant\nvoiding, stooling (neg. heme). Continues on Vit. E, iron and\nSynthroid. Synthroid dose adjusted today based on thyroid\nfunction tests. A: Infant tolerating feedings well. P:\nContinue to support infant's nutritional needs.\n\n#4 : O: Mom in this afternoon. Updated by this RN and\nMD . Mom is w/ cares and bottling.\nSigned 60day immunization consent. A: Mom very ,\ninvested. P: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. A: Alt. in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-21 00:00:00.000", "description": "Report", "row_id": 1917812, "text": "NPN 11p-7a\n\n\n#2 remains in NC O2 25cc flow with increases for\nfeeds, 100%. Occ brief desats to high 80's. LS clear and\nequal, mild subcostal retractions, RR 40-70, color pale\npink. A: stable in O2, P: probable discharge on O2.\n#3 waking for feeds, bottling fairly well, taking 50 & 45cc\nBM30beneprotein. Abd benign, soft, +BS, no loops or\ndistention, vdg qs, trace stool. weight up 10 grams. A: slow\nweight gain P: no change at present\n#4 no contact with family thusfar in shift.\n#5 stable in open crib. wakes for feeds, quietly alert with\ncares, sucks some on pacifier. A: AGA P: cont to support\ndevelopment\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-08 00:00:00.000", "description": "Report", "row_id": 1917638, "text": "NPN 1900-0700\n\n\n2. RESP: Infant remains in RA with RR 40-70's and sats\n>98%. Lung sounds are clear. Mild baseline IC/SC\nretractions. No spells so far this shift.\n\n3. F&N: TF remain at 160cc/k/d. Feeds of BM20 are at\n90cc/k. PICC had PND13 with IL infusing well at 70cc/k.\nAbd benign. BS+. A/G stable. No spits noted. Asp has\nbeen 1cc of nonbilious, partially digested breast milk all\nshift. U/O 3.1cc/k/h. One large dark green stool noted at\n. Stool was trace heme positive and made\naware. No new orders. Weight gain 14 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and alert during her cares.\nTemp stable nested on sheepskin with gel pillow in\nservo-controlled isolette. She puts her hands to her face\nand sucks on her pacifier at times. Daily head circ is 25\ncm. Sutures remain widened and fontanels are soft and flat.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-08 00:00:00.000", "description": "Report", "row_id": 1917639, "text": "Neonatology Attending Progress Note\n\nNow day of life 11, CA 3/7 weeks.\nIn RA with RR 40-70s, O2 sats >98%\nOn Vit A but not requiring caffeine.\nOnly 1 episode of apnea/bradycardia last night during feeding.\n\nCVS - HR 160-170s BP 55/49 51\n\nWt. 706gm up 14gm on 160ml/kg/d of TF -\nenteral feedings 70ml/kg/d of MM, 90ml/kg/d of PN/IL\nFeedings are well tolerated with slow advancement.\nNormal urine and stool output.\n\nNeuro - Dandy Walker malformation\nHC 25cm\n\nGenetics - karyotype 47 XXX\n\nAssessment/plan:\nBaby is doing well.\nWill continue with gradual feeding advancement.\nGenetics consultants to meet with to review diagnosis.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-08 00:00:00.000", "description": "Report", "row_id": 1917640, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. O2 sats 99-100%. Lung\nsounds cl/=. Mild IC/SC retractions. No spells thus far this\nshift. Infant continues on Vit. A injections (mon/wed/fri).\nA: Infant breathing comfortably in RA. P: Continue to\nmonitor infant's resp. status.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day. IV fluids\ncurrently @ 80cc/kg/day. PN D13 and IL infusing w/out\nincident through central PICC in R arm. Enteral feedings\nincreased today to 80cc/kg/day, BM 20. Q 3hr feedings, PG,\ngavaged over 1hr. Minimal aspirates, no spits. Infant's\nabdomen is soft, active BS, no loops. AG's stable. Infant\nvoiding well. Large brown heme pos. stool x1, team aware. A:\nInfant tolerating advancement of feedings well. P: Continue\nto support infant's nutritional needs. Continue to advance\nenteral feedings by 10cc/kg x1 day @ 1100.\n\n#4 Family: O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout\ncares. MAE. AFSF. Calms w/ pacifier. A: Alt. in G&D. P:\nContinue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-28 00:00:00.000", "description": "Report", "row_id": 1917576, "text": "Respiratory Care\nPt rec'd in DR facial CPAP. Admitted to NICU and was intubated, rec'd on one dose beractant. Currently on settings 22/5 x24. Fio2 .30. bs coarse/sightly diminished. CXR consistent with RDS. low-lung vol noted. ETT advanced .5cm to 7cm marking. initial vbg on 20/5: 7.25/58. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-08 00:00:00.000", "description": "Report", "row_id": 1917641, "text": "Neonatology note\nPE:\n\nNEURO: infant nested in isolette, active on exam, AFOS, sutures widely separated, MAE x4.\n\nRESP: infant in r/a, breath sounds = clear with mild subcostal/intercostal retractions.\n\nCARDIAC: color pink/sl jaundice well perfused, no audible murmur on exam, pulses palpable =x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: intact, PICC line dsg intact without redness at site, no lesions, bruises or rashes on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal preterm female genitalia\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917584, "text": "Respiratory Care\nPt extubated to +5cm prong CPAP today following vbg 7.40/31. Fio2 .21, bs clear, rr 60's. No spells noted. Plan to support as needed.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-10 00:00:00.000", "description": "Report", "row_id": 1917647, "text": "Neonatology Attending\n\nDOL 13 PMA 33 5/7 weeks\n\nStable in RA. 3 A/B. On Vit A.\n\nNo murmur. BP 67/37 mean 48\n\nOn 160 ml/kg/d with 60 ml/kg PN12.5/IL via central PICC and 100 ml/kg BM 20. Advancing 10 ml/kg/d. No spits or aspirates. DS 76. Voiding. Stooling (heme neg). Wt 740 grams (up 25).\n\nHC 25.5 cm (no change).\n\n in. Kangaroo qod.\n\nA: Stable. Minor spells. Tolerating feed advance. Dandy Walker malformation without hydrocephalus. Stable HC.\n\nP: Monitor\n Continue feed advance\n Follow HC\n Hct, bili, lytes, PKU on Monday\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-10 00:00:00.000", "description": "Report", "row_id": 1917648, "text": " PHysical Exam\nPE: pale pink, AFOF, sutures split, breath sounds clear/equal with mild retracting, no murmur, abd soft, non distended + bowel sounds, sleeping, flexed tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-10 00:00:00.000", "description": "Report", "row_id": 1917649, "text": "0700- NPN\n\n\nRESP: Remains in RA. RR 30's-70's, O2 sats 92-100%. LS\nclear/=. Mild retractions. A/B spells x 3, mild stim\ngiven. On Vitamin A. P: Cont to monitor for apnea of\nprematurity.\n\nFEN: TF=160cc/kg/d. IVF=60cc/kg/d of D12.5PN via central\nPICC line. EF=100cc/kg/d of BM20 PG Q 3 hours over 1 hr,\nand increasing 10cc/kg/d QD at 1100. D-stick=61. No spits.\nMax aspirate of 1.6cc. Abdomen benign. Voiding 2.9cc/kg/hr\nx 12 hours. Med stool x 1 (heme-). Lytes, Bili, Hct, PKU\nto be drawn on Monday morning. P: Cont to monitor.\n\nDEV: Temps stable in servo mode isolette, pt is nested on\nsheepskin. Alert/active with cares. Sleeps well between\ncares. Sucks pacifier and brings hands to face for comfort.\nFontanels soft/flat, sutures are spread. AGA. P: Cont to\nsupport growth and development. Cont with daily head\ncircumferences.\n\nSOCIAL: Both in to visit, updated by this RN,\nasking appropriate questions. P: Cont to support/educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-11 00:00:00.000", "description": "Report", "row_id": 1917650, "text": " On-Call\nPhysical Exam\nGeneral: alert infant in room air; P-CVL infusing in arm, dressing intact, no erythema or edema\nSkin: warm and dry; color pink\nHEENT: head appears large for body; anterior and posterior fontanels very large, flat; sutures split; alert gaze\nChest: breath sounds clear/=; comfortable respirations\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: softly distended; visible bowel loops; active bowel sounds; no masses; umbilicus healed\nGU: normal preterm female; posterior vaginal wall skin tag\nExt: moving all\nNeuro: alert; + suck; + grasps; symmetric tone\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917607, "text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOf. She is pale pink, well perfused, no murmur auscultated. She is comfortable on prong CPAp, breath sounds clear and equal. IV fluids infusing via intact DLUVC. Abd soft, active bowel sounds. Stable temp in servo isolette. Family meeting today with parents and interpreter. Discussed recent NICU history, current management plan and expected NICU course. Parents invested and appropriate. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917608, "text": "NPN Days 7am-7pm\n\n\n#2 O: Infant remains on prong CPAP of 5 cms pressure and has\nremained in 21% FIO2. Lung sounds remain clear and equal.\nResp rates 40s-60s with continued mild retractions. No\nepisodes of As or Bs this shift. A: stable in roomair CPAP.\n P: Continue to moniter.\n#3 O: Remains on trophic feeds at 10cc/k/day with IVF at\n130cc/k/day - has PN of D15W and lipids with D15W\n\"piggybacked in\", infusing via DLUVC. Blood sugar has been\n105, 151 and 132 - have therefore left the piggybacj=ked\nD15W continuing to infuse at 30cc/k/day. Abd is softly\nround, with transient soft loops, good bowel sounds, Ag\nstable. Infant had one aspirate of 2cc, non-bilious and was\nrefed and has had no spits. Voiding adeq amts, passing mec\nstool x 3. Lytes drawn this morning were 141/2.9/110/17,\ntriglycerides 153 (with adjustments planned in evening PN).\nA: aspirate X 1, feeds remain at trophic volume, blood sugar\n\"stable\". P: Continue to moniter abd closely. Recheck\nlytes and triglycerides in the morning.\n#4 O: Infant's parents were in to visit this mroning and\nwere updated at the bedside. Family was held this afternoon\nin mom's room on postpartum unit and included NNPs Rivers\nand , this RN, S. , infant's\nparents and a Portuguese interpreter. Team updated parents\non both infants progress and general plan of care. A:\ninvolved and invested parents. P: Continue to support.\n#5 O: Infant is alert and actvie with cares, is irritable at\ntimes but settles with hand containment and sucking on her\npacifier. Ant font remains soft and full, with sutures\nspread. Infant on servo control with slight adjustments made\nin setting to keep infat's temp WNL -see flow sheet.\nRemains on CPAP A: AGA, with IUGR. P: Continue to moniter\nfor milestones.\n#6 O: Remains under NeoBlue bank phototherapy with eye\npatches in place. Skin is slightly jaundiced. Bilirubin\nlevels this morning were 4.4/.7/3.7. A: hyperbilirubinemia.\n P: Continue to moniter.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-02 00:00:00.000", "description": "Report", "row_id": 1917609, "text": "NPN 1900-0700\n\n\n#2: O: Recieved infant on CPAP of 5, at infant trialed\nto RA. Remains in RA, maintaing sats >95%. RR 30's-70's with\nmild ic/sc retractions. LS c/=. No spells. A: Stable in RA.\nP: Continue to monitor.\n\n#3: O: Current weight 615g (-8g). TF 140cc/kg/day. Enteral\nfeeds are at 10cc/kg/d. of bm20, 0.8cc q3 hours. IV fluids\nare at 130cc/kg/day. Infant has PN D15 with IL infusing\nthrough a DL UVC at 100cc/kg/day with D10 with 1/2 U Heparin\npiggybacked in at 30cc/kg/d. D10 was changed from D15 for a\nd/s of 248. D/s now 184. Abdomen soft with good BS. Soft\nloops present at first set cares. Infant is voiding and had\na mec stool. No spits. Max aspirate 2cc at first set of\ncares. aware. Aspirate returned and checked an hour\nlater. No aspirate 1hr later so infant fed at that time. Min\naspirates since. Girth stable at 16.5-17cm. P: Continue to\nmonitor for s/s of feeding intolerance, monitor I&O and\ndsticks.\n\n#4: O: No contact.\n\n#5: O: Temp stable in servo isolette. Infant is alert and\nactive with cares. Sleeps well in between. Brings hands to\nface and sucks pacifier when offered. Remains nested in\nsheepskin. Head circumference this shift 24cm, no change. A:\nAGA. P: Continue to support growth and development, continue\nwith daily head circumferences.\n\n#6: O: Infant continues under neoblue phototherapy at max\nintensity. Bili this shift 3.8, 0.3. P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-02 00:00:00.000", "description": "Report", "row_id": 1917610, "text": "Respiratory Care Note\nPt. trialed off CPAP at her care time. Pt. tolerating this well. BS clear. Vent d/c'd\n" }, { "category": "Nursing/other", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 1917673, "text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA. RR 30's-60's. Breath sounds are\nclear and equal. Mild IC/SC retractions. No spells thus far.\nOn vit A. A: Stable. P: Continue to monitor resp status.\n\n#3. O: Infant remains on TF's of 160cc/k/d. IVF's of D10W\nwith elec's and heparin infusing well via PICC at .8cc/hr\n(22cc/k/d). Feeds of BM28 currently at 138cc/k/d q3hrs\ninfused over 2.5hrs. D/S 89 thus far. No spits. Minimal\naspirates. Voiding qs. No stools thus far. On vit E and Fe.\nElec's pending. Wgt is up 2gms tonight to 831gms. A: D/S\nstable thus far tonight. P: Continue to monitor closely.\n\n#4. No contact from family thus far. Planning to visit\ntoday.\n\n#5. O: Infant remains in servo isolette with stable temp.\nShe is alert and active with cares. MAEW. HC up .25cm's\ntonight to 26.25cm. Font soft and full. A: AGA. P: Continue\nto assess and support developmental needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 1917674, "text": "Neonatology NP Note\nPE\nnested in isolette\nAF full and tense(baseline), sagital and coronal sutures widely split, lamboidal approximated(baseline)\nminimal subcostal restractions in room air, lungs clear/=\nl/Vl SEM at LSb, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n PICC insertion site with occlusive dressing, no erythema or edema at site\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-17 00:00:00.000", "description": "Report", "row_id": 1917675, "text": "Attending Note\nDay of life 20 PMA 34 \nin room air RR 30-60\nmild retractions\ntwo spells in 24 hours getting vit A\nPPS murmur HR 140-160 BP 68/40 mean 62\nhct 36.6\nweight 831 up 2 grams on 160 cc/kg/day of IVF at 0.8 cc/hr of D 10 W enteral feeds at 138 cc/kg/day of BM 28 cal/oz\npg over 2.5 Q 3 hours D stick 89 and 69\nNa 138 K 4.9 Cl 104 CO2 28\n\nIMP-infant in stable condition\nFEN-will change feeding composition to 4 cal/oz HMF, 4 cal/oz MCT, and will add beneprotein. Will wean IVF to D 7.5 W when blood sugar above 100 X3.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-04 00:00:00.000", "description": "Report", "row_id": 1917737, "text": "NPN 1900-0730\n\n\n2. IN 25-50cc NC to maintain sats. Occassional desats to\nmid 80's, usually with feeds. Lungs clear. RR 40-80 with\nmild IC and SC retractions. One A&B with bottle; see\nflowsheet for details. Continue to monitor for A&B/desats.\n\n3. Wt up 45gm to 1305gm. TF 160cc/k/d BM30 w/BP= 26cc\nQ3hr. Able to bottle 10cc once; very uncoordinated and\nbrady'd as noted above. Abdomen benign. Voiding and had\none trace amt. of stool. Tolerating mostly NGT feeds with\nmin. aspirates and no spits. Continue to monitor tolerance\nto feeds and bottle once a shift.\n\n4. No parental contact thus far.\n\n5. Temp stable swaddled in off isolette. Alert and active\nwith cares. MAE, brings hands to face. Rest well inbetween\ncares. Sutures spread, fontanelles soft and flat. HC up\n0.25cm to 29cm from last Thurs. Continue to promote\ndevelopment.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-04 00:00:00.000", "description": "Report", "row_id": 1917738, "text": "/NEON DOL 36 CGA 37\nNC at 25-50 cc's l flow, RR 40-80, HR 160-170, PPS m\n1 brady with bottling.\nWt 1305 up 45 on 150 cc/kg BM30 PRO\nStarting to PO, but mostly PG\nFeeding cut back to go in over 45 minutes, but dexst today is 47, will increase to feed over 1 hour and recheck sugar post feed and prior to next feed. To maintain sugars > 50. Will go back to feed over 1 1/2 hours if unable to maintain sugars.\nHC 29\nCalled mother and gave her update\n" }, { "category": "Nursing/other", "chartdate": "2120-02-07 00:00:00.000", "description": "Report", "row_id": 1917635, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. O2 sats 100%. Lung sounds\ncl/=. Mild IC/SC retractions noted. No spells thus far this\nshift. Infant continues on Vit. A injections. A: Infant\nbreathing comfortably in RA. P: Continue to monitor infant's\nresp. status closely.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day. Enteral\nfeedings increased today to 70cc/kg/day, BM 20. Q 3hr\nfeedings, gavaged over 1hr per team orders. Minimal\naspirates, no spits. Infant's abdomen is soft, active BS, no\nloops. Girths stable. Infant voiding and stooling well (neg.\nheme). IV fluids currently @ 90cc/kg/day. PN D13 and IL\ninfusing w/out incident through central PICC in L arm. A:\nInfant tolerating advancement of feedings well. P: Continue\nto support infant's nutritional needs. Draw lytes friday AM.\n\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. AFSF. A: Alt. in G&D. P: Continue to meet infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-07 00:00:00.000", "description": "Report", "row_id": 1917636, "text": " Physical Exam\nPE: pink, AFOF, sutures split, breath sounds clear/equal with mild retracting, no murmur, well perfused, abd soft, non tender, soft bowel sounds, PICC right arm wit intact dressing, right hand slightly edematous but no change from yesterday, quiet alert, flexed tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 1917695, "text": "/NEON DOL 25 CGA 35 \nNC at 13 cc's l flow, RR 60-70, HR 150-170,PPS murmur\nWt 981 up 66 on full enteral feeds of 160 cc/kg, PG going in over 2.5 hours on a q 3 hours schedule.\nMaintaining Dexstick of IV with last sugars 80-110.\nID: No growth, site in antecubitus looks great, will do day 3 of IV oxacillin and 2 days Keflex.\nHUS on preliminary shows new G1 bilateral IVH,no hydrocephalus even though clinical exam has ongoing sl full fontanell and split sutures.Dysplasia of anterior corpus callosum.\nLeft message for mom, did not discuss hemmorhage on the phone message. Will wait for official report and then have them page me when mom is here so I can let her know that tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 1917696, "text": "Rehab/OT\n\nMet with mom to discuss developmental care. Discussed the importance of low lighting and low stimulation environment to maximize growth. Mom also with questions about back to sleep. Talked about AAP guidelines. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 1917697, "text": "NPN\n\n\n#2Resp O- sin NC 13cc's 100% with sats above\n90. RR 40-70. Lungs clear and equal. color pale/pink. Loud\nmurmur audible. HR 150-170.Echo yesterday/PPS. One quick HR\ndrop to 80 noted prior to feed. A-Stable /low flow cannula\nP- wean O2 as tol. VIT A given. (right thigh 11th dose).\n#3F/N O-Infant remains on BM 30cal with BP at 160cc/kg.\nFeeds given over 2 hours/30 minutes. No spits/aspirates.\nAbdomen is full and soft with + bowel sounds. Girth 18-19cm.\nVoiding well/passing liquidy stool g-. D-stick 90.Mom\noffered breast and infant making some sucking attempts. She\ndid not latch. A- Stable on full feeds/glucose stable over\nlast 24 hours off IV. P- PIC line to be discontinued \n . Follow wts.\n#4Family No change. Mom visited today and updated.\n#5Dev. O- Temps remains stable in heated isolette. Air temp\ndecreased x2. Infant active/alert with cares. done this\nAm. Vit A given. A- AGA P- Support dev. Dr. to\nupdate family with results.\n#7Skin O- Left arm dry/skin intact. No swelling/redness\nnoted. Last dose of oxacillin given at 1500. Triple\nantibiotic discontinued this am. A-resolving cellulitis P-\nStart po antibiotic as ordered.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 1917698, "text": "PICC line Procedure: Discontinued\nIndication: Discontinuation of IVF.\nProcedure: PICC line dressing removed and picc line withdrawn easily. No bleeding at site and site clear of infection. Bandaid placed over site.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-09 00:00:00.000", "description": "Report", "row_id": 1917642, "text": "NPN 1900-0700\n\n\n2. RESP: Infant remains in RA with RR 20-50's and sats\n>96%. Lung sounds are clear and equal. Baseline IC/SC\nretractions. One spell noted so far this shift. She is not\non caffeine.\n\n3. F&N: TF remain at 160cc/k/d. Feeds are at 80cc/k/d of\nBM20. PICC has PND13 with IL infusing well at 80cc/k. Abd\nbenign. BS+. A/G stable. No spits noted. Max asp was\n0.4cc of nonbilious, partially digested breast milk. U/O\n3.1cc/k/h. One large green heme positive stool. \n aware. No new orders as abdominal exam remains\nbenign. Weight gain 9 grams.\n\n4. PAR: in to visit with older sister.\n with cares and gave her kangaroo care for 1 hour\nwhich she tol well. They spoke lovingly to infant and asked\nappropriate questions. They will be in tomorrow afternoon.\n informed them that Genetics would like a\nmeeting with them. Our team is to arrange meeting for\nanytime after 1300 today.\n\n5. DEV: is active and alert during her cares.\nOccasionally irritable between her cares. Temp stable\nnested on sheepskin in servo-controlled isolette with gel\npillow. She puts her hands to her face and sucks vigorously\non her pacifier.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1917699, "text": "NPN nights\n\n\nRESP: Infant continues in NC 100% 13cc. Lungs are clear\nand equal, mild SC retractions. RR 50-70's. No\napnea/bradycardia spells, occasional drifts in O2 sats.\nSTable in NC, will continue to monitor.\n\nALt in F/N: Weight tonight 975 down 6g (previous gain\n66grams). Tf 160cc/k/d of Bm30with beneprotein. All gavage\nfeedings, given via ngt over 2hours. DS tonight 67.\nAbdomen is soft, pink, active bowel sounds, no loops, AG\nstable at 19cm. Voiding and stooling heme neg stools.\ntolerating feeds well, will continue to monitor closely,\ncontinue per current feeding plan.\n\nAlt in DEV: Temps stable in air mode isolette, dressed and\nswaddled. Infant is active and alert with cares. Moving\nall extremties well, brings hands to face. Sucks on\npacifier occasionally. HC 28cm up .5cm. HUS today showing\nno hydrocephaly. Will continue to monitor/support\ndevelopmental needs.\n\nAlt in Skin integrity: Area on arm, now no longer reddened\nor inflammed - healing well. Topical antibiotic oint stopped\nyesterday. IV dc'd, and antibiotics changed to oral Keflex.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-25 00:00:00.000", "description": "Report", "row_id": 1917708, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant continues on NC, 25cc flow, 100% FiO2. O2\nsats stable. Lung sounds cl/=. Mild SC retractions noted. RR\n60-80's. No spells thus far this shift. A: Infant breathing\ncomfortably w/ resp. support. Mildly tachypnic. P: Continue\nto support infant's resp. needs.\n\n#3 FEN: O: Tonight's weight = 1.048kg (+8g). Total fluids\nremain @ 160cc/kg/day, BM 30 w/ BP. Q 3hr feedings, PG,\ngavaged over 2hrs. Minimal aspirates, no spits. Infant's\nabdomen is soft, active BS, no loops. Infant voiding,\nstooling well (neg. heme). Continues on iron and vit. E. AG\n= 19-20cm. A: Infant tolerating feedings well. P: Continue\nto support infant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an air isolette.\nMaintaining stable temps. Infant sleeps well between cares.\nWakes w/ cares and remains A/A throughout. MAE. AFSF. HC =\n28cm (no change). Fontanels full/soft. Sutures spread. A:\nAlt in G&D. P: Continue to support infant's developmental\nneeds.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-25 00:00:00.000", "description": "Report", "row_id": 1917709, "text": " PHysical Exam\nPE: pale pink, AFOF, sutures separated, breath sounds clear/equal, mild retracting, very soft murmur, abd soft, full, non tender, soft bowel sounds, active, good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-25 00:00:00.000", "description": "Report", "row_id": 1917710, "text": "Neonatology Attending\nDOL 28 / PMA 35-6/7 weeks\n\nRemains in NC 25 ml/min, increasing to 215-50 ml/min during day, with mild tachypnea but no isgnificant distress and only one bradycardia in the past 24 hours. On vit A (last dose tomorrow).\n\nPPS murmur. BP 73/36 (49).\n\nWt 1048 (+8) on TFI 160 ml/kg/day BM30Prot, tolerating by gavage over 120 minutes for reflux. D-stick 104-79. Abd benign. Voiding and stooling normally (guiac negative). On iron and vit E.\n\nTemp stable. OFC unchanged today.\n\nA&P\n31-6/7 week GA infant with Dandy Walker, bilateral GMH, 47XXX karyotype, respiratory and feeding immaturity, history of hypoglycemia likely secondary to prematurity-related glycogran insufficiency\n-Continue to wean NC as tolerated\n-Follow murmur clinically (s/p echo this week).\n-Continue on current caloric density\n" }, { "category": "Nursing/other", "chartdate": "2120-02-25 00:00:00.000", "description": "Report", "row_id": 1917711, "text": "Nursing\n\n\n#2O: In nasaal cannula 1005 25 - 50cc with no desats or\nspells noted. br. sounds clear with mild retractions.\n#3O: On 160cc/kg, BM 30 with beneprotein, q 3 hr. feeds\nD-s 79. Belly soft, min. asp., no spits. Voiding and\nstooling.\n#4O: in and mom helped this RN give daughter her\n1st . Both held her after . Updated on\ncurrent plan.\n#5O: In heated covered isolette, stable temp. Active with\ncares. Had her 1st today. Red spot noted on top of\nright foot, shown to Dr. and it will be watched for\nnow; ? irritation from O2 sat probe.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-15 00:00:00.000", "description": "Report", "row_id": 1917668, "text": "0700- NPN\n\n\nRESP: Remains in RA. RR 30's-70's, O2 sats 92-100%. LS\nclear/=. Mild retractions. A/B spells x 3, mild stim given\nfor one. On Vitamin A. P: Cont to monitor.\n\nFEN: TF=150cc/kg/d (decreased from about 165cc/kg/d when\nIVF d/c'd) of BM26 cals made with 4 cals of HMF and 2 cals\nof Polycose. IVF d/c'd at 1100 for a d-stick of 78. Follow\nup d-stick at 150cc/kg/d of full EF was 37 ac. MD aware of\nlow d-stick. Feed started and one hour later, d-stick was\n56. EF gavaged over 2 hours (increased from 90 mins d/t\nd-stick). Pt is receiving feeds Q 3 hours. Central PICC\nline is hep locked. Infant went to breast x 1 for about 10\nmins with good latch and suck, full PG also given at that\ntime. No spits. Max aspirate of 2.2cc. Abdomen benign.\nVoiding, trace stool x 1. P: Cont to monitor closely.\n\nDEV: Temps stable in servo mode isolette, pt is nested on\nsheepskin. Alert/active with cares. Sleeps well between\ncares. Sucks pacifier and brings hands to face for comfort.\nFontanels soft/flat, sutures spread. P: Cont to monitor.\nCheck daily head circumferences.\n\nSOCIAL: Mom in to visit, updated by this RN, asking\nappropriate questions. Mom participated in care and held/BF\ninfant. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-16 00:00:00.000", "description": "Report", "row_id": 1917669, "text": "NPN\n\n\n#2Resp O-Infant continues in room air with sats above 90. RR\n50-70. Lungs clear/diminished at bases. Murmur audible\n(louder than yesterday) HR 130-160. Color pale. Hct 35 this\nweek. Infant had 2 epsiodes of bradycardia/SR.(see flow\nsheet) A-Stable ?murmur secondary to decreased Hct P- As per\nteam.\n#3F/N O- Infant now on feeds of BM28cal at 160cc/kg. Gavages\ngiven over 2 hours. No spits/aspirates noted. Abdomen full\nand soft with + bowel sounds. Girth 17.5-18cm. Voiding well.\nStooling liquidy yellow stool g-. Wt 829 Up 14gms. D-stick\n68 prior to feed/off IV. A- Stable Good blood sugar/wt. gain\nsmall P-Follow wts./D-stick. Continue to increase calories\nif indicated.\n#4Family No contact this shift.\n#5Dev. No changes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-16 00:00:00.000", "description": "Report", "row_id": 1917670, "text": "Nursing Addendum\nInfant noted to have D-stick of 37 at 0545. notified. D10W with heparin started at 1cc/hr via PICC. D-stick 98 at 0700.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-16 00:00:00.000", "description": "Report", "row_id": 1917671, "text": "/NEON DOL 19\nRA, RR 40-70, HR 150-170, G2m prob PPS heard out to axilla\nWt 829 up 14 on total fluids of165 cc/kg of BM 28 and D10W at 30 cc/kg thru PICC line, unable to decrease rate. Dex in high 30's off IV and up to 98 with feed over 2 hours and IV. Will wean to D7.5 if 3 sugars at 100 or more.\nTo get lytes,crit and retic in am.\nTo start ferrous sulfate and Vit E today.\nCalled and spoke with mom.\n\nNeon to cover \n" }, { "category": "Nursing/other", "chartdate": "2120-03-04 00:00:00.000", "description": "Report", "row_id": 1917739, "text": "NPN\n\n\n#2Resp O- continues in NC 13-25cc's at rest.\nIncreased to 50cc's briefly for breast/bottle feeding with\nMom. RR 40-70. Lungs clear. Murmur audible HR 160-170. color\npale/pink. Mild peri and pedal edema noted.(HOB has been\nelevated)No spelsl noted. A- Continued O2 need P- Wean As\ntolerated.\n#3F/N O- She remains on Bm30cal with BP at 160cc/kg. Gavages\nincreased this am to 1 hour for low blood glucose of 46.\nD-sticks with next feed 134/117. Feeds remains every 3\nhours. Infant voiding well and passing soft liquidy stool\nx1. Girth 20-21cm. Mom offered infant breast and she\nlatched briefly. She bottled 13cc's for Mom with yellow\nnipple. A- Infant tol. gavages over 1 hour/blood sugar\nstable P- Follow wts. Continue to have Mom offer\nbreast/bottle Mom to bring in bottle system.\n#4Family Mom in to visit and fairly independent with cares.\nMom aware lactation appointment for Wed. at 11am. Mom\nstating she is getting very litte sleep with home\nbecause he is feeding small amount every 2 hours. A- Loving\nfamily/involved/invested P- Teach and support as needed.\n#5Dev. O- Temps stable in off isolette. Infant active/alert\nwith cares. A- AGA P- Move to crib this week if she\ncontinues to gain wt. and eye exam due next week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917805, "text": "CLinical Nutrition\nO:\n~39 wk CGA BG on DOL 51.\nWT: 1645 g (+30)(<10th %Ile); birth wt: 646 g. Average wt gain over past wk ~13 g/kg/day.\nHC: 30.5 cm (<10th %Ile); last: 29.5 cm\nLN: 38.5 cm (<10th %Ile); last: 38.5 cm\nMEds include Fe and Vit E and synthroid\n not due\nNutrition: 160 dc/kg/day BM 30 w/ beneprotein, po/pg, q 3 hr feeds. Infant has taken all po feeds for last 2 shifts. Projected intake for next 24 hrs ~160 kcal/kg/day and ~4.5 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds q 3 hrs without GI problems. Taking mostly po feeds now. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC gain. Wt gain is not quite meeting recommended ~15 to 20 g/kg/day, but infant is tracking along a wt projectile following along under the 10th% growth curve. LN shows no change over past wk, but overall trend on LN growth chart is also tracking along a projectile under the 10th %ile. Will follow long term growth trends. WIll continue to follow w/team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917806, "text": "Neonatology Attending Progress Note\n\nNow day of life 51, CA 1/7 weeks.\nIn 25-50cc of nasal cannula O2.\nRR 30-80s\nHR - 150-170s BP 89/42 60\nNo apnea/bradycardia.\n\nWt. 1645gm up 30gm on 160ml/kg/d of MM30 with Beneprotein on Q3H feedings.\nFeedings well tolerated po/pg yesterday.\nNormal urine and stool output.\n\nOn Synthroid Vit E and Fe.\n\nAssessment/plan:\nWill continue with current management.\nTransitioning to Q3H feedings - will follow \nFU TFTS to be checked today.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-07 00:00:00.000", "description": "Report", "row_id": 1917637, "text": "CLinical Nutrition\nO:\n~33 wk CGA BG on DOL 10.\nWT: 692 g (+12)(<10th %Ile); birth wt: 646 g. Average wt gain over past wk ~14 g/kg/day.\nHC: 24.5 cm (<10th %Ile); last: 24 cm\nLN: 30 cm (<10th %Ile); last: 29 cm\nMEds include Vit A\nLabs noted\nNutrition: 160 cc/kg/day TF. Feeds currently @60 cc/kg/day BM 20, all pg q 3 hr feeds over 60 min, increasing 10 cc/kg/day. REaminder of fluids as PN via central PICC line; projected intake for next 24hrs from PN ~63 kcal/kg/day, ~3 g pro/kg/day, and ~1.4 g fat/kg/day. From EN: ~47 kcal/kg/day, ~0.7 g pro/kg/day and ~2.7 g fat/kg/day. GIR from PN ~7.5 mg/kg/min.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems so far w/ q3 hr feeds and 60 min gavage time. Advancing slowly and monitoring closely for tolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Current PN + EN meeting recs for kcals/pro/fat and vits. FUll mineral recs will not be met until feeds reach initial goal. Growth is meeting recs for HC and LN gain. WT gain is not meeting recommended ~15 to 20 g/kg/day yet, but anticipate improvement as feeds advance to initial goal. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-21 00:00:00.000", "description": "Report", "row_id": 1917692, "text": "/NEON DOL 24 CGA 35 \nNC at 13 cc's liter flow, RR 30-70, HR 150-170 cc/kg\nNo bradys in 24 hours\nWt 915 up 35 on 138 cc/kg enteral BM30 and lowest can go on PICC line of 22 cc/kg of D 5 with 2/1. Dex 61, on q 3 hour feeds over 2 hours. To heplock IV and see what sugar is during feed and 1 hour off. To keep sugars > 55.\nID:Blood culture neg. On oxicillin day 3, will switch to Keflex if PICC line is D'C,d. Area on arm looks very good.\nHC now 27.5, will repeat HUS in am.\nState screen sent yesterday. Methionine elevated on previous screen thought to be due to TPN.\nCalled and left word for mom.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-21 00:00:00.000", "description": "Report", "row_id": 1917693, "text": "NPN 0700-1900\n\n\nRESP: Conts in room air w/ sats >95%. Breath sounds are\nclear and equal w/ mild intercostal and subcostal\nretractions. RR 30-70's. One brady to 62- mild stim\nneeded.\nNo attempt to trial off o2 this shift as infant had failed\nlast night.\n\nF&N: TF 160cc/kg/d. PICC heplocked at 0800 w/ D/s-61 and\nenteral feeds increased to 160cc/kg/d q 3hrs over 2 1/2hrs.\nD/s at 10a=64, 11am=55, 2pm-81- will check again at 5pm (\nafter 30 minutes w/o infusion). ? the need to go to\ncontinuous feeds to maintain d/s vs restart IVF.\n Conts on BM 30 w/ Beneprotein.\n Abd is benign. Ag= 19cm. Abd is round and soft w/ active\nbowel sounds. Infant is voiding and stooling.\nA/P: Follow d/s closely- if <55,increase TF to 170cc/kg/d\nand increase to cont. feeds\n\nFAMILY: Mom in this am- updated at bedside. Mom did cares\nand tried to nurse and did kangaroo care fr 1hr.\n\nDEV: Temp is stable in servo-controlled isolette. Ant font.\nis full. HC up .75cm overnight. HUS to be done tomorrow.\nRepeat PKU sent.\n\nID/SKIN: Left antecub is slightly reddened- abx ointment\napplied and infant conts on IV Oxacillin as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917770, "text": "0700- NPN\n\n\nResp: Infant on NC, 25-50cc O2. Sats 91-95%. RR\n30-70's.Lungs clear/=.Mild subcostal retractions. No spells\nthis shift.P: Continue to monitor respiratory status.\n\nFEN: TF 160cc/k/d.Pt is a PO/PG feeder receiving BM 30 with\nBenaprotein. Infant will take PO's once per shift. Abdomen\nbenign. Voiding,stooling heme -. No spits this shift, max\naspirate 6.0. Pt receives Iron and Vitamin E.P: Continue to\nmonitor.\n\nDev: Temps stable in Off Isolette.Sucks pacifier and brings\nhands to face for comfort.Fontanels soft,full. Sleeps well\nin between cares.P: Continue to support growth and\ndevelopment.\n\n: in to visit today. Updated by this RN.\nAsking appropriate questions. independent with cares\nand feedings.P: Continue to support and update .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917771, "text": "Neonatology note\nPE:\n\nNEURO: infant swaddled being held by mom, active on exam, AFOS, sutures sl , x4.\n\nRESP: infant in nc/, breath sounds = clear with mild subcostal retractions.\n\nCARDIAC: color pink well perfused, soft audible murmur on exam, PMI ULSB, Gr I-II/VI, pulses palpable =x4, cap refill < 3secs, mucous membranes pink and moist.\n\nSKIN: intact, no lesion, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: voiding in diapers, normal female genitalia\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917772, "text": "0700- NPN Addendum\nPt has been in 50cc of NC O2 100% FiO2. Pt is receiving Q 3 hour feeds, and plan is to increase to PO every other feed for increase in PO amounts.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-12 00:00:00.000", "description": "Report", "row_id": 1917773, "text": "NPN 1900-0700\n\n\n#2Resp. Pt. on O2 via NC, 100%, 25-50cc, increased to 75cc\nfor po feed for drifts to low 80s. LS clear and equal, mild\nretractions present. RR 40s to 70s, sat mainly 91-98%. No\nbradys. Plan to monitor resp. status.\n\n#3FEN. Wt. 1490gms, up 20gms. On TF of 160cc/kg/day of\nBM30BP, 30cc q3hrs. Po fed x1, little interest, took 15cc\npo, remainder of feeding gavaged. Max. aspirate 2.5cc. No\nspits. Abd. soft, girth 22.5-23cm. Pt. voiding and passing\nliquid yellow stool, guaic negative, with each care. Desitin\napplied to reddened diaper area. Plan to po feed every other\nfeed as tolerated. Monitor for tolerance of feeds.\n\n#4Family. No contact with so far tonight.\n\n#5Dev. Pt. swaddled in off isolette. Temp. stable. Pt.\nwaking for some cares. Alert, active with cares. MAE.\nFontannels soft, full. Right cheek reddened, no drainage\nnoted, no increas in redness noted. Plan to support dev.\nneeds. Plan to have HUS this week.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-12 00:00:00.000", "description": "Report", "row_id": 1917774, "text": "/NEON DOL 44 CGA 38 \nNC 25-50 cc's, will check film today. Probably all due to severe IUGR\nHR 150-170, PPS m not heard\nWt 1490 up 20 on 160 cc/kg BM/Neos 30 cals/ounce. Attempts 2 feeds per shift taking to of feed.\nTo apply Criticaid to diaper area, having loose breastmilk stools.\nLabs in am: Nutrition and thyroid studies.\nHUS this week.\nCalled and left message for mother.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1917700, "text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 26.\nWT: 975 g (-6)(<10th %Ile); birth wt: 646 g. AVerage wt gain over past wk ~21 g/kg/day.\nHC: 26.75 cm (<10th %Ile); last: 25.5 cm\nLN: 32.5 cm(<10th %Ile); last: 32.5 cm\nMEds include Fe, Vit E, and Vit A\nLabs not due yet\nNutrition: 160 cc/kg/day BM 30 w/ beneprotein, all pg over 2 hr feeds, q 3 hrs, related to hx of low . Projected intake for next 24 hrs ~160 kcal/kg/day and ~4.5 g pro/kg/day.\nGI: ABdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. are now in 60's range off IVF, using q 3 hr feed over 2 hrs. Labs not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recs for HC gain of ~0.5 to 1 cm/wk and wt gain of ~15 to 20 g/kg/day; represents catch up growth. LN shows no change over past wk, but overall trend on LN growth chart is acceptable; will follow long term LN trends. WIll continue to follow w/ team and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1917701, "text": "/NEON DOL 26 CGA 35 \nIn NC at 13-25 cc's, RR 50-70's, chest clear, HR 160-180, PPS m softer today.\nWt 975 down 6, but up 66 yesterday.\nCurrently on all enteral feeds for past 48 hours, maintaining dex in 60's.\nFeeding 160 cc/kg of MM30 with Beneprotein, given q 3 hours over 2 hours down from 2 1/2 hours.Currently all PG. Put to breast when mom is in.\nHC at 27.5 growing approp with catch up growth. HUS on shows a new finding of bilateral GMH. This occured between 8and 24 days of life. No change otherwise, no hydrocepalus although clinically she has full but soft metopic suture and some splitting of sutures not really changed from initial findings.\nID: Antecubitus looks great, has had 3 days IV oxacillin and a day of Keflex, but starting to have loose stools, so I will D'C keflex. Blood cultures were negative, so this treatment course of antibiotics for the superficial infection should be sufficient.\nWill discuss with mother when she comes in.\n\nNeon to cover \n" }, { "category": "Nursing/other", "chartdate": "2120-03-12 00:00:00.000", "description": "Report", "row_id": 1917775, "text": "Nursing Progress Note 0700-1900\n\n\nResp O/A: Remains on NC, 100%, 25-50cc. Lungs c/=. Mild sc\nretractions. No spells. Intermittent tachypnea noted into\n80s. P: Continue to monitor and adjust O2 as indicated.\n\nFEN O/A: TF 160cc/k/d BM 30 with bp, = 30cc q3h, pg x1h.\nAlternating PO/PG, took 18cc for mom this shift. Abd benign,\ngirth 23cm. Voiding qs, small stool. No spits, min asp. On\niron and vit e. P: Continue to monitor feeding tolerance and\nencourage POs. Check nutrition labs, Hct, and in a.m.\n\nG&D O/A: Temps stable, swaddled in off isolette. MAE. Font\ns/f. Active/alert with cares. Bottom irritated, beginning to\nbreakdown - will apply criticaid prn with diaper changes. P:\nContinue to monitor and support normal infant development.\nCheck thyroid function tonight. Rpt head ultrasound and eye\nexam this week.\n\n O/A: Mom in this shift, up to date (spoke with this\nRN and Dr . Invested and appropriate, independent\nwith infant. Twin is at home. P: Continue to update,\neducate, and support NICU family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-12 00:00:00.000", "description": "Report", "row_id": 1917776, "text": "Nursing Progress Note 0700-1900\nAddendum:\n\nT max 99.3 - will consider transfer to open crib tonight if gains weight. Bottled full vol at 1700 using yellow nipple, needed frequent burps and occasional light chin support.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-28 00:00:00.000", "description": "Report", "row_id": 1917577, "text": "NICU Nursing Admission Note O: Baby girl was admitted to the DR L&D. Infant was born at 31 6/7 weeks gestation to a 26 yo G2 now P3 mom. History is signif. for twins gestation with this twin having severe IUGR and with Dandy Walker malformation noted prenatally. Please see Neonatology Note for further history. Apgars were 8 and 8 Infant was dried with stim given and needed facial CPAP breifly. Vital sogns upon admission to the NICU were temp 96.1 rectal, HR 161, RR 40s, sat 90% in roomair and B/P 68/29 mean 44. Infant was placed on an open wamrer with warming lights placed over infan. See flow sheet for further vital signs and improved temp results. Infant is alert and active with eyes open, skin is pink and warm. Infant was electively intubated and given surf X 1 thus far. Current vent settings are 22/5 BR 24 and has needed ~ 30% FIo2. Lung sounds coarse. HR regular, no murmur heard, pulses WNL, B/P stable. CBC and blood cultures were drawn and sent and infant received initial doses of Ampi and Gent. DLUVC line placed by . Initial D-stick was 42, decreased to as low as 25 and did receive 2 D10W boluses. TF are 80cc/k day and has starter PN and D10W infusing. ABd is soft, +BS, soft loops. Erythromycin eye ointment and Vitamin K given. Infant's dad in to visit and took pictures and was updated at the bedside. A: premaute infant, intubated, r/o sepsis, severe IUGR. P: Moniter resp status closely. Moniter reuslts of blood work. Provide developmentally appr. care. Provide support to parents and keep parents updated on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-28 00:00:00.000", "description": "Report", "row_id": 1917578, "text": "Neonatology NP Procedure Note\nEndotracheal Intubation\nIndication: surfactant deficiency\n2.5 ETT passed orally through cords under direct laryngoscopy. tube secured with 6.5 at upper lip. good chest wall movement and equal breath sounds present. CXr shows tip of ett just at thoracic inlet, 7 rib expansion. Infant tolerated procedure well. No complications.\n\nPlacement of umbilical venous catheter\nIndication : need for long term IV therapy.\nUmbilical area prepped and draped. 3.5 double lumen UVC inserted and threaded to 7 cm. Xrays shows tip of catheter at IVC/RA junction. Infant tolerated procedure well. No complications.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-28 00:00:00.000", "description": "Report", "row_id": 1917579, "text": "Admission Note\nNeo Attending Admission Note:\n\nGirl Twin is 32 wk, BW646 gm, severe IUGR born by c/s today due to mothers preterm contractions and ongoing concern re: this infant's lack of growth (oligohydramios, absent end-diastolic flow). Fetal U/S at 18 wk gestation revealed that Twin B girl had CNS anomaly c/w Dandy Walker malformation + IUGR.\nMother Rx with Betamethasone 2/14-15/07.\n\nMat Ob hx. - 26 yr G2 P1, A+, Ab neg, HBsAg neg, Rub Im, GBS unknown.\nPregnancy hx as noted above. No other known congen anomalies in family or relevant medical hx as related to this twin B.\n\nDelivery @ 1615 on . Twin B had weak spon cry, which improved, pink on RA, good perfusion, active. Infant had equal BS, developed increase WOB. Rx Facial CPAP with O2. Tx to NICU. Apgars .\n\nUpon admission to NICU:\nvery SGA, active, wob, well perfused.\nT 96 which increased to nl range.\nP 160s, BP 68/29, mean 44. SpO2 92-95%\n\nGlu screens: 42, 25, 43, 58, 91 (has received 2 'bolus' D10W infusions + IV infusion of D10W at 80cc/kg/day.\n\nDue to WOB, infant was intubated with 2.5 ETT. BS =bilat, Rx with 1st dose of surfactant ~1700. SIMV P22/6 FiO2 30% R 24. Weaned to SIMV 19/6, RA, Rate 20. BG with pCO2 58 then 48. CXR: mild hazy lungs, but low lung volume. CTR wnl.\n\nHEENT: Very large AF with split of sagittal sutures and lg posterior fontanelle. HC 25 cm. Eyes: red reflex, her lens have increase lenticular vascular pattern c/w immaturity. Ears, Nose, Mouth appear wnl. Neck appears nl, no masses, no adenopathy. Clavicles: nl to palpation. Lungs: improved clear=bs after surfactant.\nCV: no murmur, HR and rhythm acceptable for 32 wk. nl perfusion.\nAbd: soft, nontender, non-distended, umb 3 vessels.\n placed UVC without problem.\nGU: c/w preterm, SGA. Anus Patent, Back appears nl externally.\nExtrem: no contractures noted.\nNeuro: appropriate tone, strength, movements, activity, crys.\ninfant has voided\nHct 54.3%\nWBC 6K (diff pending)\nPlt 163K\nBlood culture pending. Rx amp/gen\n\n\nAssessment/Plan:\n1. 32 wk SGA twinB female.\n2. antenatal dx. c/w Dandy-Walker malformation. large head and fontanelles, sag suture. Plan HUS tomorrow. Will contact Neurosurgery.\n3. insufficiency: part may be due to surfactant deficiency and/or abnl lung development of SGA infants. Monitor clinical and BG. Wean as tolerated. Give 2nd dose of Surfactant.\n4. R/O sepsis as noted above.\n5. Heme: monitor for s/sx of DIC, abnl coags.\n6. Genetic consultation (SGA + D-W malformation).\n\nPt attended in delivery room and in NICU, examined and discussed with team and parents.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917580, "text": "1 Infant with Potential Sepsis\n2 RDS/31 weeker\n3 Alt. fluid/nutrition\n4 Alt. family bonding\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 RDS/31 weeker; added\n Start date: \n 3 Alt. fluid/nutrition; added\n Start date: \n 4 Alt. family bonding; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-14 00:00:00.000", "description": "Report", "row_id": 1917782, "text": "Clinical Nutrition:\nO:\n~38 week CGA BG on DOL 46.\nWT: 1580g(+45)(<10th %ile); BWT: 646g. Average wt gain over past week ~18g/kg/day.\nHC: 29.5cm(<10th %ile); last: 29cm\nLN: 38.5cm(<10th %ile); last: 37.25cm\nMeds include Fe & Vit.E\n noted.\nNutrition: 160cc/kg/day as BM 30 w/ beneprotein; po/pg over 1hr & took ~35cc of ~32cc po. Average of past 3-day intake ~160cc/kg/day, providing ~160kcal/kg/day & ~4.5g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; /pg & took some full volumes but tires & not yet well coordinated. noted with elevated ALP (772 up from 685 on ); likely d/t ?metabolic bone disease but since PO4 & Ca++ wnl's expect some improvement in bone mineralization on current formula; will recheck levels in 2 weeks. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT/HC gains but slightly exceeding recs of ~1cm/wk for LN gain. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-14 00:00:00.000", "description": "Report", "row_id": 1917783, "text": "/NEON DOL 46 CGA 38 \nRemains in NC 25-50 cc's no bradys, RR 50-80, HR 160-170\nWt 1580 up 45 on 160 cc/kg BM 30 Bene\nHct/ 29/6.8 on iron.\nSpoke with endocrine and updated them on B\rriannas's r\nrising TSH levels (22) in the face of boarderline T4 and normal free T4. They have recommended starting Synthroid, which we did yesterday\nto have f/u levels in 2 weeks.\nEye exam is mature z 3 ou and f/u in 1 year.\nSpoke with mother re all results.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-14 00:00:00.000", "description": "Report", "row_id": 1917784, "text": "NPN\n\n\n#2RESP O- continues in NC 50cc's most of shift. Weaned\nbriefly to 25cc's. RR 40-80 with mild retractions noted.\nMild edema. No spells noted. Hct 29 6.8 A-continued O2\nneed/low lung volumes by X-ray this week P- Continue to\nfollow.\n#3F/N O- She continues on feeds of Bm30cal with Bp at\n160cc/kg. Alternating po/pg and taking entire volume by\nbottle. D-stick 2 hours after bottle 74/88. Inant voiding\nand passing soft stool. A-Improving with po stable glucose\nP- Continue feeds every 3 hours/increase po if tolerated.\n#4Family Mom in for cares at 1400 and independent with\ncares. Mom bottled infant with yellow nipple. Mom asking\nappropriate questions. Mom pleased infant starting to po\nmore. P- Teach and support as needed.\n#5Dev. O- Infant waking for some feeds/ temp stable in open\ncrib. Infant with full fontanells/soft. HC 30.25cm. A-IUGR\nnow 38 P- Support dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-02 00:00:00.000", "description": "Report", "row_id": 1917732, "text": "NICU Nursing Progress Note\n\nRemains in nasal cannula 100% requiring 25cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. 1 desat noted this morning\nwhen prongs fell out of nose.\n\nSoft murmur appreciated. Cap refill brisk. Pale. VSS.\n\nRemains on q3hr feeds of 30cal BM with BP. Attempted po feed\nthis morning and infant took 9cc with leakage around mouth.\nLatched on fo BF with Mom and eagerly fed for ~5-10 mins.\nFully supplemented by gavage. Abdominal exam benign. Voiding\nand passing heme neg stool.\n\nRemains in low degree air mode isolette with stable temp.\nActive and alert with cares and sleeps between. Tone wnl.\n\nMom and relatives in to visit to discharge other twin home.\nMom held this infant for long time and was teary upon\nleaving. Updated regarding infant's status and plan of care.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-03 00:00:00.000", "description": "Report", "row_id": 1917733, "text": "NPN 1900-0730\n\n\n2. Remains in NC 25-50cc to maintain sats. Occassional\ndesats to 86-89%. Lungs clear. RR 60-70's with mild SC\nretractions. No A&B's thus far. Continue to monitor for\nA&B/desats and support as needed.\n\n3. Wt up 15gm to 1260gm. TF 160cc/k/d BM30 W/BP= 25cc\nQ3hr. Abdomen benign. Voiding and having heme negative\nstools. Able to bottle 16cc once tonight. Tolerating\nmostly NGT feeds with one medium spit after bottle and no\naspirates. Continue to encourage PO's once a shift at this\ntime.\n\n4. No parental contact thus far.\n\n5. Temp stable swaddled in low air isolette. Alert and\nactive with cares. MAE, brings hands to face. Fontanelles\nremain wide, soft. Rest well inbetween cares. Continue to\npromote development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-03 00:00:00.000", "description": "Report", "row_id": 1917734, "text": " On-Call\nPhysical Exam\nGeneral: infant in isolette, nasal cannula O2\nSkin: warm and dry color pink\nHEENT: anterior fontanel large, open, level; sutures widely split\nChest: breath sounds clear/=, mild retractions\nCV: RRR, no murmur appreciated; normal S1 S2\nAbd: soft; no masses; + bowel sounds\nExt: moves all\nNeuro: sleeping, + suck; + grasps\n" }, { "category": "Nursing/other", "chartdate": "2120-03-03 00:00:00.000", "description": "Report", "row_id": 1917735, "text": "Neonatology\nDoing well. Remains in low flow NCo2. Few spells. Comfortable appearing.\n\nWt 1260 up 15. Tol feeds at 160 cc/k/d of 30 cal. Gavage going well.\nAbdomen benign.\n\nTemp stable.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-03 00:00:00.000", "description": "Report", "row_id": 1917736, "text": "NICU Nursing Progress Note\n\nRemains in nasal cannula 100% O2 requiring 25-50cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. Occasional drifting sats with\npo feed attempt or at end of gavage feed, but self limited\nand mild.\n\nMurmur appreciated. Cap refill brisk. VSS.\n\nTF 160cc/kg/day of 30BM with BP. Attempting po feed once or\ntwice a day. Infant increasing ability slowly. Today, she\ntook 32cc po over 20 mins with a little sloppiness, but\noverall better. Abd exam benign. Voiding and passing stool.\nRemains on Iron and vit E.\n\nRemains in air mode isolette on lowest heat setting. Temp\nstable. Active and alert with cares. Tone wnl. Fontanelles\nsoft and full, sutures split slightly. Will check HC\ntonight.\n\nMom and in to visit bringing other twin in with them.\nMom gave infant a and handles infant very well. She put\ninfant to breast and infant latched briefly and searched\naround interested. Mom plans to visit again tomorrow for the\n11:00am feeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917807, "text": "0700- NPN\n\n\nResp: Pt on 25-50cc NC. Sats 92-100%. RR 40-70's. Lung\nsounds clear/=. Mild subcostal retractions. No spells this\nshift. P: Continue to monitor for spells.\n\nFEN: TF 160cc/kg/d of BM 30 with Benaprotein. Feeds changed\nfrom Q3hrs to Q4hrs. Monitoring D sticks, so far\nstable.Infant receives all PO feedings, bottling 40-50cc +\nbreastfeeding each care. Abdomen benign, voiding and\nstooling. No spits this shift.\nPt receives Iron, Synthroid and Vit E.\nP: Continue to monitor.\n\nDev: Temps stable in . Sucking pacifier and brings hands\nto face for comfort. Alert and active with cares. AGA.\n P: Continue to support growth and development.\n\n: Mom in to visit today. Asking appropriate\nquestions. Updated by this RN. Mom independent w/cares and\nfeedings.P: Continue to support and update .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917808, "text": "NP NOTE\nPE; small growing preterm infant swddled in open crib. Pink and well perfused in nasal canula. AFOF sutures widly split, eyes clear, MMMP\nChest is clear, equal bs, mildly tachypneac.\nCV: RRR, no murmur, pulses+2=\nAbd: soft with active bs\nGU: immature female\nEXT: , \nNeuro: active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-22 00:00:00.000", "description": "Report", "row_id": 1917694, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant continues on NC, 13cc flow, 100% FiO2.\nO2 sats >96%. Lung sounds cl/=. Mild SC retractions noted.\nNo spells thus far this shift. A: Infant breathing\ncomfortably w/ resp. support. P: Continue to support\ninfant's resp. needs.\n\n#3 FEN: O: Tonight's weight = 0.981kg (+66g). Total fluids\nremain @ 160cc/kg/day, BM 30 w/ BP. Q 3hr feedings, PG,\ngavaged over 2hrs 30min. Minimal aspirates, no spits.\nInfant's abdomen is soft, active BS, no loops. AG = 20cm.\nDstick of 111. Infant voiding well, no stool thus far this\nshift. Continues on vit. E and iron. A: Infant tolerating\nfeedings well. Maintaining stable blood glucose levels. P:\nContinue to monitor blood glucose. Continue to support\ninfant's nutritional needs.\n\n#4 : O: No contact from tonight thus far. P:\nContinue to update, support and teach .\n\n#5 DEV: O: Infant now swaddled in an air isolette for\nirritability and stable temps. Maintaining stable temps.\nInfant sleeps well between cares. MAE. AFSF. Sucks on\npacifier. HC = 27.5cm. Unchanged from last night. A: Alt in\nG&D. P: Continue to support infant's developmental needs.\n\n#7 Skin: O: Rash on L antecub healing. Treated w/ triple\nantibiotic ointment. Infant continues on IV oxicillin. P:\nContinue w/ current treatment plan. Continue to monitor for\ns/sx of infection.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-10 00:00:00.000", "description": "Report", "row_id": 1917764, "text": " On-Call\nPhysical Exam\nGeneral: infant in isolette, nasal cannula O2\nSkin: warm and dry; color pink\nHEENT: anterior fontanel large, open; sutures widely split; eyes wide-spaced\nChest: breath sounds clear/=; easy respirations\nCV: RRR, no murmur appreciated; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds;\nExt: moves all\nNeuro: irritable with exam, calms with pacifier; + suck; + grasps\n" }, { "category": "Nursing/other", "chartdate": "2120-03-10 00:00:00.000", "description": "Report", "row_id": 1917765, "text": "Neonatology Attending Note\nDOL# 42, CGA 37 wk\n\nIn NC 50-75cc, RR 40-60s\nNo spells in 24 hrs\n\nSoft murmur\nP 150-170s\nMBP 56\n\nWt 1425 (up 15 gm)\nOn 160 cc/kg BM 30 with Beneprotein\nBottles once q shift\n\nVOiding and stooling\n\nVit E and Fe\n\nIn off isolette\n\nA/P:\nPremature infant with mild CLD, feeding immaturity\nRESP: Continue on current NC regimen. Monitor sats.\nCV: PPS murmur.\nFEN: Continue to work on PO feeds on current nutritional regimen.\nNEURO: Follow-up imaging for Dandy-Walker\nSOC: updated on plans.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-10 00:00:00.000", "description": "Report", "row_id": 1917766, "text": "0700- NPN\n\n\nRESP: Remains on NC 100% 50-75cc to maintain O2 sats above\n90%. RR 20's-70's. LS clear/=. Mild retractions. No A/B\nspells or desats. P: Cont to monitor and wean from O2 as\ntolerated.\n\nFEN: TF=160cc/kg/d of BM30 with BP PO/PG. Pt is currently\nPO feeding about once per shift. Infant BF x 1 this shift\nand was supplemented with a full PG feed at same time. No\nspits. Min aspirates. Abdomen benign. Voiding, trace\nstool x 1. On Ferinsol, Vit E. P: Cont to monitor and\nencourage PO feeding as tolerated.\n\nDEV: Temps stable in , pt is dressed/swaddled.\nAlert/active with cares. Sleeps well between cares. Sucks\npacifier and brings hands to face for comfort. Fontanels\nsoft/flat. AGA. P: Cont to support growth and development.\n\nSOCIAL: Both in to visit, updated by this RN,\nasking appropriate questions. participated in care\nand bathed infant independently. P: Cont to support/educate\n.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-26 00:00:00.000", "description": "Report", "row_id": 1917833, "text": "/NEON DOL 58 CGA 40 \nNC 25-50 up to 75 for feeds, RR 50 HR 150-170 soft PPS m\nno bradys\nWt 1835 up 30 , took 204 cc/kg BM 28,\nRepeat thyroid screens, TSH 1.6, T4 11.2, free T4 2.0\nSpoke with endocrine and will leave dosing as is and for discharge.\nMom to fill script today.\nOxygen sat monitor training today with a interpreter present.\nTo do carseat test today and see if she passes, if not will have mom get .\nMom aware of plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-26 00:00:00.000", "description": "Report", "row_id": 1917834, "text": "0700- NPN\n\n\nResp: Pt on 50cc NC, 100%FIO2. During feedings, O2 increased\nto 75cc. RR 30-80's. LS clear/=. Mild subcostal retractions.\nNo spells this shift. P: Continue to monitor resp status.\n\nFEN: TF 160cc/k/d of BM 28 with Neosure, all PO feedings.\nInfant uses Advent bottle. Adequate PO intake.No spits this\nshift, voiding and stooling heme -.Infant of Iron,\nSynthroid, and Multivitamins.P: Continue to monitor.\n\nDev: Temps stable in . Sucks pacifier and brings hands to\nface for comfort. AGA. Fontanels soft and flat. Sleeps well\nbetween cares. P: Continue to support growth and\ndevelopment.\n\n: Mom and in to visit. Mom held infant. Asking\nappropriate questions.Updated by this RN. \nindependent with cares and feedings. received\nteaching from home oxygen company representative. Mom\nbrought in carseat for carseat test. Mom given \nfor Synthroid P: Continue to support and update .\n\nLeft eye Conjunctivitis: Erythromycin applied to both eyes.\nMinimal yellow drainage noted. P: Continue to monitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1917835, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 75cc flow. O2 sat WNL.\nLung sounds cl/=. Mild SC retractions noted. No spells thus\nfar this shift. A: Infant breathing comfortably w/ resp.\nsupport. P: Continue to support infant's resp. needs.\n\n#3 FEN: O: Tonight's weight = 1.805kg (+15g). Total fluids\nremain @ 160cc/kg/day, BM 28 w/ neosure powder. Infant\nwaking for feedings q 3-4hrs. PO intake = 50-70cc/feeding.\nNo spits. Infant's abdomen is soft, active BS, no loops.\nInfant voiding, stooling well. Continues on iron and\nsynthroid. A: Infant tolerating feedings well. P: Continue\nto support infant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and prepare for\ndischarge.\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. A: Alt. in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n#8 Eye: O: No drainage noted. Infant continues on\nerythromycin ointment TID. P: Continue w/ current plan.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1917836, "text": "/NEON DOL 59, CGA 40 \nRR 40-70, no bradys, on NC at 75 cc l flow. HR 150-170\nPPS m\nWt 1850 up 15, took 168 cc/kg of MM/Neos 28.\nImmunizations Pediarix/HIB/Pneumococcal today\n\nWorking toward Fri discharge on oxygen, with all f/u appts being made.\nMom taught medications.\nWill speak with her when she comes in today.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-13 00:00:00.000", "description": "Report", "row_id": 1917777, "text": "NPN\n\n\n#2Resp. No change remains in 25-50ccNC. RR 40-80.\n#3F/N O- Bottle offered at 2300. Infant awake and appearing\neager but suck very uncoordinated with most of milk\ndribbling. Infant has full soft belly with + bowel sounds.\ngirth 23cm. no spits/asp. Voiding well. Small yellow stool\npassed. Criticaid applied to buttocks/very tiny are of skin\nbreakdown noted. Wt 1535 up 45gms. A-poor po\nintake/requiring gavages P- check labs as ordered.\n#4Family No contact during night.\n#5Dev. O- Infant moved to open crib and temps have been\nstable. She is waking for feeds and appearing hungry. Small\namount of eye drainage noted and cleaned with water. Infant\nto have eye exam today. HC 30cm fontanelles full/soft. A-\nIUGR now 38 2/7 weeks/poor feeder P- this week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-13 00:00:00.000", "description": "Report", "row_id": 1917778, "text": "/NEON DOL 45 CGA 38 \nNC at 25 increased to 50 with feeds, chest film shows poor lung volumes but no other comments, oxygen need probably sec to IUGR.\nRR 40-80, HR 160-170, PPS m, possible flow m as well.\nWt 1535 up 45 on 160 cc/kg BM30\nWorking on PO, still PG>PO\nCa 9.9/alk phos 772/p 5.6\nAwaiting results of thyroid studies and will let endocrine know when results are back.\nHct/ pending.\nHUS shows minimal increase in ventricles of no importance and organizing germinal matrix hem. Spoke with Dr. and he feels no need for further HUS's to do MRI at CHMC as outpatient.\nIf feeding no better next week will recall neuro.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-13 00:00:00.000", "description": "Report", "row_id": 1917779, "text": "Spoke at length yesterday with mom re and xrays and HUS done. She is aware I spoke with endocrine and for the potential of treatment for hypothyroid.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-27 00:00:00.000", "description": "Report", "row_id": 1917837, "text": "NPN\n\n\n#2Resp O- continues in NC 75cc's with sats 98-100%.\nRR 60-80. Lungs clear. No spells noted. A- Stable P-\nDischarge home on low flow cannula.\n#3F/N O- is bottling every 4 hours and taking\n55-60cc's. BM28cal. Infant voiding and stooling. No spits\nnoted. A- Feeding well with bottle P- Follow wts. Mom\nhas recipe for Bm 28 cal with neosure powder.\n#4Family Mom in for PM cares. Mom aware infant given\npediarix today and aware infant to receive two more\nimmunizations this PM. Mom gave infant iron and multivits.\nMom shown follow up appointments made at CHMC. She is aware\nof dates and times. Pedi visit sceduled for Tuesday \nVNA arranged for Monday . A- family /ready for\ndischarge on Friday if infant continues to do well. P-\nContinue discharge preparations.\n#5Dev. O- Temps stable in open crib. Infant waking for\nfeeds. Pediarix given this afternoon. A- AGA now 40 2/7\nweeks P-Give remainder of immunizations this pm.\n#8 L eye O- No drainage noted from either eye today. Eyes\nclear. Erythromycin ointment discontinued. A- Resolved\nconjuctivitis P- D/C problem.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-09 00:00:00.000", "description": "Report", "row_id": 1917643, "text": "Attending Note\nDay of life 12 PMA 33 \nin room air RR 20-50 sat above 95%\non vit A no caffeine\none spells QSR\nHR 150-170 BP 73/39 mean 52\nweight 715 up 9 grams on 160 cc/kg/day enteral feeds at 80 cc/kg/day adv 10 cc/kg/day daily PN and IL D 13 via central PICC\nD stick 67\nNa 136 K 5.5 Cl 106 CO2 22\nstable girth\nno spits mininal aspirate\nvoiding and some heme positive stool\nin servocontrolled isolette\nHC 25.5 up 0.5cm today\n\nIMP-infant in stable condition\nRESP-will monitor for spells\nFEN-will plan to decrease the K in PN today. Will continue to advance enteral 10 cc/kg/day\nGENETICS-will have a family meeting today 2pm with genetics and interpreter\n" }, { "category": "Nursing/other", "chartdate": "2120-02-09 00:00:00.000", "description": "Report", "row_id": 1917644, "text": "NPN 7a-7p\n\n\n#2 Resp: Infant in room air w/resp rate 20s-40s and sat\n97-99%. Lung sounds cl/= and mild IC/SCR. One spell so far\nthis shift during sleep: HR 66, no desat, QSR. On vit A. A:\nInfant stable in room air w/occ spell. P: Cont to monitor.\n\n#3 FEN: TF 160 cc/kg. Ent feedings @ 90 cc/kg of BM 20 (8 cc\nq3h gav over 1 hr d/t hx low DS). Advancing 10 cc/kg daily @\n1100. IV fluids @ 70 cc/kg of PND13 and IL (@ 0.1 cc/hr) via\ncentral PICC. Abdomen round/pink/soft w/active bowel sounds\nand no loops. AG stable, 15.5-16 cm. Voiding 3.1 cc/kg/hr x\n6hr. No stool so far this shift. A: Infant tol feedings\nwell. P: Cont w/current plan and assess feeding tolerance.\nPlan to check DS @ next cares.\n\n#4 : Mom called x 1 and was updated. Plan for meeting\nw/ TCH genetics @ 1400 w/interpreter.\n\n#5 Dev: Infant nested in sheepskin in servo isolette, temp\nstable. Alert and active during cares and sleeps well\ninbtwn. Settles well w/hand containment. Brings hands to\nface. A: AGA. P: Cont to supp dev needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-09 00:00:00.000", "description": "Report", "row_id": 1917645, "text": "NP NOTE\nPE: small grwoth restricted preterm ifnant nelsted in isolette. Pink, well perfused in RA.\nAFOF sutures quite wide, split to PF. Eyes bright, alert, ng in place, MMMP\nChest is symmetric with clear and equal bs\nCV;RRR, no murmur, pulses+2=\nABD: soft, round, active bs, cord healing\nGU: immature female, very small anus with mior fissure at 6 and 12 o'clock, desitin applied.\nEXT: lean, PICC inatct with occlusive dsg\nNeuro: active with flexed posture, symmetric tone and relfexes.\n\nMother updated at bedside. Met with genetics regarding 47XXX, mother s questions answered. Will arrange f/u 3- 4 mo after d/c.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-10 00:00:00.000", "description": "Report", "row_id": 1917646, "text": "Nursing\n\n\n#1O: In room air with O2 sats > 96% with no noted desats or\nspells. br. sounds claer with very mild retractions.\n#3O: On 160cc/kg total fluids. Wt. up 25g. On 90cc/kg,\nBM, q 3 hrs. and IV of PN D 12.5 infusing thru noncentral\nPIC without incident. Belly soft, +BS, min. asp. and no\nspits. Void 3.5cc/kg, 1 stool guaiac neg.\n#4O: No contact.\n#5O: Temp stable on servo in heated covered isolette.\nNested with boundries. Very active with cares tonite.\nLikes pacifier. HC . Fontanelle is flat\nwith wide split sutures.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1917844, "text": "NPN Days-D/C to home\n\n8 left eye conjunctivitis\n\n#2 Resp: NC 100% 75cc, 40-80's, c/=, mild SC retrac. No\nspells.\n#3 FEN: Ad lib feeding, woke this AM and took 40cc BM with\nneosure 28. Abd benign, V/S, stooling.\n#4 : in late this morning, reviewed d/c\ninstructions, checked tags, placed infant in car seat, and\nset up portable 02. verbalized being comfortable\nwith the equipment and monitoring. F/u appts all set up,\n aware of appts and have all the information\nregarding f/u's. VNA called, appt for Monday confirmed.\nNeurology information faxed, MRI rec faxed, mom will set up\nappt this week.\n#5 G&D: Temp stable in , infant dressed, placed in car\nseat and covered with extra blanket. Alert and active, MAE,\nenjoys her pacifier.\nInfant d/c'd to home at 12:30pm.\nSee flowsheet for further details.\n\n\nREVISIONS TO PATHWAY:\n\n 8 left eye conjunctivitis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-18 00:00:00.000", "description": "Report", "row_id": 1917801, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25-50cc flow (increased to\n75cc w/ PO feedings). O2 sats WNL. Lung sounds cl/=. Mild SC\nretractions noted. No spells thus far this shift. A: Infant\nbreathing comfortably w/ resp. support. P: Continue to\nsupport infant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 3 hr feedings, all PO thus far this shift. Minimal\naspirates, no spits. Infant's abdomen is soft, active BS, no\nloops. Infant voiding, stooling well. Continues on Vit. E,\niron and synthroid. A: Infant tolerating feedings well. P:\nContinue to support infant's nutritional needs.\n\n#4 : O: Mom in this morning for 1100 cares. Mom\n w/ feedings and cares. Updated at bedside by\nthis RN. A: Mom very , asking appropriate questions.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Sleeping well today between feedings. A/A w/\ncares. MAE. Fontanels full/soft. A: Alt. in G&D. P: Continue\nto support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-18 00:00:00.000", "description": "Report", "row_id": 1917802, "text": "nursing note\n\n\n2. Remain is nasal canulla O2 100% 25cc, needing 75cc with\npo feeding. Breath sounds clear and equal with mild\nsubcostal retraction. No spells. AP:stable on 02, continue\nto wean as tolerated.\n\n3. TF 160cc/kg BM30 with BP. Baby taking all feeds po\neagerly. No spits. Abdomen soft and nontender. Weight up\n30 grams tonight. AP:stable, continue to offer po.\n\n4.No family contact this shift.\n\n5. Temp stable in open crib. ALert and active with care.\nCalms easily with pacifier and holding. Fontanelle soft and\nfull. AP:stable, continue to monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917803, "text": "NICU PCA Progress Note (7p-7a)\n\n\nRESP: O/Cont on NC 100% between 25 and 50cc flow; increasing\n to 75 with feeds. No real spells or desats so far this\nshift; mild desats to low 90's after feeds. Lung sounds\nclear and equal. (Please refer to flowsheet for resp\nassessment.) P/Cont to monitor for resp distress.\n\nFEN: O/Weight tonight 1645, up 30. TF cont at 160cc/k/d of\nBM30 with beneprotein PO Q3hr; NGT still in place but has\nnot needed to be used yet so far this shift. Voiding. Trace\ngreen stools, but no real stool yet so far this shift. No\nspits so far this shift. Abd benign. (Please refer to\nflowsheet for assessment and PO volumes.) A/Tolorating\nfeeds well. P/Cont with current regime.\n\nFAM: No contact with so far this shift.\n\nDEV: O/Temp stable. Swaddled in open crib. Active and alert\nwith cares. Sleeping well in between feeds. Waking for care\ntimes. MAE. Font S/F. A/Alt in growth and development.\nP/Cont to monitor and support growth and development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-19 00:00:00.000", "description": "Report", "row_id": 1917804, "text": "Nursing\n\nI have examined Baby Girl and agree with above note by PCA, R. Satin. Infant conts. to bottle well.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917767, "text": "NPN NOCS\naddendum: Noted to have bilateral yellow eye drainage at 0500 cares. Warm soak applied-monitor.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917768, "text": "NPN NOCS\n\n\n2. Remains in NCO2 100% at 25-50cc. LS clear. RR 50-60's. No\nspells. Stable in O2. Monitor.\n\n3. Wt 1470, up 45gms. TF at 160cc/kg of BM30 with BP. Q3hr\nfeeding schedule. Gavaged over 60min. Offered bottle-took\nfull amt. Will offer another bottle later this shift. Abd\nbenign. Voiding, no stool. No spits. Working on po feeding\nskills.\n\n4. No contact thus far.\n\n5. Temp stable in off isolette. Alert and active with cares.\nAGA.\n\nSKIN: Noted at start of shift reddness with bumpy rash to\nright cheek area where NGT taped. NGT noted to have been\npulled out by about 5cm. Tape removed gently. Area cleansed\nwith sterile H20 and steri strips applied to cheek area to\nkeep NGT in place but not over affected area. Area in\nimproving, still redened but with no bumpy rash or open\nareas noted. Continue to monitor closely.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-11 00:00:00.000", "description": "Report", "row_id": 1917769, "text": "Neonatology Attending Note\nDay 43, PMA 38\n\nNC 25-50cc, RR50-60s. Cl and =. Mild sc rtxns. +PPS murmur. HR 160-170s. BP 76/41, 53.\nWt 1470, up 45. TF 160 BM30 w pro. Tol well. Nl voiding and stooling.Fe and Vit E.\nOff isolette.\n\nA/P:\nGrowing former preterm, IUGR infant. Cont current management and monitoring. Repeat TFTs .\n" }, { "category": "Nursing/other", "chartdate": "2120-03-25 00:00:00.000", "description": "Report", "row_id": 1917831, "text": "NPN\n\n\n#2Resp O- Continues in NC 50-75cc's 100% with sats above 90.\nRR 60-80. Lungs clear. Murmur audible. Last hct 30.4. No\nspells noted. Had quick drift in sat to 71 with bottle feed.\nA- Unchanged P- As per team.\n#3F/N O- is bottling every 4 hours BM28cal with\nneosure powder taking 60cc's. Infant voiding and stooling.\noccassional small spit with wet burp. Abdomen benign.\nA-Growing well and taking above min. fluid requirement.\nP-Discharge home on 28calories. Mom aware of BM 28cal.\nrecipe . Copy of recipe given in discharge packet. Follow\nwts.\n#4Family Mom in to visit with other twin and 4 year old\nsibling. Mom aware that discharge preparation continues and\nshe is aware of discharge meds/doses/schedules. Mom has\ncopies of med information sheets in discharge packet. Mom\nstating she feels comfortable giving meds. Mom aware that\ntommorrow at 1400 meeting set up with homecare resp.\ncompany to teach her use of oximeter/home O2. Mom\npreparing for discharge P- Continue teaching as planned.\n#5Dev. No change. Passed hearing screen.\n#6Eye conjunctivitis O- Small amount of yellow drainage\nnoted from left eye /right eye clear. Erythromycin ointment\napplied as ordered. Mom shown how to do eye care with\nsterile water. A-left eye improved./culture showed scant\ns.aureus P- Continue eye ointment for 5 days as planned.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1917838, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 75cc flow, 100% FiO2. Lung\nsounds cl/=. O2 sats WNL. Mild SC retractions noted. Spell\nx1 w/ choking episode w/ feeding. Resolved by removing\nbottle from infant's mouth and providing mild stim. A:\nInfant breathing comfortably w/ resp. support. P: Continue\nto support infant's resp. needs.\n\n#3 FEN: O: Tonight's weight = 1.910kg (+60g). Total fluids\nremain @ 160cc/kg/day, BM 28 w/ neosure powder. Infant\nwaking for feedings q 4hrs. PO intake = 50-65cc/feeding\nusing bottle. No spits. Infant's abdomen is soft,\nactive BS, no loops. Infant voiding, stooling well.\nContinues on iron, multi-vits. and Synthroid. A: Infant\ntolerating feedings well. P: Continue to support infant's\nnutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and prepare for\ndischarge.\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. A: Alt in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n#8 Eye: O: No eye drainage noted. Infant continues on\nerythromycin ointment. P: Continue to monitor and treat.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1917702, "text": "NPN\n\n\n#2Resp O- Infant remains in NC 25cc's 100% to maintain sats\nabove 90. RR 40-70. Lungs clear /decreased aeration at\nbases. Mild retractions noted. No spells noted. Color\npale/pink. Murmur audible. A- Slight increase in O2 from\nyesterday P- Wean O2 as tolerated.\n#3F/N Remains on BM 30cal with BP at 160cc/kg. Feeds every 3\nhours over 2 hours. D-stick 84. A_ Stable P- Follow wts.\n#4Family Mom in to visit and held infant at 11am. Mom\noffering infant breast and she latched briefly. Dr.\n updated Mom about results. Mom aware to be\nfollowed. A- Loving family P- teach and support as needed.\n#5Dev. No changes.\n#7Alt. Skin O- Antibiotics stopped today. No signs of\ninfection or skin breakdown noted on left arm. A-No\ninfection P- D/C problem.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-23 00:00:00.000", "description": "Report", "row_id": 1917703, "text": "Nursing Addendum\nState lab called today and PKU was done . Next PKU due .\n" }, { "category": "Nursing/other", "chartdate": "2120-02-24 00:00:00.000", "description": "Report", "row_id": 1917704, "text": "NPN NICU 1900-0700\n\nRespiratory\nInfant remains in 100% O2 via nasal cannula, 25cc flow.\nRequiring increase to 50cc max at times, with feeds. RR\nmainly 60's-70's, mild intercostal/subcostal retractions\nnoted. LSC=. No apnea or bradycardia spells thus far this\nshift.\n\nFluid and Nutrition\nInfant's wt. 1040gms(+65). Total fluids 160cc/k/day; remains\non 30cal/oz feeds Q3hrs via NGT over 2 hrs. Abd. soft,\nB.S.(+), no spits, minimal aspirates. Voiding q.s., no\nstool. ABd. girth 18cm and soft. Tol. feeds.\n\nParenting\nNo contact with infant's this shift.\n\nDevelopment\nInfant awake and quietly alert with cares. Wakes on her own\nfor some feedings. Fontanells full and soft, head\ncircumference 28cm. MAE, sucks on pacifier, brings hands to\nface. Temp. stable; infant dressed in a heated, covered\nisolette, nested. Gel pillow in place. All cares clustered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-24 00:00:00.000", "description": "Report", "row_id": 1917705, "text": " PHysical Exam\nPE: pale pink, AFOF, PF open, sutures split, breath sounds clear/equal, mild retracting, soft murmur left axilla and back, abd soft, non distended, + bowel sounds, active.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-24 00:00:00.000", "description": "Report", "row_id": 1917706, "text": "Neonatology\nDOL #27, CGA 35 wks.\n\nCVR: Continues in NC cannula 25 cc oxygen, overall comfortable with mild intermittent retractions. RR 60-80s. No spells, moderate nasal secretions. Hemodynamically stable, soft murmur.\n\nFEN: Wt 1040, up 65 gm. TF 160 cc/kg/day, BM 30 w/BP, feeds pG over 2 hrs. Dstik 84. Feedings well-tolerated, voiding/stooling, no spits.\n\nDEV: In isolette.\n\nIMP: Former 31+ wk twin, SGA, with Dandy-Walker malformation, 47 XXX. Stable in low nasal cannula, tolerating full feeds. No new issues.\n\nPLANS:\n- Continue as at present.\n- Wean NC as able.\n- Continue 30 cals, monitor growth.\n- Gradual introduction of PO as able.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-24 00:00:00.000", "description": "Report", "row_id": 1917707, "text": "Nursing\n\n\n#2O: In nasal cannula 100% 25 - 50cc to keep O2 sats 90 -\n98%. Br. sounds clear with mild IC/SC retractions. RR 70 -\n80's, no spells.\n#3O: Fluids @ 160cc/kg, BM 30 with beneprotein, q 3 hr.\nfeeds. Belly soft, full +BS, no loops. D-s 104. Voids qs,\npassing sm. amt. stool. Min. asp. and no spits. Put to\nbreast, no real interest.\n#4O: and grandmotherinto . Updated at the\nbedside. Mother handles daughter well.\n#5O: stable, swaddled in heated, covered isolette.\nAlert with cares. Likes pacifier.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-05 00:00:00.000", "description": "Report", "row_id": 1917628, "text": "NPN\n\n\n#2Resp O- Infant remains in room air with O2 sats above 95.\nRR 40-70. Lungs clear/breath sounds diminished.\nIntercostal/subcostal retractions noted. Infant noted to\nhave 3 episodes of bradycardia today while at rest. (see\nflow sheet) A-Stable P- Follow closely for spells.\n#3F/N O- Infant noted to have small aspirate with visible\nblood this Am. Physical exam unremarkable at this time. MD\nalso in to exam infant. Feeds kept at 40cc/kg for remainder\nof day and increased to 50cc/kg at 1700. No further\naspirates noted. Abdomen full and soft with + bowel sounds.\nGirth 16-16.5cm Infant voiding and stooling. D-stick 104.\nA-? NG against stomach wall no further apsirates P- Continue\nto follow closely Check labs3/14.\n#4Family Mom in to visit with sibling and updated at\nbedside by MD regarding karotype results. (47XXX) Mom\ndid kangaroo care for 25 minutes. Mom also updated with \nresults. A- Loving family/updated P- Genetics to meet with\nfamily.\n#5Dev. O- Servo set point increased x1 this am after \ndone. Infant dropped temp.(8am see flow sheet)Temps stable\nthe remainder of day. Infant active/alert with cares. She\nsucks on pacifier and found her thumb to suck today. State\nLab called today and initial state screen not able to be\ntested secondary to layering of specimen.Repeat screen\nneeded. Team aware. PKU to be sent with labs A-AGA\nP- Support dev. Follow HC. Send PKU.\n#6Bili 1.8/0.6 NEOBLUE light discontinued at 0800. Rebound\nto be checked with next labs at 3/14.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-06 00:00:00.000", "description": "Report", "row_id": 1917629, "text": "npn 2300-0700\n\n6 Jaundice\n\n#2 resp\ninfant continues in r/a with sats 97-100%. lsc=. rr\n50-90's. sc/ic retractions noted. spell x3 thus far this\nshift.\n#3 fen\ntf 160cc/kg. enteral feedings currently 50cc/kg of bm20\ngavaged q4hours. ivf of pnd14 with lipids @ 110cc/kg via\ncpicc. wt. .680kg (+20gms). abd benign. voiding 2.9cc/kg\nin past 12hours. no stools thus far this shift. ag 15cm.\nno spits and max aspirate 1cc partially digested milk.\n#4 parenting\nno contact thus far this shift.\n#4 g&d\ninfant in servo control isolette with stable temps. alert\nand active with cares. maew. fontanelles soft and flat, with\nsplit sutures. sucking on binki and hands.\n\n\nREVISIONS TO PATHWAY:\n\n 6 Jaundice; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-06 00:00:00.000", "description": "Report", "row_id": 1917630, "text": "Attending NOte\nDay of life 9 PMA 33 \nin room air RR 50-70\n6 bradys in 24 hours mostly associate with feeds\non vit A but no caffeine\nHR 140-150 68/38 mean 48\nweight 680 up 20 grams on 160 cc/kg/day IVF at 110 cc/kg/day D 14 and Il Enteral feeds at 50 cc/kg/day\nblood out 9.7 cc\nno spits min aspirate\nvoiding and passing mec stool\nalert and active with cares\n\nIMP-infant making progress slowly\nRESP-will monitor for spells\nFEN-will continue to advance enteral feeds 10 cc/kg/day . Will repeat lytes tomorrow\nGI-will repeat bili on tomorrow\nPKU-will be sent because previos sample was not able to be run\n" }, { "category": "Nursing/other", "chartdate": "2120-02-06 00:00:00.000", "description": "Report", "row_id": 1917631, "text": " PHysical Exam\nPE: pale pink, AFOF, sutures split, breathosunds clear/equal with mild retracting, no murmur, well perfused, abd soft, non distended, non tender, + bowel sounds, PICC right arm with intact dressing, no redness, writs and hand slightly edematous, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-06 00:00:00.000", "description": "Report", "row_id": 1917632, "text": "0700- NPN\n\n\nRESP: Remains in RA. RR 20's-70's. O2 sats 95-100%. LS\nclear/=. Mild retractions. No A/B spells or desats. P:\nCont to monitor for apnea of prematurity.\n\nFEN: TF=160cc/kg/d. IVF=100cc/kg/d of D14PN and IL via\ncentral PICC line. EF=60cc/kg/d of BM20 PG Q 3 hours over\n10 mins, and increasing 10cc/kg/d QD. D-stick=79. No\nspits. Min aspirates. Abdomen benign. Voiding 4.9cc/kg/hr\nx 12 hours. Med stool x 1. P: Cont to monitor and advance\nfeeds as tolerated.\n\nDEV: Temps stable in servo mode isolette, pt is nested on\nsheepskin. Alert/active with cares. Sleeps well between\ncares. Sleeps well between cares. Sucks pacifier and\nbrings hands to face for comfort. Fontanels soft/flat,\nsutures spread. AGA. P: Cont to support growth and\ndevelopment. Daily head circumferences.\n\nSOCIAL: No contact from . P: Cont to\nsupport/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-07 00:00:00.000", "description": "Report", "row_id": 1917633, "text": "NPN 1900-0700\n\n\n1. FEN: WT=692gms (up 12gms). TF=160cc/k/day. Currently\nreceiving PND13 and IL at 100cc/k/day via PICC. Enteral\nfeeds are BM20 at 60cc/k/day. Min asp/no spits. Abd girth\n= 15cm. Abd is soft and round with active bs. U/O for past\n24hrs was 4.0cc/k/hr. Had 1 very small green stool o/n.\nPlan is to advance enteral feeds by 10cc/k/qd as tol. D/S\nat 0200 was 61. Lytes today were: 136/6.1/100/29.\n\n2. : came in at and were updated at\nbedside. Mom said they are looking forward to kangarooing\n today. Cont to offer support and updates.\n\n3. G&D: is very alert and active with cares.\nSleeps well between cares. Temps stable nested in sheepskin\nin servo isolette. Uses pacifier to comfort self. Brings\nhands to face. Todays HC = 25cm (down by 0.5cm). Sutures\nare spread.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-07 00:00:00.000", "description": "Report", "row_id": 1917634, "text": "Attending Note\nDay of life 10 PMA 33 \nin room air RR 30-70 sat 100% in room air\nno spells\non vit A\nHR 150-160's BP 68/38 mean 48\nmottles with cares\nweight 692 up 12 grams on 160 cc/kg/day of PN D 13 at 100 cc/kg/day eneral feeds at 60 cc/kg/day of BM 20 cal/oz adv 10 cc/kg/day\nno asp no spits\nactive bowel sound stable girth\nvoiding 4 cc/kg/hr and small green stool\nNa 136 K 6.1 Cl 100 CO2 29\nD stick 61\nbili 1.5/0.6\n\nin servo isolette\nalert and active with care\nHC 25\n\nIMP-infant in stable condition with 47 XXX\nRESP-stable in room air\nFEN-will continue to adv enteral 10 cc/kg/day. Will continue total fluids at 160 cc/kg/day.\nGENETICS-will reconsult them\n" }, { "category": "Nursing/other", "chartdate": "2120-03-26 00:00:00.000", "description": "Report", "row_id": 1917832, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 50cc flow (increased to\n75cc w/ feedings). O2 sats WNL. Lung sounds cl/=. Mild SC\nretractions noted. No spells thus far this shift. A: Infant\nbreathing comfortably w/ resp. support. P: Continue to\nsupport infant's resp. needs.\n\n#3 FEN: O: Tonight's weight = 1.835kg (+30g). Total fluids\nremain @ 160cc/kg/day, BM28 w/ neosure powder. Infant waking\nq 2-5hrs. PO intake thus far this shift = 25-70cc/feeding.\nInfant irritable, uninterested in bottling w/ 2100 cares.\nNo spits. Infant's abdomen is soft, active BS, no loops.\nInfant voiding, stooling well. Continues on Vit. E, iron,\nand synthroid. A: Infant tolerating feedings well. P:\nContinue to support infant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. Calms w/ pacifier. A: Alt. in G&D. P: Continue to\nsupport infant's developmental needs.\n\n#8 Eye: O: Very small amount L eye drainage noted. Treated\nw/ erythromycin ointment x1 this shift. P: Continue w/\ncurrent treatment plan.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-13 00:00:00.000", "description": "Report", "row_id": 1917780, "text": "Nursing Progress Note 0700-1500\n\n\nResp O/A: Remains on lowflow NC, 100%, 25-50cc flow. Lungs\nc/=, mild sc retractions. No spells. Intermittent tachypnea\nnoted, baseline per team. P: Continue to monitor and adjust\nO2 as indicated.\n\nFEN O/A: TF 160cc/k/d BM30 with bp, = 31cc q3h, pg x1hr.\nAlternating po/pg feeds as able - bottled full volume for\nmom today. Abd benign, voiding qs, no stools so far.\nCriticaid to excoriated areas on bottom q diaper change. No\nspits, min asp. On iron and vit e. P: Continue to monitor\nand encourage PO feeds.\n\nG&D O/A: Temps stable, swaddled in crib. AGA. MAE. Font\nsoft, full (baseline), sutures spread. Starting on synthroid\ntoday d/t elevated TSH MD. Repeat head ultrasound today\nresolving MD - will follow up with MRI outpt, no further\nhead ultrasounds indicated. Eyes mature today, will follow\nup at 1 yr. P: Continue to monitor and support normal infant\ndevelopment.\n\n O/A: At bedside, invested and appropriate. Updated\nby this RN and Dr . P: Continue to update, educate,\nand support NICU family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-14 00:00:00.000", "description": "Report", "row_id": 1917781, "text": "NPN 1900-0700\n\n\n#2RDS: Pt remains in NC 100%, 25-50cc. Sats 91-97%. RR\n50's-80's. Lung sounds clear and equal bilaterally. Mild\nsubcostal retractions. No spells so far this shift. P: Cont\nto monitor resp status.\n\n#3FEN: Wt 1580 (^45 gms). TF 160cc/kg/day of BM30 with\nbeneprotein, Q 3 hrs alternating PO/PG. Full feeding given\nover 60 mins, when gavaged. Pt bottled full volume at 2300.\nPt is eager with bottling but lacks coordination and tires\neasily. Tolerating feedings well, no spits, AG stable. Max\nasp 3cc of non-bilious, partially digested BM; refed. Abd\nsoft and round, no loops, +BS. Voiding and stooling. Pt cont\non iron and vit E. Started on synthroid. HCT and sent,\nas ordered, results pnd. P: Cont with current feeding plan.\nEncourage PO's.\n\n#4FAM: No contact from so far this shift. P: Cont to\nsupport and update .\n\n#5DEV: Temps stable, pt swaddled in . Alert and active\nduring cares. Settles and sleeps well in between care times.\nMAE. Fontanels soft and full. Sutures remain spread. HC=\n30.5cm. Pt has a small amt of yellow drainage from (L) eye &\nsmall amt of clear drainage from (R) eye. P: Cont to support\ndev needs. Obtain -weekly head circumferences.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1917839, "text": "/NEON DOL 60 CGA 40 \nRR 30-70, in NC at 75 cc\r'ss liter flow HR 160-180 PPS m\nWt up 60 took 183 cc/kg MM28/Neos\nReceived 2 month immun yesterday.\nDischarge planned for tomorrow\nAll f/u arrangements made.\nTo speak with mom when she comes in today.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-20 00:00:00.000", "description": "Report", "row_id": 1917688, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant continues on NC, 13cc flow, 100% FiO2 for\ndrifting. O2 sats stable on NC. Lung sounds cl/=. Mild IC/SC\nretractions noted. No spells thus far this shift. A: Infant\nbreathing comfortably w/ resp. support. P: Continue to\nsupport infant's resp. needs.\n\n#3 F/N: O: Tonight's weight = 0.880kg (-5g). Total fluids\nremain @ 160cc/kg/day. IV fluids of D 7.5 w/ 2NaCl + 1Kcl +\n U hep/cc infusing w/out incident through central PICC in\nR arm @ 22cc/kg/day (KVO). Enteral feedings remain @\n138cc/kg/day, BM 20. Q 3hr feedings, PG, gavaged over 2hrs\n30min r/t low dsticks. Dstick of 98 this shift. Infant's\nabdomen is soft, active BS, no loops. Girths stable. Infant\nvoiding, no stool thus far this shift. A: Infant tolerating\nfeedings well. P: Continue to support infant's nutritional\nneeds. Continue to monitor blod glucose.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. Fontanels remain full/soft. Sutures spread. A: Alt in\nG&D. P: Continue to support infant's developmental needs.\n\n#7 Skin: O: Red raised rash remains on left antecube.\nUnchanged from day shift assessment. No drainage noted. Left\nopen to air. Infant continues on IV oxicillin. Blood culture\npending. P: Continue to monitor and treat w/ IV antibiotics.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-20 00:00:00.000", "description": "Report", "row_id": 1917689, "text": "/NEON DOL 23 CGA 35 \nBack in NC 13 cc's, murmur down LSB to axilla can hear over L scapula not R, will reecho her today. RR 40-70, HR 150-170.\n4 bradys in 24 hours.\nWt 880 down 5 on 138 cc/kg BM and 22 cc/kg of D7.5 with 2/1, with dexst of 98. Will wean to D5W and check dextrosticks. Unable to run IV less then what amounts too 22 cc/kg/day.\nID: Blood culture remains neg, baby on oxacillin. Area in anticubitus looks much better. To do topical triple antibiotic to keep surface from rubbing against each other.\nEyes immature z 3 ou.\nState screen drawn yesterday for elevated methionine, prob secondary to when she was on TPN.\nCalled and left message for mother.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-08 00:00:00.000", "description": "Report", "row_id": 1917755, "text": "/NEON DOL 40 CGA 37 \nNC at 25-50,RR 25-50,, HR 150-170, no bradys for several days\nWt 1405 up 30 on 160 cc/kg BM 30 Benep\nWorking on PO feeds which are alt. Only taking small amts\nState screen resent yesterday. Labs from show elevated TSH with T4 normal on all state labs and boarderline at 8.9 from .Endocrine consulted and would like repeat labs drawn next week. If T4 remains boarderline, they might consider treatment.\nWill recall neurology next week if she does not pick up on feeding.\n\nNeon to cover .\n" }, { "category": "Nursing/other", "chartdate": "2120-02-20 00:00:00.000", "description": "Report", "row_id": 1917690, "text": "Nursing progress note\n\n\n#2 O: Remains in NC flow of 13cc/100% to maintain\nsaturations within parameters without drifting, lungs clear\nand equal with good aeration to bases, breathing with mild\nretractions A: comfortable in low flow cannula P: close\nmonitoring and assessment\n#3 O: Abdomen soft but full with active BS without loops, AG\nstable with minimal aspirates and no spits noted, cont. at\n138cc/kg via enteral feedings of BM30 with PIC line infusing\nat 22cc/kg of D7.5 with d/s-79, voiding with guaic negative\nstool passed A: tolerating feeds thus far with d/s remaining\nin limits P: monitor tolerance and check d/s as ordered\n#4 O: Mom in and with infant's basic care,\nholding and putting daughter to breast with baby doing fair\nwith good coordination at breast but tiring quickly, mom\nupdated at bedside A: Involved P: support, teach and keep\ninformed\n#5 O: Quiet awake and alert with cares, following soft\nspoken voice and holding fingers, loves sucking on pacifier\nwith cares, sleeping well between cares A: AGA P: provide\ndevelopmental care and interventions\n#7 O: L antebub area still with reddened and raised\ncircumferance approximately 1 inch around area but dry with\ntriple antibiotic ointment started and open to air, cont. on\noxicillin as ordered A: area healing with decreased\nweepiness P: cont. with plan and close monitoring\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-21 00:00:00.000", "description": "Report", "row_id": 1917691, "text": "NPN nights\n\n\n#2 Resp: Infant in NC 100% 13cc, lungs clear and equal ,\nmild IC/SC retractions. One desat tonight, NC had come out\nof nares, once reapplied resolved. NO apnea/bradycardia\nspells. Stable resp status in NC , will continue to\nmonitor.\n\n#3 Alt in F/N: Infant's weight 915g up 35grams. TF\n150cc/k/d - currently enteral feeds are at 138cc/k/d of BM30\nwith beneprotein. All gavage feeds given via ngt Q3hours\nover 2.5hrs. Abdomen is soft, pink, active bowel sounds, no\nloops, AG stable , voiding and stooling heme neg stools, no\nspits, min residuals. IV fluids are now D5W with 2:1 and\n0.5units of heparin / cc, infusing via PICC at 0.8cc/hour\n(22cc/k/d). This was weaned from D7.5w this evening ,\nfollow up DS 93. Tolerating feeds well, DS stable. Will\ncontinue with current feeding plan, and monitor closely.\n\n#4 Alt in family: No contact with family overnight, will\ncontinue to support and update.\n\n#5 alt in DEV: Temps are stable in servo controlled\nisolette, nested in sheepskin with gel pillow. Infant\nsleeps well between cares, is active and alert during care\ntimes. Moves all extremties. Brings hands to face. HC\n27.5 tonight. AGA. will continue to support developmental\nneeds.\n\nAlt in Skin integrity: left arm with raised reddened area\nwhere a bandaid had been. Treated w/ oxacillin IV per\norders, and triple antibiotic oint topically per orders.\nArea is slightly reddened. will continue to monitor, and\ntreat as planned.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1917840, "text": "Clinical Nutrition:\nO:\n~40 week CGA BG on DOL 60.\nWT: 1910g(+60)(<10th %ile); BWT: 646g. Average wt gain over past week ~16g/kg/day.\nHC: 31cm(<10th %ile); last: 30.5cm\nLN: 40cm(<10th %ile); last: 38.5cm\nMeds include Fe, synthroid & MVI/goldline.\n not needed.\nNutrition: /Min. 160cc/kg/day as BM 28 (8kcal/oz neosure powder). Average of past 3-day intake ~188cc/kg/day, providing ~175kcal/kg/day & ~3.6g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; feeds. not needed. Current feeds & supps meeting weaned recs for kcal/pro/vits/mins. Growth is meeting recs for WT/HC gains but exceeding recs of ~1cm/wk for LN gain; represents catch-up growth. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-28 00:00:00.000", "description": "Report", "row_id": 1917841, "text": "NPN Days\n\n\n#2 Resp: NC 100% 75cc. 50-70's, c/=, mild SC retrac. No\nspells so far this shift. P: Cont to monitor resp status.\n#3 FEN: Infant ad lib, with min 160cc/kg. Infant took 55cc\nand 40cc so far this shift. Abd benign, V/S, stooling. Cont\nMVI, iron, and Synthroid. P: Cont to monitor FEN status.\n#4 : No contact so far this shift. P: Mom had\nextensive d/c teaching yesterday, will f/u when family is\npresent to prep for tomorrow's d/c to home.\n#5 G&D: Temp stable in , swaddled. Alert and active with\ncares, sleeps well in between. Enjoys her pacifier, MAE,\nAFSF. MRI requisition faxed to MRI lab at TCH, per MRI dept,\nwill f/u with family and make appt for outptn MRI. P: Cont\nto monitor and support G&D.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1917842, "text": "Nursing\n\n\n#2O: Infant has nasal cannula in place 100% 75cc with O2\nsats 97 - 100% with no noted desats or spells. br. sounds\nclear with mild SC retractions. RR 50 - 80's, increased\nwith bottling.\n#3O: Wt. up 10g, taking in 131cc/kg, BM 28 made with\nneosure powder. Bottling every 4 hrs. with bottle and\n# 1 nipple, no spits. Belly soft, voiding and stooling,\ndesitin to bottom.\n#4O: No contact.\n#5O: Temp stable in crib. Wakes own own for feeds. Likes\npacifier. given in preparation for d/c.\nGood-bye .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-29 00:00:00.000", "description": "Report", "row_id": 1917843, "text": "/NEON DOL 61 CGA 40 \nRA, no bradys HR 160-180 PPS m\nWt \nPlease see dictated summary for all discharge plans and meds.\nF/U with Dr. .\nHome today\nSpent > 30 mins on discharge.\nCalled mom at home and cell phone and left message.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-08 00:00:00.000", "description": "Report", "row_id": 1917756, "text": "CLinical Nutrition\nO:\n~37 wk CGA BG on DOL 40.\nWT: 1405 g (+70)(<10th %Ile); birthwt: 646 g. Average wt gain over past wk ~18 g/kg/day.\nHC: 29 cm (<10th %Ile); last:28 cm\nLN: 37.25 cm (<10th %Ile); last: 34 cm\nMEds include Fe and Vit E\nLabs not due\nNutrition: 160 cc/kg/day BM 30 w/ beneprotein, alternating po/pg feeds, q 3 hrs. Infant takes minimal amounts po, maximum 20 cc. Projected intake for next 24hrs ~160 kcal/kg/day and ~4.5 g pro/kg/day.\nGI: ABdomen benign. One spit.\n\nA/Goals:\nTolerating feeds q 3 hrs without GI problems except occasional spits. Taking minimal po's so far. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN gain is exceeding recommended ~1 cm/wk; represents catch up growth. WIll continue to follow w/ Dr. and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-08 00:00:00.000", "description": "Report", "row_id": 1917757, "text": "NPN 0700-1500\n\n\n#2 O: Infant remains in NC o2 100% at 25cc's of flow. RR\n60's-80's with mild SC retractions. LS clear and =. No\nspells. A: Stable in NC. P: Cont to monitor.\n\n#3 O: TF= 160cc/kg/d. Infant taking 29cc's of BM 30 with BP\nq 3h via po/pg. Attempted to bottle with mom taking 10cc's.\nAbdomen benign; voiding, no stool. No spits, minimal\naspirates. AG 21.5cm. A: Tolerating feeds. P: Cont to\nmonitor.\n\n#4 O: Mom in for 1100 cares. Independent with temp and\ndiapering. Mom holding infant. Asking appropriate questions.\nA: Involved. P: Cont to support and update.\n\n#5 O: Maintaining temp in an \"off\" isolette. Swaddled in\nblanket with hat on. Anterior font remains full with sutures\nsplit. Opening eyes with cares and looking around. Crying\nand kicking legs during cares; sleeping well between. Sucks\non pacifier when offered and brings hands to face for\ncomfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-08 00:00:00.000", "description": "Report", "row_id": 1917758, "text": "NPN\n\n\n#2Resp O- remains in NC 25cc's 100% with sats above 90. RR\n40-80. Lungs clear. Mild generalized edema. No spells A-\nStable P- Wean as tolerated.\n#3F/N O- Remains on gavage feeds of Bm 30cal with Bp at\n160cc/kg. wt 1410 up 9 gms. Gavages over 1 hour.\nvoiding/trace stool. A-Poor po feeder although infant\nactive/alert now 37 4/7 weeks P- Follow wts. Encourage po if\nawake.\n#4Family No contact during night.\n#5Dev. O- Temps stable in off isolette. Infant active/alert\nwith cares. HC 29cm. Fontanelles soft/full. A-37 week\nIUGR/Dandy Walker Malformation /47XXX P- this\nweek/thyroid fuction tests per lab orders.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-09 00:00:00.000", "description": "Report", "row_id": 1917759, "text": "NPN 2300-0700\n\n\n#2Resp. Pt. in O2 via NC, 100%, 25-50cc, sat mainly 91-97.\nRR 50-80, LS clear and equal, ITC, SC retractions present.\nNo bradys. O2 mainly increased to 50cc during feeds for\ndrifts during po and gavage feeds. Plan to wean O2 as\ntolerated.\n\n#3FEN. Wt. 1410gms, up 9 gms. On TF of 160cc/kg/day of\nBM30BP, 28cc q3hrs gavaged over 1 hr. Pt. bottled x1 using\nyellow nipple, tires easily, took 18cc po. No spits, minimal\naspirates. Abd. soft, pink, active bowel sounds, no noted\nloops. Girth 22.5cm. Voiding and passing guaic negative\nstool. Plan to monitor for tolerance of feeds.\n\n#4Family. No contact with family so far tonight.\n\n#5Dev. Pt. swaddled in off isolette. Temp. stable. Not\nwaking for cares, is alert and active with cares, MAE,\nFontannels full, soft. Plan to support dev. needs.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-09 00:00:00.000", "description": "Report", "row_id": 1917760, "text": "NP nOTE\nPE: small growing growth restricted infant swaddled in isolette. Pale pink, well perfused in RA. LArge anterior fontanel, flat though full.Sutures split.\nEyes bright, ng in plaec, MMMP\nChest is clear, equal bs, comfortbale\nCV: RRR, no murmur, plses+2=\nAbd: soft, full with active bs\nGU: immature female\nEXT: , \nNeuro: flexed posture swaddled, symmetric tone and relfexes.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-09 00:00:00.000", "description": "Report", "row_id": 1917761, "text": "Neonatology\nDOL #41, CGA 37 wks.\n\nCVR: Continues in NC 25-50 cc oxygen, RR 50-70s, mild retractions. No spells. Hemodynamically stable, soft intermittent murmur noted.\n\nFEN: Wt 1410, up 9 grams. TF 160 cc/kg/day, BM 30 w/BP, PO/PG, limited PO intake. Voiding/stooling.\n\nDEV: In off-isolette.\n\nIMP: Former 31+ wk growth-restricted infant, mild BPD, feeding immaturity, overall stable. Continues in low nasal cannula, tolerating full feeds.\n\nPLANS:\n- Continue NC, wean as able.\n- Continue current enteral regimen, monitor growth.\n- Advance PO as able.\n- Periodic monitoring of thyroid function as planned.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-09 00:00:00.000", "description": "Report", "row_id": 1917762, "text": "Nursing Progress Note 0700-1900\n\n\nResp O/A: Remains on NC, 100%, 25-50cc flow. Lungs c/=. Mild\nsc retractions. No spells. P: Continue to monitor and adjust\nO2 as indicated.\n\nFEN O/A: TF 160cc/k/d BM30 with bp, = 28cc q3h, pg x1hr.\nBottled 30cc at 1400 care. Abd benign, girth 22-23cm.\nVoiding qs, stooling heme neg, no spits, max asp 2.4cc\n(benign, refed). On iron and vit e. P: Continue to monitor\nand encourage PO's as able.\n\nG&D O/A: Temps stable, swaddled in off isolette. AGA. MAE.\nFont s/f. Active/alert with cares. P: Continue to monitor\nand support normal infant development.\n\n O/A: At bedside for last feed. Independent with\ncares. Invested and appropriate, up to date. P: Continue to\nupdate, educate, and support NICU family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-10 00:00:00.000", "description": "Report", "row_id": 1917763, "text": "Progress note 7p-7a\n\n\nRESP: NC 100%O2 @ 25-50cc's. RR and SaO2 WNL. No spells\nnoted so far this shift. Will continue to wean O2\naccordingly.\n\nFEN: TF=160cc/K BM 30 w/ BP gavaged q. 3 hrs. Abdomen soft\nand benign. Voiding and stooling w/o difficulty. No spit or\nlarge aspirates noted. Will continue to monitor feeding\ntolerance and progession.\n\nPAR: No contact w/ so far this shift.\n\nDEV: Temps stable in off isolette. A/A w/ cares. Comforted\nby pacifer. Will continue to support developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917622, "text": "NPN\n\n\n#2Resp O- Infant remains in room air with O2 sats 97-100%.\nRR 40-60. Mild retractions noted. Breath sounds\ndiminished/clear. No spells noted. A- Stable P- Follow\nclosely.\n#3F/N O- Infant remains on total fluids of 150cc/kg. Enteral\nfeeds of BM increased to 40cc/kg. PN and lipids at 110cc/kg.\nD-sticks 91/64. Infant voiding in good amounts. She is\npassing small mec./green stool. Abdomen is full with + bowel\nsounds. Girth 16-17cm. A-Stable blood glucose P- D/c UVL\nonce new PN hung via PIC line. Check labs as ordered.\n#4Family in to visit with extended family. Mom\nhelping with care of . Mom aware infant to be held\nevery 3 days. Family aware UVL to come out. A- Loving family\nUpdated P- Teach and support as needed.\n#5Dev. O- Infant had servo set point decreased for ax temp\n99.1-99. She is active/alert with cares. Sucking on pacifier\nthis Am. A- AGA IUGR/ P- in Am. Family to hold every 3\ndays.\n#6Bili No change. Bili to be sent this PM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-04 00:00:00.000", "description": "Report", "row_id": 1917623, "text": "Nursing Addendum\nSmall amount of old blood noted under PIC dressing this Am. (has not increased in size) Slight puffyness in right hand noted.(?dependent edema/dressing very secure) Line flushed easily this Am. notified.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-05 00:00:00.000", "description": "Report", "row_id": 1917624, "text": "Nursing\n\n\n#2O: In room air with O2 sats > 97% with 1 spell, no\ndesats. br. sounds clear with mild - mod. retractions.\n#3O: Wt. up 4g on total fluids 150cc/kg. Enteral feeds are\nat 40cc/kg, BM q 3 hrs. Belly soft +BS, no loops. Had 1 -\n1.2cc asp. tonite that are brown in color. R. Buck is\naware. Aspirates have been discarded. IV of PN D15 with\nlipids infusing @ 110cc/kg thru cental PIC D-s 67 and 82.\nVoid in good amts. and passing sm. amt. meconium.\n#4O: No contact.\n#5O: Nested on servo in heated isolette. Active with\ncares, sucked on pacifier. HUS today. HC 24.5cm,\nunchanged.\n#6O: remains under neoblu photherapy with eyes covered.\nBili 1.8/0.6 which is down from 3.0/0.9. Color is pink.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-05 00:00:00.000", "description": "Report", "row_id": 1917625, "text": "Attending Note\nDay of life 8 PMA 33 0/7\nin room air RR 30-60 mild to mod retractions\nsat 97-100% on vit A\none spells QSR\nHR 150-160 BP 59/33 mean 41\nweight 660 up 4 grams on 150 cc/kg/day enterals at 40 cc/kg/day had some large aspirates last night PN and lipids at 110 cc/kg/day D stick 67 and 82\nNa 137 K 4.9 Cl 103 CO2 28 TG 75\nbili 1.8/0.6 on phototherapy\nactive and alert with cares\nHUS-showed intact corpus callosum and Dandy-Walker malformation\nKaryotype is 47 XXX\n\nIMP-infant doing well currently\nRESP-will continue to monitor for spells\nFEN-will increase to 160 cc/kg/day of total fluids will increase feeds to 50 cc/kg/day. Will check lytes on Wednesday\nGI-will check a rebound bili on Wednesday\nGENETIC-will have them follow up\n" }, { "category": "Nursing/other", "chartdate": "2120-02-05 00:00:00.000", "description": "Report", "row_id": 1917626, "text": "Neonatology NP Note\nPE\nnested in isolette\nAF open, full, and large, sagital sutures widely split\nmild subcostal retractions in room air, lungs clear/=, good air entry\nRRr, no murmur, pale with pink mm, well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nPICC insertion site with occlusive dressing, no erythema or edema\nactive with good tone\n" }, { "category": "Nursing/other", "chartdate": "2120-02-05 00:00:00.000", "description": "Report", "row_id": 1917627, "text": "Family meeting note\nMet with mom to explain the karyotype (47 XXX). All of her questions were answered. Genetics were consulted\n" }, { "category": "Nursing/other", "chartdate": "2120-03-23 00:00:00.000", "description": "Report", "row_id": 1917822, "text": "NPN 1645\n\n\n#2 Resp: Infant remains on a nasal cannula of 50cc flow,\nFIO2 100%. Increased to 75cc flow w/ bottling. Br. snds\nclear and equal bilat, mild-mod retractions. Infant had a\nchoking spell w/ the 1pm feeding, O2sat 61, dusky color,\nmild stim and increased O2 to resolve.\nA: Stable in low flow O2, occ. desat w/ feeding.\nP: Cont to monitor, cont. nasal cannula O2 as ordered.\n#3 F/N: TF 160cc/kg/d, breast milk w/ Neosure powder to\n28cals. Infant taking 35-50cc w/ bottle today. Abd\nfull, soft, active bowel snds. Infant voiding well, no stool\nthis shift. Infant tires out w/ nipple system, offered\nstandard nipple to finish volume. One choking episode today.\nA: Bottled less volume this shift, tolerating feeds.\nP: Cont to encourage po feeds.\n#4 : No contact thus far on shift. Plan to visit at\n5pm per report.\nA: Invested family.\nP: Cont prep. for d/c.\n#5 Dev.: Waking early for feedings, active and alert.\nSwaddled in an open crib w/ stable temps.\nBottles fairly well but tires out approx halfway through the\nbottle.\nA: Developing stamina now 39 wks.\nP: Cont to provide dev .supports.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-24 00:00:00.000", "description": "Report", "row_id": 1917823, "text": "NPN:\n\nRESP: NC-100%, 50-75cc 02 to maintain sats 95-97%. 02 increased to 75-100cc w/bottle feeds. RR=40-60s w/SC retraction. BBS =/clear. No A&Bs for several days. No desats w/fdgs thus far; desat (61) w/fdg x 1 over past 24 h.\n\nCV: Soft murmur. HR=150-170. BP=74/29 (45). Color pale pink w/good perfusion. Hct=30.4 ().\n\nFEN: Wt=1765g (+ 10g). TF=min 160cc/kg/d (= 47cc q 4 h). Bottled well w/ bottle for 50-60cc BM-28 q 4 h. No spits. Abd benign. Voiding qs; small yellow stool. FeS04 and Multi-Vits.\n\nG&D: CGA=39-6/7 wk. Temp stable in crib. Active and alert w/cares. AF, PF large, soft, flat. Sagittal suture separated. Hemangioma on rt buttocks. Small amt yellow eye drainage from lt eye; Erythromycin Ophth TID. Discharge planned for next week with home-02 and oximeter. Thyroid function tests to be done (infant is on Synthroid) and 60-day immunizations to be given prior to discharge.\n\nSOCIAL: No contcat w/.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-24 00:00:00.000", "description": "Report", "row_id": 1917824, "text": " On-Call\nPhysical Exam\nGeneral: infant in open crib, nasal cannula O2\nSkin: warm and dry; color pink, well-perfused\nHEENT: large anterior and posterior fontanels; sutures widely split anterior fontanel tense\nChest: breath sounds clear/=, well-aerated\nCV: Gr II/VI systolic murmur left sternal border with radiation; normal S1 S2; pulses +2\nAbd; soft; non-tender; no masses; + bowel sounds\nNeuro: sleeping infant, roused to drowsy state with exam\n" }, { "category": "Nursing/other", "chartdate": "2120-03-24 00:00:00.000", "description": "Report", "row_id": 1917825, "text": "Neonatology Attending Note\nDay 56, PMA 39 6\n\nNC 50cc. Inc w feedings. RR50-70s. 1 desat w feeding. +Murmur. HR 160-170s. BP 74/29, 45.\n\nWt 1765, up 20 gms. BM28 w NeoSure. All po. TFI: 110. Synthroid.\n\nOpen crib.\n\nA/P:\nGrowing preterm infant with IUGR and XXX. Discharge plan in progress. Cont present management and monitoring. TFTs due Tuesday.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-24 00:00:00.000", "description": "Report", "row_id": 1917826, "text": "NPN 1800\n\n\n#2 Resp: remains on a nasal cannula of 50-100cc\nflow, FIO2 100%. Placed in 100cc flow for po feedings then\nweans to 50cc during sleep. RR 40-80, O2sat 91-100%. No\nspells, no desats. Color pale pink. Br. snds clear and equal\nbilat. Mild SC/IC retractions.\nA: Stable in low flow O2\nP: Cont to assess for change in resp. status.\n#3 F/N: TF 160cc/kg/d breast milk 28 neosure added. Infant\nbottle fed 70, 45, 55cc today using bottle. No\nspits. Tol feedings. Abd full, soft, bowel snds active.\nInfant voiding and stooling qs. Receiving Vitamins and Iron\nas ordered. On Syntroid, received dose as ordered.\nA: Taking oral feedings well.\nP: Cont to monitor intake, encourage po's.\n#4 : No contact w/ mom today, in at 5pm w/ fresh\nbreast milk. are learning baby care, resp. company\nto come in on Tues for family teaching.\nA: preparing for discharge in the near future.\nP: Cont parent prep. for d/c.\n#5 Dev.: Infant remains in an open crib w/ stable temps.\nAlert and active prior to feedings. Has a well coordinated\nsuck and swallow during feeds.\nA: AGA, 39 wks corrected.\nP: Cont dev. supports.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-25 00:00:00.000", "description": "Report", "row_id": 1917827, "text": "NPN\n\n\n#2 Resp-Remains in NC 100%, 50cc at rest, increased to 100cc\nfor feeds.BS clear. Mild retractions. RR= 50-80.No desats\nw/feeds so far tonight.\n#3 F/N- Abd soft,+bs, no loops.Tolerating PO feeds w/o\nspits.Bottles slowly q 4 hrs taking 55-70cc.Voiding+\nstooling in adeq amts.Wt up 40gms.Min -160cc/kg/day=49cc q 4\nhrs.Remains on synthroid as ordered.\n#4 Family-No contact.\n#5 Dev- Alert and active w/ cares. Temp stable swaddled in\nopen crib.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-25 00:00:00.000", "description": "Report", "row_id": 1917828, "text": "/NEON DOL 57 CGA 40 \nNC at 25-100 cc's RR 40-80, HR 150-180 PPS m\nWt 1805 up 40 on adlib of MM 28 cals with Neos\nTook 195 cc/kg\nOn erythro for L eye drainage, sparce staph aureus, to erythro\nTo redraw thyroid functions tonight on new dose of synthroid.\nWorking toward Fri/Sat discharge on oxygen.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-25 00:00:00.000", "description": "Report", "row_id": 1917829, "text": "Rehab/OT\n\nMom requesting information on bouncy seats. OT to assess next week. Mom discouraged from placing her in one at this point due to her small size. OT to follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-25 00:00:00.000", "description": "Report", "row_id": 1917830, "text": "Discharge Planning\n\nThe following d/c plans have been coordingated for :\n\n1. Denmarks Home Medical (T:) will provide home oxygen. Their liaison, , RPT, will meet with mom at 2pm to in-service her on portable O2 and oximeter. They will coordinate home delivery of O2.\n\n2. VNA (T:, F:) will provide skilled nursing visits beginning Monday, 5/7 per mom's request.\n\n3. Criterion Early Intervention () has been notified of possible d/c at end of week.\n\n RN\n Case Manager\nBeeper: \n" }, { "category": "Nursing/other", "chartdate": "2120-02-26 00:00:00.000", "description": "Report", "row_id": 1917714, "text": "NICU Nursing Progress Note\n\nRemains in nasal cannula 100% O2 requiring 25cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. No apnea or bradycardia\nobserved.\n\nSoft murmur appreciated. VSS. Cap refill brisk.\n\nTF 160cc/kg/day of 30cal BM with BP by gavage every 3 hrs\nover 2 hrs. Abd exam full, soft, non-tender. AG stable.\nVoiding.\n\nSwaddled in air mode isolette with stable temp. Ambient temp\nweaned slightly. Tone wnl. Active and alert for cares and\nsleeps between.\n\nMom in and put infant to breast briefly. Baby was eager and\nlatched on but tired quickly. Handles infant with\nconfidence. Updated regarding infant's status and plan of\ncare.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-27 00:00:00.000", "description": "Report", "row_id": 1917715, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25cc flow, 100% FiO2. O2\nsats >90%. Lung sounds cl/=. Mild SC retractions noted. No\nspells thus far this shift. A: Infant breathing comfortably\nw/ resp. support. P: Continue to support infant's resp.\nneeds.\n\n#3 FEN: O: Tonight's weight = 1.095kg (+35g). Total fluids\nremain @ 160cc/kg/day, BM 30 w/ BP. Q 3hr feedings, PG,\ngavaged over 2hrs. Bottle attempted x1, intake = 5cc.\nMinimal aspirates, no spits. Infant's abdomen is soft,\nactive BS, no loops. AG = 20cm. Infant voiding, stooling\nwell (neg. heme). Continues on Vit. E and iron. A: Infant\ntolerating feedings well. P: Continue to support infant's\nnutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an air isolette.\nMaintaining stable temps. Infant sleeps well between cares.\nWakes for cares and remains A/A throughout. MAE. Sutures\nremain spread. Fontanels full/soft. HC = 28cm. A: Alt. in\nG&D. P: Continue to support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-27 00:00:00.000", "description": "Report", "row_id": 1917716, "text": "/NEON DOL 30 CGA 36 \nNC at 25 cc'c liter flow, RR 30-80, HR 150-170 PPS m\nWt 1095 up 35 on BM 30 with Beneprotein, PO offered .\nOn vit E, iron\nCalled and left message for mom.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-15 00:00:00.000", "description": "Report", "row_id": 1917785, "text": "NPN 1900-0700\n\n\n#2RDS: Pt remains in NC 100%, 25-50cc. Sats 90-97%. RR\n30's-70's. Lung sounds clear and equal bilaterally. Mild\nsubcostal retractions. No spells so far this shift. P: Cont\nto monitor resp status.\n\n#3FEN: Wt 1580 (no change). TF 160cc/kg/day of BM30 with\nbeneprotein, Q 4 hrs alternating PO/PG. Full feeding given\nover 60 mins, when gavaged. Pt took a full bottle at &\n0200 feedings. Pt is fairly well coordinated with bottling,\nbut messy; tires easily. Tolerating feedings well, no spits,\nAG stable. Max asp 5cc of non-bilious, partially digested\nBM; refed to pt. Voiding & no stool so far this shift.\nCriticaid applied to slightly pink area of bottom. Pt cont\non iron, vit E, and Synthroid. P: Cont with current feeding\nplan. Encourage PO's.\n\n#4FAM: No contact from so far this shift. P: Cont to\nsupport and update .\n\n#5DEV: Temps stable, pt swaddled in . Alert and active.\nSettles and sleeps well in between care times. MAE. AFSF.\nLikes pacifier. Font soft/full. Sutures remain spread. Small\namt of eye drainage. Last HC= 30.25cm. P: Cont to support\ndev needs. Obtain -weekly head circumferences.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-01 00:00:00.000", "description": "Report", "row_id": 1917725, "text": "Nursing\n\n\n#2O: In nasal cannula 100% 25 - 50cc, no spells noted. br.\nsounds clear with mild retractions.\n#3O: Wt. up 55g on BM30 with beneprotein, q 3 hr. feeds.\nBelly soft, voiding and stooling. Min. asp. and no spit.\nTook her 1st whole bottle tonite, doing well. Gavage fed\nover 1 1/2 hrs.\n#4O: No contact.\n#5O: In heated, covered isolette that was weaned 0.3C x 1,\nstable temp. Active with cares, swaddled, likes pacifier.\nHead circ. up .25cm to 28.75 cm. Fontanelle, full, and\nsutures are split.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-01 00:00:00.000", "description": "Report", "row_id": 1917726, "text": "/NEON DOL 33 CGA 36 \nRR 30-80, on NC 25-50 cc's l flow, HR 160-170, PPS m\nWt 1225 up 55 on 160 cc/kg of MM30 cals, 1 breastfeed and 1 PO / day.\nHC 28.7, normal growth\nDoing well.\n\nNEON to follow 4/7,8\n" }, { "category": "Nursing/other", "chartdate": "2120-03-01 00:00:00.000", "description": "Report", "row_id": 1917727, "text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 33.\nWT: 1225 g (+55)(<10th %Ile); birth wt: 646 g. Average wt gain over past wk ~29 g/kg/day.\nHC: 28 cm (<10th %Ile); last: 26.75 cm\nLN: 34 cm (<10th %Ile); last: 32.5 cm\nMeds include Fe and Vit E\nLabs noted\nNutrition: 160 cc/kg/day BM 30 w/ beneprotein, po/pg over 90 min feeds due to hx of spits. Infant po feeds ~1x per day, taking ~full volume on last po feed. Also breastfeeds ~1x per day. Projected intake for next 24hrs ~160 kcal/kg/day and ~4.5 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. Learning feeding skills. Labs noted and within acceptable range, although PO4 level is borderline low at 4.3 and alk phos level is borderline high at 685. However, neither level indicates need for further treatment or feeding supplementation, and infant is getting higher than our normal amount of Ca, P, and Vit D by virtue of the fact that feeds are run at 160 cc/kg/day. Will recheck labs in ~2 wks to make sure they stay in acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recs for all parameters; represents catch up growth. WIll continue to follow w/ Dr. and participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-16 00:00:00.000", "description": "Report", "row_id": 1917793, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25-50cc flow, 100% FiO2.\nFlow increased to 75cc w/ PO feedings. O2 sats >90%. Lung\nsounds cl/=. Mild SC retractions noted. No spells thus far\nthis shift. A: Infant breathing comfortably w/ resp.\nsupport. P: Continue to support infant's resp. needs. Wean\nflow as tolerated.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 3hr feedings, all PO since 2300 last night. Bottling w/\nreg. yellow nipple. Infant's abdomen is soft, active BS, no\nloops. No spits. Infant voiding, stooling well (neg. heme).\nContinues on Vit. E, iron and synthroid. A: Infant\ntolerating feedings well. P: Continue to support infant's\nnutritional needs.\n\n#4 Family: O: Mom, , Grandma and brother in this\nafternoon. are w/ cares and feedings.\nUpdated at bedside by this RN. Asking appropriate questions.\nA: very , involved. P: Continue to update,\nsupport and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Waking for\nfeedings and remains A/A throughout cares. MAE. Fontanels\nfull/soft. A: Alt. in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-15 00:00:00.000", "description": "Report", "row_id": 1917786, "text": "/NEON DOL 47 CGA\nNC at 25-50 cc's,RR 30-70, HR 160-170\nNo bradys\nWt 1580 no change, on 160 cc/kg BM 26 Benep\nWorking on PO\nOn Fe/Vit E /Synthroid\nCalled and left message for mom.\n\nNeon to cover \n" }, { "category": "Nursing/other", "chartdate": "2120-03-15 00:00:00.000", "description": "Report", "row_id": 1917787, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25-50cc flow, 100% FiO2.\nO2 sats >90%. Lung sounds cl/=. Mild SC retractions noted.\nNo spells thus far this shift. A: Infant breathing\ncomfortably w/ resp. support. P: Continue to support\ninfant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 3hr feedings, PO/PG as tolerated. Infant has bottled full\nvolumes x3 thus far this shift. Infant's abdomen is soft,\nactive BS, no loops. Minimal aspirates, no spits. Infant\nvoiding, stooling well. Continues on Vit. E, iron and\nsynthroid. A: Infant tolerating feedings well. P: Continue\nto support infant's nutritional needs. Continue to encourage\nPO feedings.\n\n#4 Family: O: Mom in for 1400 cares and feeding. Mom gave\ninfant independantly and bottled infant. Updated at\nbedside by this RN. A: Mom very , involved.\nComfortable caring for infant. P: Continue to update,\nsupport and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes w/\ncares and remains A/A throughout. MAE. AFSF. given\ntoday. A: Alt. in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-15 00:00:00.000", "description": "Report", "row_id": 1917788, "text": "SOCIAL WORK\nTouched base with mother during her visit to the nicu today. She states everything is going well, eager to have daugher home with her when she is ready. Baby is beginning to bottle, mum hopes that infant will be all bottles soon, paving the way for d/c.\nMum denies any questions or concerns, managing well. Will follow. Thank you.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-17 00:00:00.000", "description": "Report", "row_id": 1917797, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains on NC, 25-50cc flow, increased to\n75cc w/ feedings. Lung sounds cl/=. Mild SC retractions\nnoted. Infant suctioned x1 for mod. amount thick yellow\nplugs from both nares. No spells. A: Infant breathing\ncomfortably w/ resp. support. P: Continue to support\ninfant's resp. needs.\n\n#3 FEN: O: Total fluids remain @ 160cc/kg/day, BM 30 w/ BP.\nQ 3hr feedings, all PO. Bottling w/ reg. yellow nipple.\nInfant's abdomen is soft, active BS, no loops. No spits.\nInfant voiding, stooling well. Continues on Vit. E, iron,\nand synthroid. A: Infant tolerating feedings well. P:\nContinue to support infant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains swaddled in an . Maintaining\nstable temps. Infant sleeps well between cares. Wakes w/\ncares and remains A/A throughout. MAE. Fontanels full/soft.\nA: Alt. in G&D. P: Continue to support infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-18 00:00:00.000", "description": "Report", "row_id": 1917798, "text": "NPN 1900-0700\n\n\n#2Resp. In O2 via NC, 100%, 25-50cc, increased to 75cc with\nsome feeds for drifts in sat. RR 40-80, LS clear and equal,\nSC retractions present. No bradys. Plan to monitor resp.\nstatus.\n\n#3FEN. Wt. 1615gms, up 15gms. On TF of 160cc/kg/day of\nBM30with BP, 32cc q3hrs.. Fed by at , took 22cc\npo, crying through some of po feed. Gavaged at 2300, then\ntook full volume po at next 2 feeds.No spits, minimal\naspirates. Abd. soft, girth 23cm, active bowel sounds, no\nnoted loops. Voiding each care, passed trace amt green stool\nx1.pt. continues on vitamin E, iron, and synthroid. Plan to\nencourage po feeds as tolerated.\n\n#4Family. in for evening cares with other visitors,\nasking appropriate questions, independent with cares. Plan\nto continue to support .\n\n#5Dev. Pt. swaddled in , temp. staable. Pt. awake for\ncares, fussy during some cares, falls asleep between cares,\nbut wakes between cares. MAE. AF full, soft. Head circ.\n30.5cm. Continues to have yellow drainage from left eye,\nwarm soaks applied. Plan to support dev. needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-18 00:00:00.000", "description": "Report", "row_id": 1917799, "text": "NP NOTE\nPE: small growth restricted infant swaddled in open crib. Pale pink, mildly mottles with exam. AFOF sutures widely split to PF. EYes bright alert, ng and nasal in place. MMMP\nChest is clear, equal bs, comfortbale\nCV: RRR, sinus tacyhcardia, pulses+2=\nAbd: round full with active bs\nGU: immature\nEXT: , \nNeuro: irritable,consoles with sawddling. Flexed posture with symmetric tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-18 00:00:00.000", "description": "Report", "row_id": 1917800, "text": "Neonatology Attending\nNow day of ife 50, CA \n25-50cc of 100% O2 by nasal cannula\nRR 40-80s\nCVS - HR 150-180s BP 75/53 59\nNo apnea/bradycardia.\n\nWt. 1615gm up 15m on 160ml/kg/d of MM30 with Beneprotein - on Q3H feedings.\nNeeded some gavage supplementation in the past 24 hours.\n\nOn Synthroid Vit E and Fe\n\nHC 30.5cm\n\nAssessment/plan:\nSteady progress continues.\nWeight gain is still suboptimal.\nWill monitor irritability - will check TFTs this week.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917598, "text": "NURSING PROGRESS NOTE\n\n\n1. SEPSIS\n48 HOUR COURSE COMPLETED.\n2. RESPIRATORY\nCONTINUES ON PRONG CPAP AT 5 CM. NO O2 REQUIREMENT. BBS\nCLEAR. RR 30-50'S. NO APNEA OR DESATS.\n3. F/N\nTONIGHT'S WEIGHT DOWN 31 GRASM TO .625KG. TOTAL FLUIDS AT\n120CC/KG. CURRENTLY INFUSING VIA DUVC IS D10PN AN IL AT\n100CC/KG, AND D15W AT 20CC/KG. GLUCOSE 24 AT 0200, D10\nBOLUS GIVEN AND PN INCREASED TO 120CC/KG. GLUCOSE 56 AT\n0300. AT 0530 GLUCOSE 40, BOLUS GIVEN AND D15 ORDERED. D15\nINFUSION HUNG AT 0700. VOIDING 4.2CC/KG/HOUR FOR 24 HOURS,\nSTOOLING WITH EACH DIAPER CHANGE. ACTIVE BOWEL SOUNDS, AG\n16, ABD IS FULL, SOFT. AM LABS AS PER FLOW SHEET.\n4. FAMILY\nDAD IN WITH MANY VISITORS EARLY IN SHIFT. SPEAKS LITTLE\nENGLISH. FAMILY MEETING PLANNED FOR THURSDAY, TIME NEEDS TO\nBE DETERMINED SO INTERPRETER CAN BE BOOKED.\n5. G&D\nMOVED TO ISOLETTE. TEMP STABLE. ALERT AND ACTIVE. LOVES\nPACIFIER.\n6. BILI\nSPOTLIGHT CHANGED TO NEOBLUE BANK. BILI THIS AM 4.4/.5.\nEYES COVERED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917599, "text": " PHysical Exam\nPE: pink, under neoblue phototherapy with eyes covered, on nasal prong CPAP with intact nares, breath sounds clear/equal with fair to good air entry, mild retracting, no murmur, normal pulses and perfusion, abd soft, non distended, soft intermittent bowel sounds, active with AGA tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917600, "text": "Attending Note\nDay of life 3 PMA 32 \nin CPAP 5 FiO2 21% RR 40-60\nHR 130-150 BP 77/51 mean 58\nweight 625 down 31 grams on 120 cc/kg/day of PN/IL and D 15\nD stick 24, 58, 40, 39, 47\non neoblue photo bili 4.4/0.5\nabdomen soft with active bowel\nUO 4.2 cc/kg/hr and passed mec stools\nstable temp in isolette\nHC 24 cm unchanged from the night before\nKarotype pending\n\nIMP-infant SGA in stable but guarded condtion\nRESP-will plan to continue CPAP for now\nCV-normal ECHO yesterday\nFEN-will continue TF of 120 cc/kg/day. Will begin enteral feeds of 10 cc/kg/day now. Will check lytes tomorrow.\nHYPOGLYCEMIA-likely due to SGA staus. Will r/o polycythemia\nID-will draw cbc with diff today.\nGENETIC-will await karyotye\nNEURO-will have a head ultrasound for tomorrow\n" }, { "category": "Nursing/other", "chartdate": "2120-02-13 00:00:00.000", "description": "Report", "row_id": 1917661, "text": "Clinical Nutrition:\nO:\n~34 week CGA BG on DOL 16.\nWT: 785g(+33)(<10th %ile); BWT: 646g. Average wt gain over past week ~19g/kg/day.\nHC: 25.5cm(<10th %ile); last: 24.5cm\nLN: 32.5cm(<10th %ile); last: 30cm\nMeds includes Vit.A\nLabs noted.\nNutrition: 160cc/kg/day. Feeds BM 22, >10cc daily; pg fed. D10 IVF's w/ 2Na/1K+ via PICC. Projected intake for next 24hrs from feeds ~130cc/kg/day, providing ~95kcal/kg/day & ~2.5g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds advancement w/o GI problems; pg fed. IVF's tapering as feeds advance. Labs noted & within accceptable ranges. Current feeds & supps not yet meeting recs for kcal/pro/vits/mins; feeds advancing as tolerated. is meeting recs for WT/HC gains but LN gain is exceeding recs of ~1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-13 00:00:00.000", "description": "Report", "row_id": 1917662, "text": "Nursing Note 0700-1530\n\n\nRESP: Remains in RA. RR 40's-60's, O2 sats 90-99%. LS\nclear/=. Mild retractions. A/B spells x 2, QSR.\nOccasional O2 sats to low 80%'s that are self resolved. On\nVitamin A. P: Cont to monitor.\n\nFEN: TF=160cc/kg/d. IVF=30cc/kg/d of D12.5PN via central\nPICC line. EF=130cc/kg/d of BM22 PG Q 3 hours over 1 hr.\nD-sticks=61, 58. No spits. Min aspirates. Abdomen\nslightly full, but otherwise benign. Voiding, stooling\n(heme-). P: Cont to monitor closely and advance feeds\n10cc/kg/d QD as tolerated.\n\nDEV: Temps stable in servo mode isolette, pt is nested on\nsheepskin. Alert/active with cares. Sleeps well between\ncares. Sucks pacifier and brings hands to face for comfort.\nFontanels soft/flat. AGA. PKU to be drawn with next set of\nlabs. P: Cont to support growth and development.\n\nSOCIAL: Mom in to visit, updated by this RN, asking\nappropraite questions. Mom participated in care and\nkangaroo'd infant. P: Cont to support/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-14 00:00:00.000", "description": "Report", "row_id": 1917663, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Recieved infant in NC, 13cc flow, 100% FiO2.\nInfant trialled in RA since 0200. O2 sats >90%. Lung sounds\ncl/=. Mild IC/SC retractions noted. Continues on Vit. A\ninjections (mon/wed/fri). Spell x1 thus far this shift, at\nrest, QSR. A: Infant breathing comfortably in RA. P:\nContinue to monitor infant's resp. status.\n\n#3 FEN: O: Tonight's weight = 0.808kg (+23g). Total fluids\nremain @ 160cc/kg/day. Enteral feedings currently @\n130cc/kg/day, BM22. Q 3hr feedings, gavaged over 1hr 20min\nr/t low dsticks. IV fluids @ 30cc/kg/day. D10 w/ 2NaCl +\n1KCl + U hep/cc infusing w/out incident through central\nPICC in R arm. Infant's abdomen is soft, +BS, no loops.\nMinimal aspirates, no spits. Dstick this AM of 53. \naware. Infant voiding, stooling well. A: Infant tolerating\nfeedings well. P: COntinue to monitor blood glucose levels.\nContinue to support infant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. AFSF. HC of 26cm. Unchanged A: Alt in G&D. P: Continue\nto support infant's developmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-29 00:00:00.000", "description": "Report", "row_id": 1917723, "text": "/NEOON DOL 32 CGA 36 \nNC 25 cc's , RR 30-70, HR 150-170,PPS m, 2 bradys in 24 hours.\nWt 1170 up 30 on 160 cc/kg of MM30, given q 3 hours and over 1 1/2 hours down from 2. Dex on this regimen have been good at 101/97.\nNutrition labs done and normal.\nHct/ 30.1/6.8\nCalled and left message for mom.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-29 00:00:00.000", "description": "Report", "row_id": 1917724, "text": "Nursing Progress Note\n\n\n#2-O/A- Received infant on NCO2 100% 25cc flow. Infant\nremains on NCO2 100% 25-75cc flow. No resp distress. P-\nCont to assess for Resp needs.\n#3-O/A- TF=160cc/kg/d of BM30 w/BP via po/pg. Abd exam\nbenign. Voiding and stooling. Tol feeds. P- Cont to\nassess for FEN needs.\n#4-O/ Mom in to visit with updates given. Mom held\ninfant and put her to breast. Loving and involved. P-\nCont to enc parental calls and visits.\n#5-O/A- cont to be awake and active with cluster\ncares q3hrs. Sleeps well between cares. Temp stable in\nheated isolette swaddled. P- Cont to assess for G&D needs.\nSee flowsheet for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-17 00:00:00.000", "description": "Report", "row_id": 1917794, "text": "NP NOTE\nPE: small growing preterm infant, pal e pink, well perfused in low flow nasal canula. Quietly sleeping in open crib. AFOF sutures split to PF, eye bright, nares patent, MMMP\nChest is symmertic with clear equal bs, comfortably tachypneac.\nCV: RRR soft systolic murmur LUSB, pulses+2=\nAbd: round, soft active bs\nGU: immature female\nEXT: ,\nNeuro: quiet, responsive good tone, symmetric relfexes\n" }, { "category": "Nursing/other", "chartdate": "2120-03-17 00:00:00.000", "description": "Report", "row_id": 1917795, "text": "NPN 1900-0700\n\n\n#2RESP. Pt. remains in O2 via NC, 100%, 50cc flow, increased\nto 75cc with po feeds for drifts. RR 40-80, LS clear and\nequal, SC retractions present. Plan to continue lowflow O2,\nmonitor resp. status.\n\n#3FEN. Wt. 1600gms, up 10gms. On TF of 160cc/kg/day of\nBM30BP, 32cc q3hrs, trialing all po feeds. Has taken full\nvolume first 3 feeds tonight,uncoordinated with bottling,\ntires toward end of feeds. No spits. Abd. soft, active bowel\nsounds, no noted loops. Girth 23cm. Voiding and passing\ntrace amounts liquid yellow stool. Desitin applied to\nreddened diaper area. Plan to continue po feeds, monitor for\ntolerance of feeds.\n\n#4Family. No contact with family so far tonight.\n\n#5Dev. Pt. swaddled in , temp. stable. Anterior fontannel\nfull, soft.MAE. Pt. waking for some feeds, alert, active\nwith feeds. Settles well between cares. Yellow drainage from\nleft eye continues, warm soaks applied. Plan to support dev.\nneeds.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-17 00:00:00.000", "description": "Report", "row_id": 1917796, "text": "Neonatology Attending Progress Note:\nDOL #49\nPMA 38 6/7 weeks\ncontinues in 25-50cc nasal cannula at rest, to 75cc with feedings, RR=40-80's, clear/equal, mild sc retx. no spells\nall pos, soft PPS murmur, HR=150-180's BP mean=50\nwt=1600g (inc 10g), TF=160cc/kg/d. BM 30 with beneprotein q 3 hours feeding\nno spits, voiding, stooling\nImp/Plan: premie infant with triple X and Dandy Walker malformation, CLD,hypothyroidism, now with slight tachypnea, possibly related to all po feeidngs now\n--monitor respiratory rate.\n--monitor weight\n--wean cannula as tolerated\n--continue synthroid\n--continue rest of present management\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917591, "text": "Clinical Nutrition:\nO:\n31 week gestational age BG, SGA, now on DOL 2.\nBWT: 646g(<10th %ile); current WT: 656g(+10)( WT is up ~2% from BWT).\nHC @ Birth: 24cm(<10th %ile)\nLN @ Birth: 29cm(<10th %ile)\nMeds include Vit.A\nLabs noted.\nNutritiion: TF @ 100cc/kg/day. NPO. Starter PN initiated on DOL 0. PN started on DOL 1. PN infusing via DUVC. Projected intake for next 24hrs ~50kcal/kg/day, ~2.5g pro/kg/day & ~0.7g fat/kg/day. Glucose infusion rate ~6.7mg/kg/min.\nGI: Abd benign.\n\nA/Goals:\nRemains NPO. PN infusing via DUVC. Labs noted & PN adjusted accordingly. Initial goal for PN ~90-110kcal/kg/day, ~3-3.5g pro/kg/day & ~3g fat/kg/day. Advancing per protocol. When able to start feeds, initial goals are ~150cc/kg/day BM/SSC 24, providing ~120kcal/kg/day & ~3.2-3.6g pro/kg/day. Further advances as per growth & tolerance. Appropriate to start Fe & Vit.E supps when feeds reach initial goal. Growth goals after initial diuresis are ~15-20g/kg/day for WT gain, ~0.5-1cm/wk for HC gain & ~1cm/wk for LN gain. Will follow w/ team & participate in nutrition plans.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917592, "text": " Physical Exam\nAwake and alert. AFOF with good tone and activity. BCS and equal on CPAP with good transmission and mild retractions. No audible murmur, well perfused with 2+ pulses in 4 ext. Extrimities warm to the touch and pink. ABD soft and rounded with active BS, no masses. UVC intact. Mild jaundice and ruddy.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917593, "text": "Respiratory Care Note\nInfant remains on NCPAP +5, 21% - BS clear, RR's 30-50's - no spells thus far this shift - cardiac consult/ECHO planned - continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917594, "text": "Nursing Problem:\n#1 - Sepsis: 48 hour rule out completed. Amp and gent d/c'd.\nBlood cultures neg to date.\n#2 - RESP: Remains on CPAP 5. 21%. No spells. Lungs clear\nand equal. Int/sub retractions. Remains on vit A inj.\n#3- FEN: TF increased to 100cc/kilo = 2.7cc/hour. - TPN D10W\ninfusing into DLUVC without difficulty. Abdomin soft and\nround. Girth 15cm. Voiding and stooling mec stool today.\nPLAN: Lytes, bili and triglyceride in am.\n#4 - Family: Mom and Dad in this afternoon. Updated at the\nbedside. Planning for family meeting on thurday. No time\nyet.\n#5 - DEv: Temp instability briefly due to probe falling off.\nStable now. Alert and active with cares. MAE. Ant font full.\nSutures widely spaced. HC last noc 24cm. 7 day HUS planned\nfor monday. Chromosomes sent this am. Being followed by\ngenetics and neurology. MRI prior to discharge.\n#6 - JAundice: Remains under double phototherapy. Eye\nshields on. NPO. Voiding and stooling. Bili in am.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917595, "text": "Nursing Addendum:\nCardiac echo done this evening. UVC pulled back. BAbygram done. Checked placement of line.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917596, "text": "Procedure note: UVC adjustment\nInfant had indwelling UVC which was in good placement on in the IVC. ECHO today revealed UVC tip in the the PFO. CXR done and showed tip in the heart. Withdrawn 1 cm and CXR repeated. Tip in the IVC now. Infant tolerated the procedure well.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917597, "text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. No documented spells thus far. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-12 00:00:00.000", "description": "Report", "row_id": 1917656, "text": "Addendum to above note\nLab results Bili.9/.5 Lytes 135/4.5/104/13 Hct 35.6 Infant noted to have edema over L upper chest. Examined by . Pic line with blood flash back. Infant repositioned with L side elevated. Edema improved.\n+\n" }, { "category": "Nursing/other", "chartdate": "2120-02-12 00:00:00.000", "description": "Report", "row_id": 1917657, "text": "/NEON DOL 15, CGA 34\nRA, no bradys past 24 hours, RR 30-70, HR 160-170\nWt 752 up 7 on 160 cc/kg of which 120 is enteral. As of today, off hyperal and on D12.5 with 3 Na and 1 K. On MM20.\nHct 35.6, Dstick 80.\nOn Vit A dose #, .\nHC stable at 25.5, f/u HUS at 30 days, sooner if HC growth is too rapid. MRI at term, post discharge at CHMC.\nCalled and left message for mom stating I am taking on care of the twins.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-12 00:00:00.000", "description": "Report", "row_id": 1917658, "text": "NPN DAYS\n\n\nRDS 31 weeker: Remains in room air with O2 sats 98-100%.\nLS clear and equal. Mild retractions. No spells or desats.\nNot on caffeine. On Vitamin A. Stable resp status. Continue\nto follow.\nAlt in Fluid/Nutrition: TF 160cc/kg/day. IV fluids currently\nPND12.5 infusing via PIC line at 40cc/kg/day. Will change to\nD12.5 with lytes today. Feeds are currently at 120cc/kg/day\nBM20. Minimal aspirates. No spits. Voiding and stooling.\nUrine output 3.1cc/kg/day. Belly soft, full. AG 17-19cm.\nIncreasing feeds 10cc/kg/day at 1100. Tolerating feeds.\nContinue with current plan of care.\nAlt Family bonding: Mom in to visit and kangaroo'd brother.\nShe checked temp and changed her diaper. Updated\nher on the baby's day. She will kangaroo Tuesday. Will\ncontinue to provide support and updates.\nAlt Development: Temp stable while nested in servo isolette\nwith boundaries in place. Awake and alert with cares. Sleeps\nwell between cares. AGA. Continue to provide for\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-13 00:00:00.000", "description": "Report", "row_id": 1917659, "text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. O2 sats >95%. Lung sounds\ncl/=. Mild IC/SC retractions noted. Spells x3 thus far this\nshift. At rest, QSR. Infant continues on Vit. A injections\n(m/w/f). A: Infant breathing comfortably in RA. P: Continue\nto monitor infant's resp. status.\n\n#3 F/N: O: Tonight's weight = 0.785kg (+33g). Total fluids\nremain @ 160cc/kg/day. IV fluids currently @ 40cc/kg/day.\nD12.5 + 3NaCl + 1KCl w/ U hep/cc infusing w/out incident\nthrough central PICC line in R arm. Enteral feedings\ncurrently @ 120cc/kg/day, BM 20. Q 3hr feedings, gavaged\nover 1hr. Infant's abdomen is soft/full, +BS, no loops. Max\naspirate = 1.6cc. Infant voiding well. Stooling (neg. heme).\nA: Infant tolerating feedings well. P: Continue to support\ninfant's nutritional needs.\n\n#4 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. AFSF. A: AGA. P: Continue to support infant's\ndevelopmental needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-13 00:00:00.000", "description": "Report", "row_id": 1917660, "text": "/NEON DOL 16m CGA 34 \nRA, RR 40-70, 4 bradys, sr, HR 140-150\nWt 785 up 33 grams, on 40cc/kg D10 with 2Na and 1 KCl, 120 enteral of MM20>22.\nDex 63, will watch as switch to D10, but on very low peripheral volume.\nHC 26, up 0.5 cm today, but no change for several days prior.\nCalled and left message for mother.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-27 00:00:00.000", "description": "Report", "row_id": 1917717, "text": "NICU Nursing Progress Note\n\nInfant remains in 100% nasal cannula requiring 25cc flow to\nmaintain O2 sats within parameters. Breath sounds, resp\nrate, and WOB are at baseline. No apnea or bradycardia\nobserved.\n\nSoft murmur appreciated. VSS. Cap refill brisk.\n\nReceiving gavage feeds of 30BM with BP every 3 hrs pumped in\nover 2 hrs for a hx of spitting. Abd exam benign. Voiding\nand passing heme neg stool.\n\nMom in to visit for several hours. She held both infants\ntogether. Mom is independent in infant's care as well as\nbreastfeeding. Update regarding infant's status and plan of\ncare.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917585, "text": "Nursing Progress Note:\n#1 - Sepsis: Remains on 48 hour rule out. To receive amp and\ngent this evening as ordered. Initial blood culture neg to\ndate.\n#2 - RESP: Venous gas this am - 7.40, 31. Extubated to CPAP\n5 at 11am. REmains in RA. RR (40-70). int/sub retractions.\nLungs clear and equal. O2Sats 94-98%. To receive first Vit a\ninjection today. No spells thus far. Considering Caffeine if\nneeded.\n#3 - FEN: TF at 80cc/kilo/day = 2.1cc/hour. DLUVC. Primary\nport - D10 1.2 unit/hep and secondary port Started TPN.\nDstick 104. Abdomin soft and round. Girth 14.5cm. +BS.\nVoiding good amounts. No stool thus far today.\n#4 - FAMILY: Mom and Dad in this afternoon. Updated at the\nbedside. Father only speaking. Mother understands\nenglish and did well speaking. Bringing in friends and\nfamily. Asking appropriate questions. Made mother aware of\nfamily meeting prior to discharge.\n#5 - DEV: Temps stable on open warmer. Very active today.\nMAE. Fontanels full. Sutures widely spaced. Seen by neuro\nand genetics today. Initial HUS - no hydrocelphalus,\nagenesis of corpus collosum.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917586, "text": "6 Jaundice\n\nNursing Addendum:\nPhototherapy started this evening at 1700pm - double. For\nbili of 7.5/0.3. REpeat bili in am with lytes and\nkaryotype.\n\nREVISIONS TO PATHWAY:\n\n 6 Jaundice; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-29 00:00:00.000", "description": "Report", "row_id": 1917587, "text": "Neonatology NP Note\nAF open and taut with split sagital sutures\nminimal subcostal and intercostal retractions on CPAP, lungs clear/=, good air entry\nRRR, no murmur, pink and well perfused, quiet precordium, femoral pulses present\nabdomen soft, nontender and nondistended, hypoactive bowel sound\nactive with good tone\n" }, { "category": "Nursing/other", "chartdate": "2120-02-28 00:00:00.000", "description": "Report", "row_id": 1917718, "text": "Nursing\n\n\n#2O: In nasal cannula, 100% 37 - 50cc, no spells. br.\nsounds clear, nasal congestion, mild retractions.\n#3O: Wt. up 45g on 160cc/kg, BM 30 with beneprotein, q 3\nhr. feeds. Belly soft, full, min. asp., no spits.\n#4O: No contact.\n#5O: In heated, covered isolette, stable temp. Active with\ncares, likes pacifier.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-28 00:00:00.000", "description": "Report", "row_id": 1917719, "text": "/NEON DOL 31 CGA 36 \nNC at 25 cc l flow, prob sec to IUGR and alveolar growth, no bradys in 48 hours, HR 150-170, PPS m at times.\nWt 1140 up 45 grams on 160 cc/kg BM 30. To try and decrease infusion rate from 2 hours q 3 to 1 1/2 hours and check dstick.\nTo get Hep B today as brother is receiving his immunization.\nWill speak with mother when she comes.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-28 00:00:00.000", "description": "Report", "row_id": 1917720, "text": "NPN\n\n\n#2Resp O- remains in NC 25cc's most of day with sats\nabove 90. RR 60's. Lungs clear. Color pale. No bradycardia\nnoted but does have occassional drift in O2 sat. A-Minimal\nO2 need P- Wean if tol. Check hct/ MD.\n#3F/N O- Infant continues on BM 30cal with BP at 160cc/kg.\nShe had gavage interval decreased to 1 hour 30 minutes. No\nspits /aspirates noted.D-stick 101. Girth 19.5cm. Voiding\nand passing soft stool. A- Tol. feeds good wt. gain P- Check\nnutrition labs as ordered.\n#4Family Mom called x1 and plans to visit later in day.\n#5Dev. O- Infant remains in heated isolette. Air temp\nweaned to 28.5. Infant active/alert with cares. HC 28.5cm\nFontanelles unchanged.Hep B vaccine given. A-AGA P- Wean\nisolette as tolerated. to be checked MD.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-28 00:00:00.000", "description": "Report", "row_id": 1917721, "text": "Nursing Addendum\nInfant noted to have HR drop to 66 while holding her. (see flow sheet) Mild stim. given.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-29 00:00:00.000", "description": "Report", "row_id": 1917722, "text": "NPN 1900-0700\n\n\n#2Resp. Pt. in O2 via NC, 100%, 25-50cc, RR 30-70, LS clear\nand equal, ITC/SC retractions present. One brady, mild stim.\nto resolve. Occ. drift in sat to mid-high 80s. Plan to\nmonitor resp. status.\n\n#3FEN. Wt. 1170gms, up 30gms. On TF of 160cc/kg/day of\nBM30with beneprotein, 23ccq3hrs gavaged over 90 minutes.\nDstick 97. Nutritional labs drawn and pending. Abd. soft,\nfull, active bowel sounds, no noted loops. Minimal\naspirates, no spits. Voiding and passing guaic negative\nstool. On vitamin E and iron. Desitin applied to reddened\ndiaper area with cares. Plan to monitor for tolerance of\nfeeds. Check results nutrtional labs, continue vitamin E and\niron.\n\n#4Family. in at beginning of shift, no further\ncontact. to continue to update and support family.\n\n#5Dev. Pt. swaddled in air control isolette. Temp. stable.\nAwake and alert with cares, settles well between cares.MAE.\nAFF full. Plan to support dev. needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917588, "text": "NPN 2300-0700\n\n\nSEPSIS: Infant remains on Ampi & Gent. Blood cultures\nnegative to date. Will continue to monitor.\n\nRESP: Infant remains on prong CPAP 5, 21%. LS clear,\nslightly diminished. IC/SC retractions noted. Continues on\nVitamin A.\n\nFEN: Remains NPO. DLUVC infusing PND10. Abdomen soft/flat,\nactive BS, voiding, no stool ever thus far.\n\nPARENTS: No contact thus far.\n\nG/D: Temp remains stable/warm nested on radiant warmer. A&A\nw/cares, settles well in between. HC remains 24cm.\n\nBILI: Continues under double phototherapy, eye shields in\nplace. Checked bili at first cares with plans to recheck at\nnext cares.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917589, "text": "Respiratory Care\nBaby remains on cpap 5 21%.Bs clear throughout.RR 30-50's.No spells documented thus far this shift.Appears comfortable on cpap.\n" }, { "category": "Nursing/other", "chartdate": "2120-01-30 00:00:00.000", "description": "Report", "row_id": 1917590, "text": "Attending Note\nDay of life 2 pMA 32 \non CPAP 5 FiO2 21% RR 30-50 no spells\non vit A\nHR 140-160's BP 62/42 mean 47\nweight 656 up 10 grams on 80 cc/kg/day of PN and IL\nvoiding 3.5 cc/kg/hr and passing mec stool\nD stik 90\nNa 134 K 4.0 Cl 103 CO2 18\nblood out 4.6 cc\nbili 5.5/0.4 on photo this am 4.8/0.4\nBcx-NGTD on amp/gent\non warmer with stable temp\nHC 24 cm no change\n\nIMP-infant making progress\nRESP-will continue with CPAP for now\nFEN-will increase to 100 cc/kg/day. Will check lytes and bili on tomorrow. will keep NPO for now\nID-will d/c amp/gent today\nNEURO-will have a repeat HUS on MOnday\n" }, { "category": "Nursing/other", "chartdate": "2120-02-11 00:00:00.000", "description": "Report", "row_id": 1917651, "text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA with O2 sats = 96-100%.\nRR=40-70's. Mild ICR/SCR. LS clear. No spells this shift.\n3 yesterday.\n\n2. FEN: WT=745gms (up 5gms). TF=160cc/k/day. Currently\nreceiving PN D12.5 at 60cc/k/day via PICC at 1.9cc/hr.\nEnteral feeds are BM20 at 100cc/k/day = 9cc q3hr. At \ninfant had a 5cc asp and abd was distended. Belly was loopy\nand girth was up to 18.5cm. into assess. Infant had lg\nbrown mucousy heme neg stool at this time, also. Infant was\nplaced prone and 1hr later asp was 0.2cc. Feeding began at\nthat time. Next feeding, abd girth was 17.5cm and there\nwere no loops. Max asp = 0.6cm. U/O for past 24hrs was\n3.3cc/k/hr. No spits.\n\n3. : No contact this shift.\n\n4. G&D: is quietly alert and active with cares.\nSleeps well between cares. Appropriately irritable at\ntimes. Uses pacifier to comfort self. Temps stable nested\nin sheepskin in servo isolette. AFSF. Head circ = 25.5cm\n(no change). Sutures are spread.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-11 00:00:00.000", "description": "Report", "row_id": 1917652, "text": " PHysical Exam\nPE: pale pink, AFOf, sutures separated, breath sounds clear/equal with mild retracting, very soft murmru audible left axilla and left back, abd soft, full, non tender, + bowel sounds, active with good tone.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-11 00:00:00.000", "description": "Report", "row_id": 1917653, "text": "Neonatology\nDOing well. Intermittent spells continue. Soft murmur.\n\nWt 745 up 5. Tolerating feeds at 100 cc/k/d out of TF 160. Rest via PN. Abdomen benign.A dvancing 10 cc/k/d. Toelrating advance at present. Abdomen benign.\n\nActive alert. Temp stable.\n\nContinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-16 00:00:00.000", "description": "Report", "row_id": 1917789, "text": "NPN 7PM-7AM\n\n\nRESP: Infant remains on NC 25-50cc's needing increase with\nfeeding. RR 50-70's with upper airway congestion noted. Sats\n90-97%. LS clear and equal with mild SC rets. No spells at\nthis time in shift. Drift in sats during feeds recovered\nwell with pacing. A: Stable with NC. P: Will cont to monitor\nresp status and wean O2 as possible.\n\nFEN: Current weight 1590gms up 10gms. TF 160cc/kg/day of\nBM30 with BP = 32cc's q3hrs. Attempting to bottle when\ninterested. Took 32-35cc's at 11pm and 2am. Abd soft, girth\nstable. +bs, no loops. Voiding and no stool at this time in\nshift. No spits and min asp. A: Feeding well, doing better\nwith bottle. P: will cont to monitor weight and exam.\n\n: Mom called and spoke with UC. She will be in today\nfor 2pm feeding and wishes to give infant bottle. A:\nInvolved. P: Will cont to support.\n\nG/D: Infant is swaddled in open crib. Temp stable. Alert and\nactive with cares. Sucks on pacifier. Ant font soft and\nfull. P: Will cont to support dev needs.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-16 00:00:00.000", "description": "Report", "row_id": 1917790, "text": "Addendum NPN 7pm-7am\nAbove note written by RN under password of .\n" }, { "category": "Nursing/other", "chartdate": "2120-03-16 00:00:00.000", "description": "Report", "row_id": 1917791, "text": "NP NOTE\nPE: small growing preterm ifnant swaddled in open crib.Pale pink, well perfused in RA.\nAFOF sutures split to PF, eyes large and bright, ng in place, MMMP\nChest is clear, and equal\nCV: RRR, no murmur, pulses+2=\nAdb: soft with active bs\nGU: immature\nEXT: ,\nNeuro: alert and responsive, active with good tone.\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-16 00:00:00.000", "description": "Report", "row_id": 1917792, "text": "Neonatology Attending Progress Note\n\nNow day of life 48, CA 5/7 weeks.\nOn 25-50cc of 100% O2 - RR 50-70s\nNeeds increased O2 during feedings.\nNo apnea/bradycardia.\nHR 140-170s BP 82/ 46 59\n\nWt. 1590gm up 10gm on 160ml/kg/d TF - MM30 with Beneprotein.\nFeedings well tolerated all po Q3H.\nDS 99\nNormal urine and stool output.\n\nOn Synthroid, Vit E and Fe.\n\nAssessment/plan:\nSteady progress conntinues for this SGA infant with hypothyroidism, trisomy xxx.\nWill continue with current management.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917601, "text": "Nursing Progress Note:\n\n1 Infant with Potential Sepsis\n\n#1 ID: Infant S/P 48hr R/O ampi and gent. CBC sent this\nafternoon benign. A: Infant w/out s/sx of infection. P:\nIssue resolved.\n\n#2 Resp: O: Infant continues on prong CPAP of 5, 21% FiO2.\nO2 sats stable. Lung sounds cl/=. Mild IC/SC retractions.\nInfant suctioned q 4hrs for small amount cloudy oral\nsecretions. Infant continues on Vit. A injections\n(mon/wed/fri). No episodes of apnea or bradycardia today\nthus far. A: Infant breathing comfortably on CPAP. P:\nContinue to support infant's resp. needs.\n\n#3 FEN: O/A: Total fluids remain @ 120cc/kg/day. Dstick this\nAM of 39. 2cc/kg D10 bolus given and D15 infusion rate\nincreased to 40cc/kg/day at this time. Infant w/ DLUVC.\nCurrently, PN D10 infusing through both , and D15\npiggybacked into secondary port. Dsticks of 47, 51 this\nafternoon. Infant's abdomen is soft, full, +BS, soft loops\nx1. Infant voiding well. No stool. Trophic feedings started\n@ 1400. Feedings @ 10cc/kg/day, q 3hrs, BM/SC 20 PG. P:\nContinue to monitor infant's blood glucose levels closely.\nContinue to support infant's nutritional needs.\n\n#4 Parents: O: Mom and Dad in briefly this afternoon.\nParents updated at bedside by this RN. A: Parents seem\nloving. Mom asking appropriate questions. P: Continue to\nupdate, support and teach parents.\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. A/A w/ cares. MAE. AFSF. neurology\nin briefly this afternoon to see infant. A: AGA. P: Continue\nto support infant's developmental needs.\n\n#6 Bili: O: Infant remains pale pink, slightly jaundiced.\nContinues under neoblue bank phototherapy. Eye shields\nremain in place. P: Continue w/ phototherapy. Plan to draw\nbili level tomorrow AM.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n" }, { "category": "Nursing/other", "chartdate": "2120-01-31 00:00:00.000", "description": "Report", "row_id": 1917602, "text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .21, bs clear, rr 30-60 with mild retractions. No spells noted. Plan to support as needed. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917603, "text": "NPN\n\n\n#2Resp O- She continues on prong CPAP 5cm 21% O2 with sats\n98-100%. RR 40-70. Breath sounds clear/diminished. No murmur\naudible. No spells noted. A- Stable P-continue to follow.\n#3F/N O-Infant had total fluids increased to 130cc/kg and\nD10W changed to D15W to maintain D-sticks in the 70's. (see\nflow sheet) Feeds of BM every 3 hours at 10cc/kg (not\ncounted in total fluids) Abdomen is soft and full with +\nbowel sounds. Girth 16-16.5cm. No aspirates noted. Voiding\nwell and passing mec. stool. Wt 623gms down 2 gms. A-blood\nglucose improved P- Continue to follow D-stick check\nlytes/bili.\n#4Family Parents in to visit with sibling and updated at\nbedside by this RN. A- Family aware of plan of care P- FM\ntoday/with interpreter. Have Mom hold infant today if she is\ndoing well/team approval with UVL in place.\n#5Dev. O- Temps stable in servo heated isolette. Infant\nsucking well on pacifier when offered. She appears hungry.\nActive/alert with cares. HC 24cm Fontanelles full/soft.\nSutures wide. A-AGA severe IUGR P- Support dev.\n#6Bili Remains under NEOBLUE double light /Bili to be sent.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-01 00:00:00.000", "description": "Report", "row_id": 1917604, "text": "Respiratory Care Note\nPt. continues on 5cmh2O of nasal prong CPAP and 21%. BS clear. To follow.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-14 00:00:00.000", "description": "Report", "row_id": 1917664, "text": "/NEON DOL 17 CGA 34 \nRA, required cannula for several hours last nite. RR 30-70, HR 140-170 with 3 bradys.\nWt 808 grams up 23 on 160 cc/kg of 30cc/kg IV and 130 enteral of MM22>24. To run IV at 0.8 cc's hr next 24 hours which is the least it can go and see how blood sugars are. Were 53 and 59.\nRepeat state screen to be sent on week off TPN. Has had elevation in some aa's but currently only methionine.\nHC remains at 26, has metopic suture and slight fullness, had last HUS on . To continue to observe with daily HC and f/u HUS at 1 month or sooner if increase in HC is abnormal.\n" }, { "category": "Nursing/other", "chartdate": "2120-02-14 00:00:00.000", "description": "Report", "row_id": 1917665, "text": "0700- NPN\n\n\nRESP: Remains in RA. RR 40's-60's, O2 sats 90-96% with\noccasional O2 sats to 70-80%'s that are QSR. LS clear/=.\nMild retractions. A/B spell x 1, QSR. On Vitamin A. P:\nCont to monitor.\n\nFEN: TF=165cc/kg/d. IVF=25cc/kg/d of D10 with Lytes and\nHeparin via central PICC line. EF=140cc/kg/d of BM24 PG Q 3\nhours over 90 mins. EF increasing 10cc/kg/d QD at 1100.\nD-sticks=58, 72. Pt bottlefed x 1, taking 7cc PO. No\nspits. Max aspirate of 3 cc. Abdomen benign. Voiding\n2.4cc/kg/hr x 12 hours. Small stool x 1 (heme-). P: Cont\nto monitor d-sticks and feeding tolerance closely and\nincrease feeds QD as tolerated.\n\nDEV: Temps stable in serv mode isolette, pt is nested on\nsheepskin. Alert/active with cares. Sleeps well between\ncares. Sucks pacifier and brings hands to face for comfort.\nFontanels soft/flat with spread sutures. PKU to be drawn in\nnext 1-2 weeks. P: Cont to support growth and development.\n\nSOCIAL: Mom called x 2, updated by this RN, asking\nappropriate questions. Mom plans to visit at 1700. P: Cont\nto support/educate .\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-15 00:00:00.000", "description": "Report", "row_id": 1917666, "text": "NPN\n\n\n#2Resp O- remains in room air with sats above 94.\nRR40-70. Lungs clear. Soft murmur audible. Color pale. No\nspells noted. A- Stable P- Continue to follow.\n#3F/N O- Infant continues on feeds of BM 24cal (140cc/kg)and\n D10W w/lytes at (25cc/kg). She is voiding in good amounts\nand passed small yellow stool g-. Abdomen is full and soft\nwith girth 17cm.No spits/ minimal aspirates noted. Wt .815\nup 7gms. D-stick 51/66. A-Tol. feeds. need to stool more\nP- Follow wts. Check d-sticks as needed.\n#4Family No contact during night.\n#5Dev. O- Temp 97.8 x1 and set point increased. Infant\nactive/alert with cares. She will suck well on pacifier. A-\nAGA now 34 P- Support dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-15 00:00:00.000", "description": "Report", "row_id": 1917667, "text": "/NEON DOL 18 CGA 34 \nRA, 2 bradys, RR 40-70, HR 140-170, has soft murmur, probable PPS, previous ECHO had normal cardiac structure.\nWt 815 grams up 7, on 160 cc/kg, to be off IV later today and all enteral feeds of MM26 with HMF and polycose..\nSugars 51,66 so will add polycose and see if we can get off D10.\nShe was put to breast yesterday and did well.\nHC stable at 26 since .\nOn Vit A, will add iron when on full enteral feeds.\nTo find out if mom wants to make other arrangement then me leaving messages in the morning, which because of language limitations is hard for her..\n" }, { "category": "Nursing/other", "chartdate": "2120-03-01 00:00:00.000", "description": "Report", "row_id": 1917728, "text": "NPN Days 7am-7pm\n\n\n#2 O: Infant remains in NC O2, in 100% and needing mostly\n25-50ss of flow, occasionally <25cc. Lung sounds remain\nclearc and equal. Resp rates have remained in the 60s-70s\nwith continued mild retractions. Infant having occasional\ndrifting of sats to the upper 80s, no episodes of As or Bs\nnoted. A: continued minimal O2 need. P: COntinue to\nmoniter.\n#3 O: Infant remains on BM 30 cals per oz and is tolerating\nq 3 hour gavage feeds well with volume given over 1.5 hours.\n Abd remains softly full, good BS, no loops, Ag stable. No\nspits noted, max aspirate 2cc. Voiding and stooling adeq\namts, stool somewhat \"liquidy\". A: tolerating gavage feeds\nwell. P: Continue to moniter.\n#4 O: Infant's were in to visit this morning. They\nwere somehwat focused on infnat's sibling as he is nearing\ndischarge readiness. Mom did try to put to breast\nbut infant was sleepy/uninterested. asking appr.\nquestions. P: Continue to support.\n#5 O: Infant remains in heated isolette - temp remains\nstable with infant swaddled and hat on. Infant alert and\nactive with some cares, sleeps well between cares. Attempted\nto breastfeed X 1 but she was sleepy. Ant font remains full\nand soft, sutures are split. A:attmpting some po feedings,\nremains in heated isolette. P: COntinue to moniter for\nmilestones.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-02 00:00:00.000", "description": "Report", "row_id": 1917729, "text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. She is pale pink, well perfused, no murmur auscultated. She is comfortable in NCO2, breath sounds clear and equal. She is tolerating enteral feeds, abd soft, soft bowel sounds. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2120-03-02 00:00:00.000", "description": "Report", "row_id": 1917730, "text": "NPN 1900-0730\n\n\n2. In NC, 13-50cc to maintain sats. Occassional desats to\n86-89%. Lungs clear. RR 60-70's with mild IC and SC\nretractions. No A&B's thus far. Continue to monitor for\nA&B/desats and support as needed.\n\n3. Wt up 20gm to 1245gm. TF 160cc/k/d BM30 w/BP= 24.5cc\nQ3hr. Abdomen benign. Voiding and having trace amount of\nyellow stool with every diaper change. Able to bottle 5cc\nat 0200. Infant not interested in latching onto bottle.\nTolerating mostly NGT feeds without spits and no aspirates.\nContinue to encourage PO's once a shift as tolerated.\n\n4. No parental contact thus far.\n\n5. Temp stable swaddled in low air isolette. Alert and\nactive with cares. MAE. Fontanelles soft, flat. Sutures\nspread. Rest well inbetween cares. Continue to promote\ndevelopment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-03-02 00:00:00.000", "description": "Report", "row_id": 1917731, "text": "NICU Attending Note\n\nDOL # 34 = 36 5/7 weeks PMA. IUGR, NCO2, learning to PO feed, weaning out of isolette.\n\nAgree with full \n\nCVR/RESP: RRR with soft systolic murmur c/w PPS. Skin pink and well perfused, BS clear/=, mild rectractions, NCO2, 100% FiO2, 50 cc/min flow, last A/B . Will continue to monitor.\n\nFEN: Abd benign, weight today 1245 gm, up 20 gm, on 160 mL/kg/day 30kcal/oz MM with beneprotein. Majority PG. Will continue current diet, encourage PO intake.\n\nENV'T: Weaning in air mode isolette.\n\nNEURO: AFSOF, sutures spread, HC 28.75 (acceptable rate of growth), new GMH bleed noted on most recent head U/S. WIll continue to follow HC.\n\nGENETICCS: Knwon 47 XXX with dandy walker malformation\n\nOPHTHO: immature zone III.\n\nRHCM: hep B vaccine given\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-11 00:00:00.000", "description": "Report", "row_id": 1917654, "text": "0700- NPN\n\n\nRESP: Remains in RA. RR 30's-70's, O2 sats 94-100%. LS\nclear/=. Mild IC/SC retractions. A/B spells x 2, mild-mod\nstim given. On Vitamin A. P: Cont to monitor for spells.\n\nFEN: TF=160cc/kg/d. IVF=50cc/kg/d of PND12.5 via central\nPICC line. EF=110cc/kg/d of BM20 PG Q 3 hours over 1 hr,\nand increasing 10cc/kg/d QD at 1100. D-stick=77. No spits.\nMin aspirates. Abdomen benign. Voiding, no stool. P: Cont\nto monitor and advance feeds as tolerated.\n\nDEV: Temps stable in servo mode isolette, pt is nested on\nsheepskin with water pillow under head. Alert/active with\ncares. Sleeps well between cares with firm boundaries.\nSucks pacifier and brings hands to face for comfort.\nFontanels soft/flat. Daily head circumference remains\nstable, sutures are spread. Fontanels soft/flat. AGA. P:\nCont to support growth and development. MRI prior to d/c to\nhome.\n\nSOCIAL: No contact from as of yet. P: Cont to\nsupport/educate .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-12 00:00:00.000", "description": "Report", "row_id": 1917655, "text": "NPN\n\n\n#2 Resp:\nO; remains in RA with sats 95-99, RR 40-50, lungs cl=, no\nspells\nA: Pot for spells\nP: Cont to monitor\n\n#3 FEN:\nO; Wt .752 (+ 7) On TF 160cc/k/d. PN infusing into Pic well.\n Abd. soft, active BS, no loops. Max asp .2cc. Voiding qs,\npassed seedy yellow stool, guiac neg D/S 80 Feeds advanced\nto 110cc/k/d. Lytes,, Hct, PKU pending\nA: Adequate nutritional support\nP: Cont to support and development\n\n#4 Social:\no; No contact this shift.\n\n#5 dev:\nO; Temps stable Alert and active with cares, MAE. Nested in\nsheepskin with bendybumper\\\nA: AGA\nP: Cont to support dev.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-26 00:00:00.000", "description": "Report", "row_id": 1917712, "text": "NPN\n\n\n#2Resp O- continues in her NC 25cc's 100% to maintain\nsats above 90. RR 60-80. Lungs clear. mild retractions\nnoted. Occassional drift in O2 sat to mid 80's/no\nbradycardia. color pale.Last dose Vit A given. A-continued\nO2 need. P- ? check hct this week.\n#3F/N O- She remains on BM30with Bp at 160cc/kg. She is\ntolerating feeds over 2 hours. No spits/aspirates. She is\nvoiding well and passing soft yellow stool. Wt 1060 Up 12\ngms. A- Gaining steadily P- Follow wts. Mom to breast feed\nonce a day.\n#4Family No contact during night.\n35Dev. O- Temp stable swaddled in air heated isolette.\nInfant active/alert/ sucks on pacifier. HC 28cm /fontanelles\nfull/soft. A-AGA now 36 weeks/IUGR P- Family signed Hep B\nconsent. to be repeated this week.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2120-02-26 00:00:00.000", "description": "Report", "row_id": 1917713, "text": "/NEON DOL 29 CGA 26\nNC at 13-25 cc's RR 50-60, HR 150-170, intermittent PPS m\nWt 1060 up 12, on 160 cc/kg BM30Bene, PG feeds.\nGoing in over 2 hours, dex has been 104, 99.\nRepeat state screens were normal, next due on \nOn Vit E, iron, completed her 12 doses of Vit A.\nTo speak with mom when she comes in.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2107-12-19 00:00:00.000", "description": "Report", "row_id": 1516415, "text": "pt tranferred to SICU from ED and then brought to CT for image of head. Pt remained sedated through shift. ABG in normal limits. MD requesting a CO2 around 30.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-19 00:00:00.000", "description": "Report", "row_id": 1516416, "text": "focus hemdynmics\ndata: neuro: pupils #3 and reaacts very sluggishly. no movement inlegs. moves arms on the bed to painful stimuli. vent drain placed by dr and bloody drainage drainaing. 50cc from 0330-0700am. ct scan done and tol procedure. vent drain 10 at the tragus. on nipide at 1.0 mcg and titrated to keep bp < 140. propofol gtt infusing at 10mcg and off for neuro assessment. during neuro rounds. pt moves arms on the bed and withdraws r leg. slight withdraw on the left leg.\n\nresp: intubated and suctioned for scant amt of white sputum. abg's ok.,\n\ncardiac: remains in nsr. no ectopy seen. iv ns with 20meq kclat 70cc/hr.\n\ngu: foley patent and draining yellow urine.\n\ngI ngt patent and to lcws. ngt draining brpwn ddrainage.\n\naction: as ordered. vent drain placed and draining bloody ddrainage. suctioned prn. to ct scan this am. and tol trip. on iv nipride for bp control of sbp< 140. propofol for sedation. on iv dilantin, iv mannitol x1 given. neuro signs q1hr.\n\nresponse: monitor closely.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-19 00:00:00.000", "description": "Report", "row_id": 1516417, "text": "Respiratory Care\nPt remains on mechanical ventilation, adjustments to settings made as a result of ABG results.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-19 00:00:00.000", "description": "Report", "row_id": 1516418, "text": "nursing note\nNeuro: Following commands, complete L sided weakness, nsurg made aware. Pupils fluctuate L slightly bigger and sluggish. nsurg aware. ICP waveform poor, nsurg aware. Ventric oozing from entrance site, nsurg aware. Ventric cherry red but lightening at this time to pinkish. ICP with poor form . Follwoing commands with R side, propofol increased this eve secondary to agitation, coughing assocated with increase in BP.\nCV:SR, PVC's. SBP <140-changed to nicardipine. pboots on. +pp.\nRESP: vent changes made. ? lab error with ABG, resent and results in computer and noted. scant white sputum.\nGI:NPO. OGT for meds, drng clear white.\nGU: adeq urine output. Cr high.\nSKIN: intact.\nSOCIAL: multiple family member in and calling. Spoke with mother and brother upon visit. wish no info to be given except to them. Mother and brother told that all people calling will be told to reach them for info.\n\nPLAN:cont neuro checks, mannitol if ICP >20. ? cnetral line. renal u/s in AM. ventric.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-20 00:00:00.000", "description": "Report", "row_id": 1516419, "text": "FOCUS HEMODYNMICS\nDATA: NEURO: ON IV PROPOFOL GTT. AT 10MCG. PROPOFOL OFF FOR NEURO ASSESSMENT Q1HR. MOVES RIGHT AND LEFT ARM AND LEG ON THE BED. NO MOVEMENT IN LEFT ARM OR LEG. PUPILS #3 BILATERALLY AND REACTS SLUGGISHLY. ABLE TO FOLLOW SIMPLE COMMANDS SUCH AS SQUEEZE MY HAND. STICK TONGUE OUT AND OPEN EYES. UNABLE TO MOUTH WORDS. BP < 140 AND ON IV NICARDIPINE GTT. NICARDIPINE GTT DOSE DECREASED. DILANTIN IV GIVEN.\nVENT DRAIN AT 10 AT THE TRAGUS. DRAINING BLOOD TINGE DRAINAGE.\n\nRESP: REMAINS INTUBATED AND SUCTIONED FOR SCANT AMOT OF SPUTUM.PCO2 GOAL 35-40. RATE AND TIDAL VOLUME INCREASED. O2SAT 97-100%.\n\nCARDIAC: REMAINS IN NSR. OCC PVC NOTED. K 3.9 AND KCL 10MEQ/100 VIA PERIPEHERAL LINE. NICARDIPINE GTT INFUSING FOR BP CONTROL. HR 58-65.\n\nGI NGT TO LCWS. DRAINING BROWN DRAINAGE. ABD SOFT WITH HYPOACTIVE BOWEL SOUNDS. NO STOOL.\n\nACTION: LABS AS ORDERED. NEURO VS Q1HR. VENT DRAIN AT 10 AT THE TRAGUS. ON IV PROPOFOL GTT AND SHUT OFF FOR NEURO ASSESSMENT. NICARDIPINE GTT FOR BP CONTROL. IV DILANTIN. IV CEFAZOLIN. TO HAVE CT ANGIO TODAY. IV NS WITH 20MEQ AT 70CC/HR.\nMOTHER AND BROTHER NEXT OF AND INFO ONLY TO BE GIVEN TO THEM.\n\nRESPONSE: MONITOR CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-20 00:00:00.000", "description": "Report", "row_id": 1516420, "text": "nursing update\nNuero: opens eyes to voice, follows commands briskly, R side strong-shows two fingers and lifts off bed. No movement with L side. Ventric remians with waveform, MD aware. Samall amount of old drng on dressing. SPeech garbled post extubation. poor gag, Strong cough. Dilantin 500mg given for low dilantin level.\nCV:Sr to ST, nicardipine remains to keep SBP <150. per renal want close to 150. Hydralazine added for control. p-boot on. echo done. CPK;s not indicative of MI.\nRESP:extuabted without difficutly. strong cough. ABG good on 2l NC.\nGI:NPO. to attempt PO's with meds. abd remains large, soft. renal u/s done.\nGU:foely patent clear adeq yellow urine.\nSKIN:intact.\nSOCIAL: mother and ex wife calling for updates. Mother retrieved old medical records from .\n\nplan:cont neuro checks. ? angio vs CTA when Cr falls. ventric opn at 10. await renal u/s results.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-21 00:00:00.000", "description": "Report", "row_id": 1516421, "text": "MORE AWAKE AND RESPONDS TO SIMPLE COMMANDS; SPEECH NOT ACTUAL GARBLED JUST HARD TO UNDERSTAND (LIKE A PERSON WITH A SOFT LISP). BEGINNING TO WITHDRAWN ON LEFT SIDE.\nNICARDEPINE TITRATED FOR SBP >150.\nURINE IMPROVED WITH CREAT DOWN TO 3.1\n" }, { "category": "Nursing/other", "chartdate": "2107-12-21 00:00:00.000", "description": "Report", "row_id": 1516422, "text": "nursing note\nNeuro: Pt lethargic, sleeps but easily arousable. some period of agitation with right side. nto restrained, no attempts to pull at ventric or lines. PERL, R side normal. left side able to lift 2 inches off bed and falls back. +sensatoin. +gag/cough, problem swallowing. CT done. MRI/MRA ordered- awaiting d/c of nicardipine to do. Pan cx'd for increasing WBC. ventric with damp waveform, ICP 0-1. draign cherry red.\nCV:SR, no ectopy. Nicardipine weaning off.\nRESP: LS clear. O2 sat 96-100%. strong cough, no sputum.\nGI: Tol reg diet, no n/v. + inc of large BM.\nGU: foley patent clear yellow urine adeq amounts.\nSKIN: intact.\nSOCIAL: duaghter in to visit. mother for update.\n\nPLAN: MRI when stable. await CT results. Decadron wean. follow BS. reg diet. ventric open at 10\n\n\n" }, { "category": "Nursing/other", "chartdate": "2107-12-21 00:00:00.000", "description": "Report", "row_id": 1516423, "text": "NSG ADDENDUM\nWHILE THIS RN OFF FLOOR, A-LINE ALARM RANG DISCONNECT. PER REPORT: PT FELL OOB. FAMILY WAS INSTRUCTED TO ALERT UPON LEAVING ROOM AND FAILED TO DO SO. DENIES HITTING HEAD, NO LOC, VSS, NEURO STATUS UNCHANGED. MD NOTIFIED, HEAD CT ORDERED.\n\n" }, { "category": "Nursing/other", "chartdate": "2107-12-22 00:00:00.000", "description": "Report", "row_id": 1516424, "text": "Nursing\nSee flowsheet for details. Pt. restless this a.m. and A&Ox3. Occasionally will ask the same question a couple of times. Follows commands and MAE. Right side full strength and left side minimally. PERRLA 4mm, brisk. Ventriculostomy intact at 10 tragus and draining blood tinged. Lungs CTA on RA. HR NSR with frequent bradycardia and no ectopy. Abdomen soft with pos. BS. Good appetite. Foley draining clear, light yellow. Plan to monitor pt. vent. drainage and work on ROM today.\n" }, { "category": "Nursing/other", "chartdate": "2107-12-23 00:00:00.000", "description": "Report", "row_id": 1516425, "text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nNEURO: PT &O X3, APPROPRIATE CONVERSATION. FOLLOWING COMMANDS CONSISTENTLY AND MOVING SPONT/PURP W/ RT SIDE, ABLE TO MOVE ON BED HIS LT SIDE, LT ARM OCC APPEARS TO BE POSTURING. PERL. VENT DRAIN REMAINS AT 10CM ABOVE TRAGUS W/ BLOOD TINGED FLUID, ICP 1-2.\n\nCV: HR 63-100'S, NSR-ST, SBP PARAMETERS <150, PT RECEIVED HYDRALAZINE 20MG IV PRN AND LOPRESSOR 5MG IV FOR INC HR TO >100 AND SBP>150. DR. INFORMED.\n\nRESP: LUNG SOUNDS CLEAR, NO SOB, O2 SAT 96-99% ON R/A.\n\nGI: ABD SOFT NT/ND, + BOWEL SOUNDS, TOLERATING PO INTAKE WITHOUT N/V.\n\nGU: FOLEY DRAINING ADEQ CLEAR YELLOW URINE.\n\nID: TMAX 99.3\n\nPLAN: MONITOR VS, LABS, RESP STATUS, NEURO STATUS. ?AWAITING MRI. CONT TO MONITOR SBP AND TREAT W/ PRN HYDRALAZINE AND LOPRESSOR. OT/PT CONSULT FOR LT ARM FOR POSTURING. ?TRANSFER TO STEP DOWN UNIT.\n" }, { "category": "Echo", "chartdate": "2107-12-20 00:00:00.000", "description": "Report", "row_id": 77526, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Assess for cardiac SOE.\nHeight: (in) 72\nWeight (lb): 218\nBSA (m2): 2.21 m2\nBP (mm Hg): 135/69\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:12\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Patient was unable to cooperate with\nmaneuvers.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect or patent foramen ovale\nis seen by 2D, color Doppler or saline contrast with maneuvers. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated. The ascending aorta is moderately dilated.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. No masses or vegetations are seen on\nthe aortic valve. There is no aortic valve stenosis. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nIMPRESSION: No cardiac source of embolism seen. Normal biventricular size and\nsystolic function. Mildly dilated ascending aorta. No significant valvular\ndisease.\n\n\n" }, { "category": "Radiology", "chartdate": "2107-12-19 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 853220, "text": " 5:19 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: HCP\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with IVH and HCP\n REASON FOR THIS EXAMINATION:\n HCP\n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow/up intraparenchymal hemorrhage, status-post drain placement.\n\n COMPARISON: at 1:53 AM.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: A drainage catheter enters the left frontal bone, and enters the\n left lateral ventricle, and terminates in the region of the 3rd ventricle.\n There is one level of air adjacent to the catheter in the left frontal lobe.\n There is also some air and soft tissue stranding in the left frontal scalp.\n Again seen, is the right thalamic hemorrhage. This is not significantly\n changed in size. Blood remains in both lateral ventricles, and the 3rd\n ventricle. The left lateral ventricle has decreased in size. The right\n lateral ventricle is not appreciably changed in size. There is still stable\n mild right-to-left midline shift. No definite new areas of hemorrhage. There\n is also probably some blood along the falx, not changed. The sulci continue\n to appear effaced consistent with some edema, more pronounced on the right\n cerebral hemisphere. Mucosal thickening remains in both maxillary sinuses,\n left greater than right, within the sphenoid sinus and ethmoid air cells. The\n osseous structures are unchanged, other than the left frontal burr-hole.\n\n IMPRESSION\n 1. Placement of a drainage catheter, which appears to be terminating in the\n region of the 3rd ventricle.\n 2. Stable right thalamic hemorrhage and intraventricular hemorrhage.\n 3. Interval decrease in size in the left lateral ventricle.\n\n" }, { "category": "Radiology", "chartdate": "2107-12-25 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 853949, "text": " 11:12 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with IVH\n REASON FOR THIS EXAMINATION:\n interval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intraventricular hemorrhage. Follow/up.\n\n COMPARISON: CT head performed at 3:25 AM.\n\n TECHNIQUE: Head CT without contrast.\n\n FINDINGS: There is stable appearance of the extensive hemorrhage in the\n region of the right thalamus and the region of the right lateral ventricle,\n extending into the temporal . The drainage catheter has been repositioned\n and now lays within the ventricles. Mass effect is stable.\n\n A large left maxillary retension cyst is again noted.\n\n IMPRESSION: Stable appearance of the large thalamic and right ventricular\n hemorrhage with interval repositioning of the drainage catheter, now\n terminating in the ventricles.\n\n" }, { "category": "Radiology", "chartdate": "2107-12-21 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 853572, "text": " 9:28 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: check for head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old man with right sided thalamic bleed, just fell out of bed.\n REASON FOR THIS EXAMINATION:\n check for head bleed\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right thalamic bleed, fell out of bed.\n\n COMPARISON: Eight hours prior.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: The left-sided drainage catheter is unchanged in position. The\n lateral ventricles are prominent, but unchanged. The right thalamic\n hemorrhage with surrounding edema, extending into the right lateral ventricle,\n is stable. A small amount of hemorrhage is also seen in the occipital of\n the left lateral ventricle, stable. No new areas of hemorrhage or edema are\n seen. Stable left maxillary sinus thickening.\n\n IMPRESSION: Stable head CT with right thalamic hemorrhage.\n\n" }, { "category": "ECG", "chartdate": "2108-01-06 00:00:00.000", "description": "Report", "row_id": 185518, "text": "Sinus rhythm. Late transition. Possible left ventricular hypertrophy. Compared\nto the previous tracing no significant change.\n\n" }, { "category": "ECG", "chartdate": "2107-12-19 00:00:00.000", "description": "Report", "row_id": 185519, "text": "Sinus rhythm\nProminent QRS voltage - may be within normal limits but consider also left\nventricular hypertrophy\nST-T wave changes early repolarization pattern\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 498121, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo M with h/o CAD, Systolic CHF (EF 45%), Stage III NSCLC -\n refusing chemo, dementia, and recurrent LE edema c/b cellulitis who\n presents with fever, altered mental status, and worsening LLE\n cellulitis. Hypotensive, but family refusing central lines and\n pressors given DNR/DNI.\n 24 Hour Events:\n - Hypotension (72/11) resolved with IVF\n - Afebrile overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 AM\n Piperacillin/Tazobactam (Zosyn) - 08:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications: Aspirin, Aricept, Proscar, Oxybutin, Lipitor, Vanco,\n Lovenox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (61 - 86) bpm\n BP: 106/66(75) {67/38(46) - 145/123(141)} mmHg\n RR: 18 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 2,257 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 2,257 mL\n Blood products:\n Total out:\n 1,670 mL\n 410 mL\n Urine:\n 1,670 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 1,847 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4L\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, L>R erythema\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): Person, place, month/year, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.4 g/dL\n 128 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Imaging: LENIS neg; LUE DVT; CTA neg for PE, infiltrate; Head CT neg;\n CXR unremarkable on admission. CXR \n Possible RLL infiltrate vs\n atelectasis.\n Microbiology: Blood/urine cx pending.\n Assessment and Plan\n yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n # Hypotension: Likely septic physiology given fevers and cellulitis.\n Now resolved.\n - IVF boluses prn\n - No CL or pressors per HCP\n # Fever: Sources include cellulitis (most likely) or UTI given\n incontinence. CXR unremarakble on admission, but now may have RLL\n infiltrate (?aspiration PNA) vs atelectasis. CT with b/l basilar\n atelectasis.\n - F/U blood/urine cultures\n - Continue abx\n vanc/cefepime\n # Altered mental status: Likely infection superimposed upon baseline\n dementia. No signs/symptons c/w meningitis.\n - Panculture, abx\n - F/U B12, TSH, LFTs\n - Follow\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient.\n - Vancomycin as above\n # LUE basilic vein thrombus:\n - Lovenox, but will d/w with daughter given overall goals of care\n - Would decide on long-term anticoagulation after mental status\n recovers out of concern for fall risk\n # Chronic systolic CHF: Patient has EF of 45%.\n - Gentle IVF\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n - Continue ASA, Atorvastatin, plavix.\n - Hold BB given hypotension\n ICU Care\n Nutrition: Regular diet. Aspiration precautions.\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Lovenox)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: No central line, no\n pressors per daughter (HCP)\n status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 497994, "text": "Pt. is a year old man with a history of CAD, systolic CHF, NSCLC,\n dementia and recurrent LE edema c/b cellulitis. Presented from his\n facility today after being found lethargic, confused\n and lying in urine in his bed. He was recently discharged after\n being treated for lower extremity cellulitis. Of note he had a recent\n EGD on for dysphagia. Pt. presented today with worsening lower\n extremity erythema of his LLE and swelling of his LUE. In ED he was\n initially lethargic and confused. Temp 100.3. Blood cultures sent.\n 87% on RA, BP 80's to 90's after receving 4 liters of fluid. Received\n Levofloxacin, Zosyn, and Tylenol. LENIs negative for DVT. LUE\n ultrasound showed positive DVT. CTA negative for PE. CXR normal.\n Code status confirmed DNR/DNI. Daughter refusing central line for\n patient. Does not want pressors at this time. Pt. transfered to the\n MICU for further management.\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP on arrival to MICu was 90\ns to 100\ns systolic. HR sinus rhythm\n with frequent PAC\ns and occasional dips to 40\ns. BP dropping as low as\n 70\ns systolic.\n Action:\n Patient received two 500cc NS boluses for BP in the 70\ns systolic. Pt.\n received KCL 40mEqs in 500cc for K of 3.5. Received a total of 4\n liters of fluid in the ED.\n Response:\n BP fluid responsive. Currently 90\ns to 100\ns. Patient asymptomatic\n with low BP and HR. Slightly lethargic, but easily arousable and\n following commands appropriately.\n Plan:\n Monitor BP and hemodynamics.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. found to have left upper extremity DVT. Left arm swollen and\n erythematic.\n Action:\n Pt. started on Lovenox.\n Response:\n Ongoing.\n Plan:\n Continue Lovenox. Monitor for signs of bleeding. Pt. with active type\n and cross.\n Altered mental status (not Delirium)\n Assessment:\n Pt. very hard of hearing. Lethargic, but appropriate. Follows\n commands. Moves all extremities. Has pinpoint pupils, difficult to\n see if they are reactive. MICU resident aware.\n Action:\n Patient hears better out of left ear. Reoriented as needed.\n Response:\n Ongoing.\n Plan:\n Reorient as needed. Patient is cooperative and easily arousable.\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 497996, "text": "Pt. is a year old man with a history of CAD, systolic CHF, NSCLC,\n dementia and recurrent LE edema c/b cellulitis. Presented from his\n facility today after being found lethargic, confused\n and lying in urine in his bed. He was recently discharged after\n being treated for lower extremity cellulitis. Of note he had a recent\n EGD on for dysphagia. Pt. presented today with worsening lower\n extremity erythema of his LLE and swelling of his LUE. In ED he was\n initially lethargic and confused. Temp 100.3. Blood cultures sent.\n 87% on RA, BP 80's to 90's after receving 4 liters of fluid. Received\n Levofloxacin, Zosyn, and Tylenol. LENIs negative for DVT. LUE\n ultrasound showed positive DVT. CTA negative for PE. CXR normal.\n Code status confirmed DNR/DNI. Daughter refusing central line for\n patient. Does not want pressors at this time. Pt. transfered to the\n MICU for further management.\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP on arrival to MICu was 90\ns to 100\ns systolic. HR sinus rhythm\n with frequent PAC\ns and occasional dips to 40\ns. BP dropping as low as\n 70\ns systolic.\n Action:\n Patient received two 500cc NS boluses for BP in the 70\ns systolic. Pt.\n received KCL 40mEqs in 500cc for K of 3.5. Received a total of 4\n liters of fluid in the ED.\n Response:\n BP fluid responsive. Currently 90\ns to 100\ns. Patient asymptomatic\n with low BP and HR. Slightly lethargic, but easily arousable and\n following commands appropriately.\n Plan:\n Monitor BP and hemodynamics.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. found to have left upper extremity DVT. Left arm swollen and\n erythematic.\n Action:\n Pt. started on Lovenox.\n Response:\n Ongoing.\n Plan:\n Continue Lovenox. Monitor for signs of bleeding. Pt. with active type\n and cross.\n Altered mental status (not Delirium)\n Assessment:\n Pt. very hard of hearing. Lethargic, but appropriate. Follows\n commands. Moves all extremities. Has pinpoint pupils, difficult to\n see if they are reactive. MICU resident aware.\n Action:\n Patient hears better out of left ear. Reoriented as needed.\n Response:\n Ongoing.\n Plan:\n Reorient as needed. Patient is cooperative and easily arousable.\n Cellulitis\n Assessment:\n Patient with bilateral extremity erythema and swelling. Recently\n discharged after treatment for cellulitis.\n Action:\n LENI\ns negative for DVT\ns. Pt. on Vanc and Zosyn. One set of blood\n cultures sent with am labs.\n Response:\n Pulses present with Doppler.\n Plan:\n Continue antibiotics, Zosyn needs ID approval.\n" }, { "category": "Physician ", "chartdate": "2126-09-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 497935, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presented\n from his after he was found to be lethargic, confused,\n and lying in bed soaked with urine, which is not usual for him.\n Of note he had a recent admit in for lower extremity\n cellulitis, at which time was treated with Vancomycin. On outpatient\n follow up in clinic, he was treated with supressive keflex.\n The patient had a recent EGD performed on for dysphagia. Per his\n daughter, he tolerated the procedure well, and felt well until today.\n The patient now presents with worsening erythema and edema of his LLE,\n and new swelling of LUE. He presents with his daughter, who states\n that he is behaving more quiet than usual.\n .\n In the ED, initial VS: T 100.3 RR 20 87% on RA, BP 121/62 HR 100s. He\n was A+Ox1, and not able to interact. LLE was erythematous and\n edematous. LUE erythematous. Guaiac positive, but no stool found, only\n mucus. Received levofloxacin and zosyn empirically. LENIs were\n negative, but LUE US showed DVT. CTA chest negative for PE. CXR\n negative for pneumonia. CT head negative. In the ED, HR went up to\n 110-120s, and systolic BP dropped to 80s. At that time, the ED\n physician spoke with the patient's daughter about central line and\n pressors, and the daughter refused. status was confirmed DNR/DNI.\n Got 4L IF fluids in ED, and 1g tylenol. Prior to transfer, most recent\n vitals were Tmax 101.8 BP 86/45, HR 66, RR 18, 96% on 4L.\n .\n Currently, the patient denies any pain or discomfort. He is not able\n to recount much history. Denies feeling chills, cough, shortness of\n breath, chest pain, abdominal pain, or diarrhea.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, shortness of breath, chest\n pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Other medications:\n HOME MEDICATIONS:\n 1. Metoprolol Tartrate 6.25 mg PO BID\n 2. Multivitamin one tab po daily\n 3. Atorvastatin 10 mg po daily\n 4. Docusate Sodium 100 mg po daily\n 5. Oxybutynin Chloride 5 mg po daily\n 6. Finasteride 5 mg po daily\n 7. Donepezil 10 mg po qhs\n 8. Aspirin 81 mg po daily\n 9. Clopidogrel 75 mg po daily\n 10. Heparin 5,000 u sc tid\n 11. Senna 8.6 mg po qhs PRN constipation.\n Past medical history:\n Family history:\n Social History:\n Dementia\n CAD s/p NSTEMI \n Chronic Systolic CHF, EF 45%\n Chronic LE edema\n Benign prostatic hypertrophy\n stage IIIA NSCLC daignosed , offered chemo and refused\n Cellulitis\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently a resident at (not a\n nursing home, but part of system). The patient is widowed\n with 3 children, his daughter lives in the area.\n ADL: The patient sometimes ambulates with a cane or a walker. He\n makes his own breakfast but has help bathing and cleaning.\n Tobacco: 100 pack-year\n ETOH: None\n Illicits: None\n Review of systems:\n Flowsheet Data as of 11:03 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 61 (61 - 86) bpm\n BP: 92/44(55) {92/38(46) - 116/90(141)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,498 mL\n PO:\n TF:\n IVF:\n 498 mL\n Blood products:\n Total out:\n 0 mL\n 1,500 mL\n Urine:\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,998 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GENERAL: Elderly gentleman, NAD\n HEENT: NCAT. EOMI. Pinpoint pupils bilaterally. Oropharynx clear, no\n plaques or exudates. Neck supple. No meningismus. No LAD.\n CARDIAC: RRR. No murmurs.\n LUNG: CTAB. No wheezes or crackles.\n ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.\n EXT: WWP. 1+ pedal edema bilaterally. Erythema over LLE upto proximal\n leg, and RLE upto ankle.\n NEURO: Alert to person, place, and month and year.\n Labs / Radiology\n 150 K/uL\n 11.0 g/dL\n 118 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 23 mEq/L\n 110 mEq/L\n 3.5 mEq/L\n 141 mEq/L\n 31.5 %\n 8.6 K/uL\n [image002.jpg]\n \n 2:33 A11/8/ 08:42 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.6\n Hct\n 31.5\n Plt\n 150\n Cr\n 1.1\n Glucose\n 118\n Other labs: PT / PTT / INR:15.6/40.7/1.4, ALT / AST:16/18, Alk Phos / T\n Bili:81/0.8, Amylase / Lipase:/22, LDH:175 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Imaging: CTA\n 1. No acute PE.\n 2. Unchanged appearance of the large subcarina mass, compatible with\n the known\n adenoCA.\n 3. Unchanged emphysema.\n .\n LENIs: No LE DVT\n .\n Left upper extremity US\n 1. thrombus in left basilic vein.\n 2. small-caliber Left IJ with evidence of flow.\n .\n CT head: No acute intracranial process.\n No infiltrates or pleural effusions. Small nodules seen bilaterally.\n Largely unchanged from prior x-ray.\n .\n EGD:\n Abnormal motility of the esophagus was noted. There were continuous\n vigorous contractions throughout the esophagus. The LES was not\n hypertonic. The esophagus was tortuous. There were no intrinsic or\n extrinsic lesions seen. Normal stomach. Normal duodenum.\n Impression: Abnormal esophageal motility\n Otherwise normal EGD to third part of the duodenum\n Microbiology: Urine culture pending\n Blood culture pending\n ECG: NSR @ 103bpm. Nl axis. No ST segment changes.Unchanged from prior\n on .\n Assessment and Plan\n yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presents\n with fever, altered mental status, and worsening LLE cellulitis.\n .\n .\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology. However, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Sources of infection include cellulitis, fevers from DVT, and UTI. It\n is conceivable that with altered mental status patient has meningitis\n or encephalitis, however no neuro deficits or meningismus on exam.\n Given history of NSCLC, patient may have a post obstructive pneumonia.\n CXR negative for infiltrate. UA with few bacteria and epis. No\n diarrhea at this time. Received Zosyn and levofloxacin in ED. Another\n potential etiology is infection after EGD performed 3 days prior to\n admission. Patient does not have any abdominal pain. No ptx seen on\n CXR.\n -repeat UA\n -UCx, Blood cultures\n -Vanc, Zosyn empirically to cover gram positives that may be from\n cellulitis, and gram negatives that may be associated with UTI\n -f/u final read of CXR\n -tylenol PRN fever\n .\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, this is the most\n likely etiology. See above for infectious work up. Will also assess for\n Vitamin B12 deficiency, hypo/hyperthyroidism, and MI. EKG unchanged\n from baseline, but will cycle cardiac enzymes. Not on any new\n medications that would cause a change in mental status. Given known\n NSCLC, brain mets always a concern. Head CT negative. Consider head MRI\n to eval for mets.\n -panculture\n -B12, TSH, LFTs\n -ROMI\n .\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n .\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -consider heparin gtt\n .\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED. Has mild lower extremity edema just over ankles bilaterally. Given\n earlier hypotension, will continue gentle IV fluids overnight.\n -Normal saline @ 125cc/hr x1L\n .\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB overnight given earlier hypotension. Would likely restart in\n AM.\n .\n # Dementia: Continue donepzil and oxybutynin.\n .\n # BPH: Continue finasteride, per outpatient regimen.\n .\n # FEN: IVFs / replete lytes prn / Dysphagia diet, aspiration\n precautions\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV x2\n # CODE: DNR/DNI confirmed with daughter (HCP) in the and on the\n phone on admission. No central lines, no pressors.\n # CONTACT: daughter (cell) who is health\n care proxy\n # DISPO: ICU\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2126-09-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 497938, "text": "Chief Complaint: altered mental status\n HPI:\n Mr. is a yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presented\n from his after he was found to be lethargic, confused,\n and lying in bed soaked with urine, which is not usual for him.\n Of note he had a recent admit in for lower extremity\n cellulitis, at which time was treated with Vancomycin. On outpatient\n follow up in clinic, he was treated with supressive keflex.\n The patient had a recent EGD performed on for dysphagia. Per his\n daughter, he tolerated the procedure well, and felt well until today.\n The patient now presents with worsening erythema and edema of his LLE,\n and new swelling of LUE. He presents with his daughter, who states\n that he is behaving more quiet than usual.\n .\n In the ED, initial VS: T 100.3 RR 20 87% on RA, BP 121/62 HR 100s. He\n was A+Ox1, and not able to interact. LLE was erythematous and\n edematous. LUE erythematous. Guaiac positive, but no stool found, only\n mucus. Received levofloxacin and zosyn empirically. LENIs were\n negative, but LUE US showed DVT. CTA chest negative for PE. CXR\n negative for pneumonia. CT head negative. In the ED, HR went up to\n 110-120s, and systolic BP dropped to 80s. At that time, the ED\n physician spoke with the patient's daughter about central line and\n pressors, and the daughter refused. status was confirmed DNR/DNI.\n Got 4L IF fluids in ED, and 1g tylenol. Prior to transfer, most recent\n vitals were Tmax 101.8 BP 86/45, HR 66, RR 18, 96% on 4L.\n .\n Currently, the patient denies any pain or discomfort. He is not able\n to recount much history. Denies feeling chills, cough, shortness of\n breath, chest pain, abdominal pain, or diarrhea.\n .\n ROS: Denies fever, chills, night sweats, headache, vision changes,\n rhinorrhea, congestion, sore throat, cough, shortness of breath, chest\n pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,\n melena, hematochezia, dysuria, hematuria.\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Other medications:\n HOME MEDICATIONS:\n 1. Metoprolol Tartrate 6.25 mg PO BID\n 2. Multivitamin one tab po daily\n 3. Atorvastatin 10 mg po daily\n 4. Docusate Sodium 100 mg po daily\n 5. Oxybutynin Chloride 5 mg po daily\n 6. Finasteride 5 mg po daily\n 7. Donepezil 10 mg po qhs\n 8. Aspirin 81 mg po daily\n 9. Clopidogrel 75 mg po daily\n 10. Heparin 5,000 u sc tid\n 11. Senna 8.6 mg po qhs PRN constipation.\n Past medical history:\n Family history:\n Social History:\n Dementia\n CAD s/p NSTEMI \n Chronic Systolic CHF, EF 45%\n Chronic LE edema\n Benign prostatic hypertrophy\n stage IIIA NSCLC daignosed , offered chemo and refused\n Cellulitis\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently a resident at (not a\n nursing home, but part of system). The patient is widowed\n with 3 children, his daughter lives in the area.\n ADL: The patient sometimes ambulates with a cane or a walker. He\n makes his own breakfast but has help bathing and cleaning.\n Tobacco: 100 pack-year\n ETOH: None\n Illicits: None\n Review of systems:\n Flowsheet Data as of 11:03 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 61 (61 - 86) bpm\n BP: 92/44(55) {92/38(46) - 116/90(141)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,498 mL\n PO:\n TF:\n IVF:\n 498 mL\n Blood products:\n Total out:\n 0 mL\n 1,500 mL\n Urine:\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,998 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n GENERAL: Elderly gentleman, NAD\n HEENT: NCAT. EOMI. Pinpoint pupils bilaterally. Oropharynx clear, no\n plaques or exudates. Neck supple. No meningismus. No LAD.\n CARDIAC: RRR. No murmurs.\n LUNG: CTAB. No wheezes or crackles.\n ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.\n EXT: WWP. 1+ pedal edema bilaterally. Erythema over LLE upto proximal\n leg, and RLE upto ankle.\n NEURO: Alert to person, place, and month and year.\n Labs / Radiology\n 150 K/uL\n 11.0 g/dL\n 118 mg/dL\n 1.1 mg/dL\n 15 mg/dL\n 23 mEq/L\n 110 mEq/L\n 3.5 mEq/L\n 141 mEq/L\n 31.5 %\n 8.6 K/uL\n [image002.jpg]\n \n 2:33 A11/8/ 08:42 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.6\n Hct\n 31.5\n Plt\n 150\n Cr\n 1.1\n Glucose\n 118\n Other labs: PT / PTT / INR:15.6/40.7/1.4, ALT / AST:16/18, Alk Phos / T\n Bili:81/0.8, Amylase / Lipase:/22, LDH:175 IU/L, Ca++:8.0 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.8 mg/dL\n Imaging: CTA\n 1. No acute PE.\n 2. Unchanged appearance of the large subcarina mass, compatible with\n the known\n adenoCA.\n 3. Unchanged emphysema.\n .\n LENIs: No LE DVT\n .\n Left upper extremity US\n 1. thrombus in left basilic vein.\n 2. small-caliber Left IJ with evidence of flow.\n .\n CT head: No acute intracranial process.\n No infiltrates or pleural effusions. Small nodules seen bilaterally.\n Largely unchanged from prior x-ray.\n .\n EGD:\n Abnormal motility of the esophagus was noted. There were continuous\n vigorous contractions throughout the esophagus. The LES was not\n hypertonic. The esophagus was tortuous. There were no intrinsic or\n extrinsic lesions seen. Normal stomach. Normal duodenum.\n Impression: Abnormal esophageal motility\n Otherwise normal EGD to third part of the duodenum\n Microbiology: Urine culture pending\n Blood culture pending\n ECG: NSR @ 103bpm. Nl axis. No ST segment changes.Unchanged from prior\n on .\n Assessment and Plan\n yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presents\n with fever, altered mental status, and worsening LLE cellulitis.\n .\n .\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology. However, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Sources of infection include cellulitis, fevers from DVT, and UTI. It\n is conceivable that with altered mental status patient has meningitis\n or encephalitis, however no neuro deficits or meningismus on exam.\n Given history of NSCLC, patient may have a post obstructive pneumonia.\n CXR negative for infiltrate. UA with few bacteria and epis. No\n diarrhea at this time. Received Zosyn and levofloxacin in ED. Another\n potential etiology is infection after EGD performed 3 days prior to\n admission. Patient does not have any abdominal pain. No ptx seen on\n CXR.\n -repeat UA\n -UCx, Blood cultures\n -Vanc, Zosyn empirically to cover gram positives that may be from\n cellulitis, and gram negatives that may be associated with UTI\n -f/u final read of CXR\n -tylenol PRN fever\n .\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, this is the most\n likely etiology. See above for infectious work up. Will also assess for\n Vitamin B12 deficiency, hypo/hyperthyroidism, and MI. EKG unchanged\n from baseline, but will cycle cardiac enzymes. Not on any new\n medications that would cause a change in mental status. Given known\n NSCLC, brain mets always a concern. Head CT negative. Consider head MRI\n to eval for mets.\n -panculture\n -B12, TSH, LFTs\n -ROMI\n .\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n .\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -consider heparin gtt\n .\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED. Has mild lower extremity edema just over ankles bilaterally. Given\n earlier hypotension, will continue gentle IV fluids overnight.\n -Normal saline @ 125cc/hr x1L\n .\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB overnight given earlier hypotension. Would likely restart in\n AM.\n .\n # Dementia: Continue donepzil and oxybutynin.\n .\n # BPH: Continue finasteride, per outpatient regimen.\n .\n # FEN: IVFs / replete lytes prn / Dysphagia diet, aspiration\n precautions\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV x2\n # CODE: DNR/DNI confirmed with daughter (HCP) in the and on the\n phone on admission. No central lines, no pressors.\n # CONTACT: daughter (cell) who is health\n care proxy\n # DISPO: ICU\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n I have seen and examined the patient with the resident and agree with\n the assessment and plan as above the following emphasis/modifications:\n year old male with history of CAD, chronic and recurrent LE\n cellulitis, dementia, non-small cell lung CA, DNR/DNI who presents to\n the ED with fevers, mental status change and ultimately dropped blood\n pressure 80s/40s. He was given 4 liters of fluids and broad-spectrum\n antibiotics. There was a discussion with family who confirmed DNR/DNI\n and further refused central line or vasopressors. Patient was admitted\n to the ICU.\n Temp 101 in ED, currently 97 HR: 65 BP 86/52 Sat: 97%\n Awake, dementia (mild confusion)\n Chest: CTA\n Heart: S1 S2 reg\n Abd: soft, NT ND\n Ext: +1 edema\n HCT: negative\n Chest CT: negative for PE\n US: LUE clot\n A/P:\n 1) Sepsis/septic shock: unclear source\n most likely cellulitis,\n though urine/pneumonia (CT not impressive but some infiltrate right\n lower) are possible\n a. Broad-spectrum antibiotics (Zosyn and Vancomycin)\n b. IVFs\n c. Family conveyed both to the ED physicians and to resident\n that they do not want central line or any higher level of care such as\n vasopressors\n as he is hypotensive now, will give fluid bolus.\n 2) Altered mental status\n likely secondary to underlying\n infection in the face of underlying dementia\n 3) Left Upper extremity thrombosus: will give dose of lovenox.\n Discuss long-term goals with daughter tomorrow given her wishes\n regarding other interventions\n Patient is critically ill (Time Spent 35 minutes)\n ------ Protected Section Addendum Entered By: , MD\n on: 23:36 ------\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 498017, "text": "Chief Complaint: altered mental status\n 24 Hour Events:\n URINE CULTURE - At 12:22 AM\n BLOOD CULTURED - At 04:22 AM\n BP intermittenly as low as 72/11. Got 2 500cc NS boluses.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 67 (61 - 86) bpm\n BP: 98/49(62) {67/38(46) - 145/123(141)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 1,165 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 1,165 mL\n Blood products:\n Total out:\n 1,670 mL\n 290 mL\n Urine:\n 1,670 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 128 K/uL\n 10.4 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Microbiology: Blood culture pending\n Urine culture pending\n Blood culture pending\n Urine culture pending\n Assessment and Plan\n CELLULITIS\n HYPOTENSION (NOT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 498020, "text": "Chief Complaint: altered mental status\n 24 Hour Events:\n URINE CULTURE - At 12:22 AM\n BLOOD CULTURED - At 04:22 AM\n BP intermittenly as low as 72/11. Got 2 500cc NS boluses.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 67 (61 - 86) bpm\n BP: 98/49(62) {67/38(46) - 145/123(141)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 1,165 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 1,165 mL\n Blood products:\n Total out:\n 1,670 mL\n 290 mL\n Urine:\n 1,670 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 128 K/uL\n 10.4 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Microbiology: Blood culture pending\n Urine culture pending\n Blood culture pending\n Urine culture pending\n Assessment and Plan\n CELLULITIS\n HYPOTENSION (NOT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presents\n with fever, altered mental status, and worsening LLE cellulitis.\n .\n .\n # Hypotension: In the setting of fever, concerning for septic\n physiology.\n .\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology. However, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Sources of infection include cellulitis, fevers from DVT, and UTI. It\n is conceivable that with altered mental status patient has meningitis\n or encephalitis, however no neuro deficits or meningismus on exam.\n Given history of NSCLC, patient may have a post obstructive pneumonia.\n CXR negative for infiltrate. UA with few bacteria and epis. No\n diarrhea at this time. Received Zosyn and levofloxacin in ED. Another\n potential etiology is infection after EGD performed 3 days prior to\n admission. Patient does not have any abdominal pain. No ptx seen on\n CXR.\n -repeat UA\n -UCx, Blood cultures\n -Vanc, Zosyn empirically to cover gram positives that may be from\n cellulitis, and gram negatives that may be associated with UTI\n -f/u final read of CXR\n -tylenol PRN fever\n .\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, this is the most\n likely etiology. See above for infectious work up. Will also assess for\n Vitamin B12 deficiency, hypo/hyperthyroidism, and MI. EKG unchanged\n from baseline, but will cycle cardiac enzymes. Not on any new\n medications that would cause a change in mental status. Given known\n NSCLC, brain mets always a concern. Head CT negative. Consider head MRI\n to eval for mets.\n -panculture\n -B12, TSH, LFTs\n -ROMI\n .\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n .\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -consider heparin gtt\n .\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED. Has mild lower extremity edema just over ankles bilaterally. Given\n earlier hypotension, will continue gentle IV fluids overnight.\n -Normal saline @ 125cc/hr x1L\n .\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB overnight given earlier hypotension. Would likely restart in\n AM.\n .\n # Dementia: Continue donepzil and oxybutynin.\n .\n # BPH: Continue finasteride, per outpatient regimen.\n .\n # FEN: IVFs / replete lytes prn / Dysphagia diet, aspiration\n precautions\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV x2\n # CODE: DNR/DNI confirmed with daughter (HCP) in the and on the\n phone on admission. No central lines, no pressors.\n # CONTACT: daughter (cell) who is health\n care proxy\n # DISPO: ICU\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 497990, "text": "Pt. is a year old man with a history of CAD, systolic CHF, NSCLC,\n dementia and recurrent LE edema c/b cellulitis. Presented from his\n facility today after being found lethargic, confused\n and lying in urine in his bed. He was recently discharged after\n being treated for lower extremity cellulitis. Of note he had a recent\n EGD on for dysphagia. Pt. presented today with worsening lower\n extremity erythema of his LLE and swelling of his LUE. In ED he was\n initially lethargic and confused. Temp 100.3. Blood cultures sent.\n 87% on RA, BP 80's to 90's after receving 4 liters of fluid. Received\n Levofloxacin, Zosyn, and Tylenol. LENIs negative for DVT. LUE\n ultrasound showed positive DVT. CTA negative for PE. CXR normal.\n Code status confirmed DNR/DNI. Pt. transfered to the MICU for further\n management.\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 498087, "text": " yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Cellulitis\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 498090, "text": " yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Cellulitis\n Assessment:\n Cellulitis and/ or UTI given incontinence. CXR unremarakble on\n admission, but now may have RLL infiltrate (?aspiration PNA) vs\n atelectasis. CT with b/l basilar atelectasis. Legs are red and\n swollen R>L, but not painful.Has +pulses as per Doppler. Is afebrile.\n Action:\n Rec\ning IV antibx\ns Vanco/Cefpime.\n Response:\n Cellulitis continues.\n Plan:\n Continue abx\n vanc/cefepime, check culture results. Check CXR\n observe aspiration precautions.\n Hypotension (not Shock)\n Assessment:\n BP-90/110/50\ns HR 80\ns SR no ectopy.\n Action:\n Has rec\nd IVF on previous shift.\n Response:\n BP>90 MAP\ns>55\n Plan:\n Continue to assess BP\ns and administer ICF\ns as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 498051, "text": "Chief Complaint: altered mental status\n 24 Hour Events:\n URINE CULTURE - At 12:22 AM\n BLOOD CULTURED - At 04:22 AM\n BP intermittenly as low as 72/11. Got 2 500cc NS boluses.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 67 (61 - 86) bpm\n BP: 98/49(62) {67/38(46) - 145/123(141)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 1,165 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 1,165 mL\n Blood products:\n Total out:\n 1,670 mL\n 290 mL\n Urine:\n 1,670 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: Elderly gentleman, NAD\n HEENT: NCAT. EOMI. Pinpoint pupils bilaterally. Oropharynx clear, no\n plaques or exudates. Neck supple. No meningismus. No LAD.\n CARDIAC: RRR. No murmurs.\n LUNG: CTAB. No wheezes or crackles.\n ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.\n EXT: WWP. 1+ pedal edema bilaterally. Erythema over LLE upto proximal\n leg, and RLE upto ankle.\n NEURO: Alert to person, place, and month and year.\n Labs / Radiology\n 128 K/uL\n 10.4 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Microbiology: Blood culture pending\n Urine culture pending\n Blood culture pending\n Urine culture pending\n Assessment and Plan\n CELLULITIS\n HYPOTENSION (NOT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n yo M with h/o CAD, Systolic CHF (EF 45%),\n NSCLC, dementia, and recurrent LE edema c/b cellulitis who presents\n with fever, altered mental status, and worsening LLE cellulitis.\n .\n .\n # Hypotension: In the setting of fever, concerning for septic\n physiology. The other likely possibility is hypovolemia. BP is\n responsive to IV fluid boluses. HCP does not want central access or\n pressors.\n -panculture\n -IV fluid boluses to keep MAP>55\n .\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology. However, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Sources of infection include cellulitis, fevers from DVT, and UTI. It\n is conceivable that with altered mental status patient has meningitis\n or encephalitis, however no neuro deficits or meningismus on exam.\n Given history of NSCLC, patient may have a post obstructive pneumonia.\n CXR negative for infiltrate. UA with few bacteria and epis. No\n diarrhea at this time. Received Zosyn and levofloxacin in ED. Another\n potential etiology is infection after EGD performed 3 days prior to\n admission. Patient does not have any abdominal pain. No ptx seen on\n CXR.\n -f/u UCx, Blood cultures\n -Vanc, Zosyn empirically to cover gram positives that may be from\n cellulitis, and gram negatives that may be associated with UTI\n -f/u final read of CXR\n -tylenol PRN fever\n .\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, infection is the\n most likely etiology. See above for infectious work up. B12 and TSH\n wnl. EKG unchanged from baseline, but will cycle cardiac enzymes. Not\n on any new medications that would cause a change in mental status.\n Given known NSCLC, brain mets always a concern. Head CT negative. Head\n MRI from was negative for mets. LFTs not elevated.\n -panculture\n -ROMI -2 sets negative\n .\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n .\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -started lovenox \n -speak with HCP regarding goals of care and whether anticoagulation is\n warranted.\n .\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED and an additional 1L bolus overnight. Has mild lower extremity\n edema just over ankles bilaterally.\n -IV fluid boluses to keep MAPs > 55\n .\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB given hypotension.\n .\n # Dementia: Continue donepzil and oxybutynin.\n .\n # BPH: Continue finasteride, per outpatient regimen.\n .\n # FEN: IVFs / replete lytes prn / Dysphagia diet, aspiration\n precautions\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV x2\n # CODE: DNR/DNI confirmed with daughter (HCP) in the and on the\n phone on admission. No central lines, no pressors.\n # CONTACT: daughter (cell) who is health\n care proxy\n # DISPO: ICU\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 498083, "text": "Chief Complaint: altered mental status\n 24 Hour Events:\n URINE CULTURE - At 12:22 AM\n BLOOD CULTURED - At 04:22 AM\n BP intermittenly as low as 72/11. Got 2 500cc NS boluses.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:46 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 67 (61 - 86) bpm\n BP: 98/49(62) {67/38(46) - 145/123(141)} mmHg\n RR: 20 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 1,165 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 1,165 mL\n Blood products:\n Total out:\n 1,670 mL\n 290 mL\n Urine:\n 1,670 mL\n 290 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n GENERAL: Elderly gentleman, NAD\n HEENT: NCAT. EOMI. Pinpoint pupils bilaterally. Oropharynx clear, no\n plaques or exudates. Neck supple. No LAD.\n CARDIAC: RRR. No murmurs.\n LUNG: CTAB. No wheezes or crackles.\n ABDOMEN: Soft, NT, ND. No masses. No rebound or guarding.\n EXT: WWP. 1+ pedal edema bilaterally. Erythema over LLE upto proximal\n leg, and RLE upto ankle.\n NEURO: Alert to person, place, and month and year.\n Labs / Radiology\n 128 K/uL\n 10.4 g/dL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Microbiology: Blood culture pending\n Urine culture pending\n Blood culture pending\n Urine culture pending\n Assessment and Plan\n CELLULITIS\n HYPOTENSION (NOT SHOCK)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n DEEP VENOUS THROMBOSIS (DVT), UPPER EXTREMITY\n yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis.\n .\n .\n # Hypotension: In the setting of fever, concerning for septic\n physiology. The other likely possibility is hypovolemia. BP is\n responsive to IV fluid boluses. HCP does not want central access or\n pressors.\n -panculture\n -IV fluid boluses to keep MAP>55\n .\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology. However, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Sources of infection include cellulitis, fevers from DVT, and UTI. It\n is conceivable that with altered mental status patient has meningitis\n or encephalitis, however no neuro deficits or meningismus on exam.\n Given history of NSCLC, patient may have a post obstructive pneumonia.\n CXR negative for infiltrate on admission, but more concerning for RLL\n infiltrate this morning. UA with few bacteria and epis. No diarrhea\n at this time. Received Zosyn and levofloxacin in ED. Another potential\n etiology is infection after EGD performed 3 days prior to admission.\n Patient does not have any abdominal pain. No ptx seen on CXR.\n -f/u UCx, Blood cultures\n -Vanc, Cefepime empirically to cover gram positives that may be from\n cellulitis, and gram negatives that may be associated with UTI, and\n aspiration pneumonia\n -tylenol PRN fever\n .\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, infection is the\n most likely etiology. See above for infectious work up. B12 and TSH\n wnl. EKG unchanged from baseline, but will cycle cardiac enzymes. Not\n on any new medications that would cause a change in mental status.\n Given known NSCLC, brain mets always a concern. Head CT negative. Head\n MRI from was negative for mets. LFTs not elevated.\n -panculture\n -ROMI -2 sets negative\n .\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n .\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -started lovenox \n -speak with HCP regarding goals of care and whether anticoagulation is\n warranted.\n .\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED and an additional 1L bolus overnight. Has mild lower extremity\n edema just over ankles bilaterally.\n -IV fluid boluses to keep MAPs > 55\n .\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB given hypotension.\n .\n # Dementia: Continue donepezil and oxybutynin.\n .\n # BPH: Continue finasteride, per outpatient regimen.\n .\n # FEN: IVFs / replete lytes prn / Dysphagia diet, aspiration\n precautions\n # PPX: PPI, lovenox SQ, bowel regimen\n # ACCESS: PIV x2\n # CODE: DNR/DNI confirmed with daughter (HCP) in the and on the\n phone on admission. No central lines, no pressors.\n # CONTACT: daughter (cell) who is health\n care proxy\n # DISPO: call out to floor today\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 498049, "text": "Pt. is a year old man with a history of CAD, systolic CHF, NSCLC,\n dementia and recurrent LE edema c/b cellulitis. Presented from his\n facility today after being found lethargic, confused\n and lying in urine in his bed. He was recently discharged after\n being treated for lower extremity cellulitis. Of note he had a recent\n EGD on for dysphagia. Pt. presented today with worsening lower\n extremity erythema of his LLE and swelling of his LUE. In ED he was\n initially lethargic and confused. Temp 100.3. Blood cultures sent.\n 87% on RA, BP 80's to 90's after receving 4 liters of fluid. Received\n Levofloxacin, Zosyn, and Tylenol. LENIs negative for DVT. LUE\n ultrasound showed positive DVT. CTA negative for PE. CXR normal.\n Code status confirmed DNR/DNI. Daughter refusing central line for\n patient. Does not want pressors at this time. Pt. transfered to the\n MICU for further management.\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP on arrival to MICu was 90\ns to 100\ns systolic. HR sinus rhythm\n with frequent PAC\ns and occasional dips to 40\ns. BP dropping as low as\n 70\ns systolic.\n Action:\n Patient received two 500cc NS boluses for BP in the 70\ns systolic. Pt.\n received KCL 40mEqs in 500cc for K of 3.5. Received a total of 4\n liters of fluid in the ED.\n Response:\n BP fluid responsive. Currently 90\ns to 100\ns. Patient asymptomatic\n with low BP and HR. Slightly lethargic, but easily arousable and\n following commands appropriately.\n Plan:\n Monitor BP and hemodynamics.\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Pt. found to have left upper extremity DVT. Left arm swollen and\n erythematic.\n Action:\n Pt. started on Lovenox.\n Response:\n Ongoing.\n Plan:\n Continue Lovenox. Monitor for signs of bleeding. Pt. with active type\n and cross.\n Altered mental status (not Delirium)\n Assessment:\n Pt. very hard of hearing. Lethargic, but appropriate. Follows\n commands. Moves all extremities. Has pinpoint pupils, difficult to\n see if they are reactive. MICU resident aware.\n Action:\n Patient hears better out of left ear. Reoriented as needed.\n Response:\n Ongoing.\n Plan:\n Reorient as needed. Patient is cooperative and easily arousable.\n Cellulitis\n Assessment:\n Patient with bilateral extremity erythema and swelling. Recently\n discharged after treatment for cellulitis.\n Action:\n LENI\ns negative for DVT\ns. Pt. on Vanc and Zosyn. One set of blood\n cultures sent with am labs.\n Response:\n Pulses present with Doppler.\n Plan:\n Continue antibiotics, Zosyn needs ID approval.\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 498071, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo M with h/o CAD, Systolic CHF (EF 45%), Stage III NSCLC -\n refusing chemo, dementia, and recurrent LE edema c/b cellulitis who\n presents with fever, altered mental status, and worsening LLE\n cellulitis. Hypotensive, but family refusing central lines and\n pressors given DNR/DNI.\n 24 Hour Events:\n - Hypotension (72/11) resolved with IVF\n - Afebrile overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 AM\n Piperacillin/Tazobactam (Zosyn) - 08:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (61 - 86) bpm\n BP: 106/66(75) {67/38(46) - 145/123(141)} mmHg\n RR: 18 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 2,257 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 2,257 mL\n Blood products:\n Total out:\n 1,670 mL\n 410 mL\n Urine:\n 1,670 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 1,847 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4L\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, L>R erythema\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): Person, place, month/year, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.4 g/dL\n 128 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Imaging: LENIS neg; LUE DVT; CTA neg for PE, infiltrate; Head CT neg;\n CXR unremarkable.\n Microbiology: Blood/urine cx pending.\n Assessment and Plan\n yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n # Fever: T 101.8 in the ED. Patient became hypotensive and tachycardic,\n concerning for septic physiology.\n - F/U cultures\n - Continue abx\n # Altered mental status: Patient is demented at baseline. but per\n daughter is less interactive currently. Given fevers, this is the most\n likely etiology. See above for infectious work up. Will also assess for\n Vitamin B12 deficiency, hypo/hyperthyroidism, and MI. EKG unchanged\n from baseline, but will cycle cardiac enzymes. Not on any new\n medications that would cause a change in mental status. Given known\n NSCLC, brain mets always a concern. Head CT negative. Consider head MRI\n to eval for mets.\n -panculture\n -B12, TSH, LFTs\n -ROMI\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient. He most recently\n has been on suppressive keflex. Patient has no history of MRSA, though\n was recently hospitalized.\n -Vancomycin as above\n # LUE basilic vein thrombus: Patient had no stool on guaiac, but mucus\n from rectum was guaiac positive.\n -consider heparin gtt\n # Chronic systolic CHF: Patient has EF of 45%. Received 4L IV fluids in\n ED. Has mild lower extremity edema just over ankles bilaterally. Given\n earlier hypotension, will continue gentle IV fluids overnight.\n -Normal saline @ 125cc/hr x1L\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n -continue ASA, Atorvastatin, plavix.\n -hold BB overnight given earlier hypotension. Would likely restart in\n AM.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: No central line, no\n pressors per daughter (HCP)\n status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2126-09-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 498072, "text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n yo M with h/o CAD, Systolic CHF (EF 45%), Stage III NSCLC -\n refusing chemo, dementia, and recurrent LE edema c/b cellulitis who\n presents with fever, altered mental status, and worsening LLE\n cellulitis. Hypotensive, but family refusing central lines and\n pressors given DNR/DNI.\n 24 Hour Events:\n - Hypotension (72/11) resolved with IVF\n - Afebrile overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:03 AM\n Piperacillin/Tazobactam (Zosyn) - 08:03 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:46 PM\n Enoxaparin (Lovenox) - 02:00 AM\n Other medications: Aspirin, Aricept, Proscar, Oxybutin, Lipitor, Vanco,\n Lovenox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 77 (61 - 86) bpm\n BP: 106/66(75) {67/38(46) - 145/123(141)} mmHg\n RR: 18 (11 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,123 mL\n 2,257 mL\n PO:\n TF:\n IVF:\n 1,123 mL\n 2,257 mL\n Blood products:\n Total out:\n 1,670 mL\n 410 mL\n Urine:\n 1,670 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,453 mL\n 1,847 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4L\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+, L>R erythema\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Oriented (to): Person, place, month/year, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.4 g/dL\n 128 K/uL\n 96 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 113 mEq/L\n 142 mEq/L\n 30.7 %\n 6.4 K/uL\n [image002.jpg]\n 08:42 PM\n 03:15 AM\n WBC\n 8.6\n 6.4\n Hct\n 31.5\n 30.7\n Plt\n 150\n 128\n Cr\n 1.1\n 1.0\n TropT\n <0.01\n Glucose\n 118\n 96\n Other labs: PT / PTT / INR:16.3/63.8/1.4, CK / CKMB /\n Troponin-T:118/3/<0.01, ALT / AST:16/18, Alk Phos / T Bili:81/0.8,\n Amylase / Lipase:/22, LDH:175 IU/L, Ca++:7.5 mg/dL, Mg++:1.8 mg/dL,\n PO4:1.9 mg/dL\n Imaging: LENIS neg; LUE DVT; CTA neg for PE, infiltrate; Head CT neg;\n CXR unremarkable on admission. CXR \n Possible RLL infiltrate vs\n atelectasis.\n Microbiology: Blood/urine cx pending.\n Assessment and Plan\n yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n # Hypotension: Likely septic physiology given fevers and cellulitis.\n Now resolved.\n - IVF boluses prn\n - No CL or pressors per HCP\n # Fever: Sources include cellulitis (most likely) or UTI given\n incontinence. CXR unremarakble on admission, but now may have RLL\n infiltrate (?aspiration PNA) vs atelectasis. CT with b/l basilar\n atelectasis.\n - F/U blood/urine cultures\n - Continue abx\n vanc/cefepime\n # Altered mental status: Likely infection superimposed upon baseline\n dementia. No signs/symptons c/w meningitis.\n - Panculture, abx\n - F/U B12, TSH, LFTs\n - Follow\n # Cellulitis: Patient has chronic bilateral lower extremity\n cellulitis, followed in clinic as an outpatient.\n - Vancomycin as above\n # LUE basilic vein thrombus:\n - Lovenox, but will d/w with daughter given overall goals of care\n - Would decide on long-term anticoagulation after mental status\n recovers out of concern for fall risk\n # Chronic systolic CHF: Patient has EF of 45%.\n - Gentle IVF\n # CAD s/p NSTEMI in . EKG unchanged from baseline. Denies chest\n pain.\n - Continue ASA, Atorvastatin, plavix.\n - Hold BB given hypotension\n ICU Care\n Nutrition: Regular diet. Aspiration precautions.\n Glycemic Control:\n Lines:\n 18 Gauge - 07:29 PM\n 22 Gauge - 02:52 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Lovenox)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments: No central line, no\n pressors per daughter (HCP)\n status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n Patient is critically ill\n" }, { "category": "ECG", "chartdate": "2126-09-29 00:00:00.000", "description": "Report", "row_id": 263675, "text": "Sinus tachycardia, rate 103. Cannot exclude septal myocardial infarction of\nindeterminate age (although unlikely). Borderline low voltage in standard\nleads. Cannot exclude inferior myocardial infarction of indeterminate age\n(although unlikely). Occasional atrial premature beat. Compared to the previous\ntracing of normal sinus rhythm has given way to sinus tachycardia.\nOtherwise, probably there is no significant change.\n\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 498147, "text": " yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Cellulitis\n Assessment:\n Cellulitis and/ or UTI given incontinence. CXR unremarakble on\n admission, but now may have RLL infiltrate (?aspiration PNA) vs\n atelectasis. CT with b/l basilar atelectasis. Legs are red and\n swollen R>L, but not painful.Has +pulses as per Doppler. Is afebrile.\n Action:\n Rec\ning IV antibx\ns Vanco/Cefpime.\n Response:\n Cellulitis continues.\n Plan:\n Continue abx\n vanc/cefepime, check culture results. Check CXR\n observe aspiration precautions.\n Hypotension (not Shock)\n Assessment:\n BP-90/110/50\ns HR 80\ns SR no ectopy. U/O just 10-15cchr for 2 hrs.\n Action:\n Rec\ning NS 500cc over 1-2hrs for low u/o\n Response:\n BP>90 MAP\ns>55, u/o 30-40cc/hr.\n Plan:\n Continue to assess BP\ns and administer ICF\ns as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left arm not swollen, or painful has + radial pulse\n Action:\n Rec\ning Lovenox sq\n Response:\n +LUE Baslic Vein thrombus.\n Plan:\n Continue to assess L arm and administer Lovenox\n Altered mental status (not Delirium)\n Assessment:\n Is A&Ox3, Pupils are pinpoint but are reactive.\n Action:\n Assess MS.\n Response:\n Increased alertness and oreintation\n Plan:\n Monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Came from on thickened liquids, and s/p EDG for\n dysphagia. Crushing pills and mixing with apple sauce, with thickened\n fluids. Poor appetite and and slight difficulty swallowing to have\n Speech and Swallowing eval.\n Action:\n Had Speech and Swallow eval done. Please see written eval and\n recommendations.\n Response:\n Had difficulty swallowing.\n Plan:\n To be NPO except meds crushed and mixed with apple sauce until Video\n Swallowing Eval tomorrow.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Height:\n Admission weight:\n 71 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Smoker\n CV-PMH: CAD, CHF\n Additional history: Dementia, CAD s/p NSTEMI , chronic systolic CHF\n EF 45%, chronic LE edema, benign prostratic hypertrophy, Stage 3 NSCLC\n diagnosed refused chemo, cellutlis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:109\n D:58\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,875 mL\n 24h total out:\n 620 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:15 AM\n Potassium:\n 3.9 mEq/L\n 03:15 AM\n Chloride:\n 113 mEq/L\n 03:15 AM\n CO2:\n 22 mEq/L\n 03:15 AM\n BUN:\n 16 mg/dL\n 03:15 AM\n Creatinine:\n 1.0 mg/dL\n 03:15 AM\n Glucose:\n 96 mg/dL\n 03:15 AM\n Hematocrit:\n 30.7 %\n 03:15 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: Hearing aids, L eft aid in place, R aid in case.\n Clothes: Sent home with: none\n Wallet / Money:none\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: MICU-7\n Transferred to: to CC7 727\n Date & time of Transfer: / 1700\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 498139, "text": " yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Cellulitis\n Assessment:\n Cellulitis and/ or UTI given incontinence. CXR unremarakble on\n admission, but now may have RLL infiltrate (?aspiration PNA) vs\n atelectasis. CT with b/l basilar atelectasis. Legs are red and\n swollen R>L, but not painful.Has +pulses as per Doppler. Is afebrile.\n Action:\n Rec\ning IV antibx\ns Vanco/Cefpime.\n Response:\n Cellulitis continues.\n Plan:\n Continue abx\n vanc/cefepime, check culture results. Check CXR\n observe aspiration precautions.\n Hypotension (not Shock)\n Assessment:\n BP-90/110/50\ns HR 80\ns SR no ectopy. U/O just 10-15cchr for 2 hrs.\n Action:\n Rec\ning NS 500cc over 1-2hrs for low u/o\n Response:\n BP>90 MAP\ns>55, u/o 30-40cc/hr.\n Plan:\n Continue to assess BP\ns and administer ICF\ns as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left arm not swollen, or painful has + radial pulse\n Action:\n Rec\ning Lovenox sq\n Response:\n +LUE Baslic Vein thrombus.\n Plan:\n Continue to assess L arm and administer Lovenox\n Altered mental status (not Delirium)\n Assessment:\n Is A&Ox3, Pupils are pinpoint but are reactive.\n Action:\n Assess MS.\n Response:\n Increased alertness and oreintation\n Plan:\n Monitor MS.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Came from on thickened liquids, and s/p EDG for\n espogeal spasms. Crushing pills and mixing with apple sauce.\n Action:\n Response:\n Plan:\n" }, { "category": "Rehab Services", "chartdate": "2126-09-30 00:00:00.000", "description": "Bedside Swallowing Evaluation", "row_id": 498129, "text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this y/o male with h/o CAD,\nSystolic CHF (EF 45%), NSCLC, dementia, and recurrent LE edema\nc/b cellulitis (recent hospitalization for tx of LLE\ncellulitis) who presented to from his \nfacility on after he was found to be lethargic, confused,\nand lying in bed soaked with urine, which is not usual for him.\nPatient found with worsening erythema and edema and new swelling\nof LLE. CTA chest negative for PE. CXR negative for pneumonia,\nhowever with ? of RLL consolidation. CT head negative.\nPatient is known to our department for previous bedside and video\nswallow evaluations. Most recent video swallow performed on\n revealed mild oropharyngeal dysphagia with prespill which\nresulted in penetration before/during the swallow of thin liquids\nwhich cleared spontaneously. Patient was noted with difficulty\ntransitioning a barium tablet and aspirated thin liquid while\nattempting to swallow tablet whole. Of note, all of patient's\nprevious video swallows revealed reduced UES relaxation which did\nnot interfere with the passage of solids, however large pills\nwere recommended to be crushed. A dilation was not recommended in\ninitial video swallow in concern for backflow. A barium\nswallow study performed during the same week in also\nrevealed small hiatal hernia, Schatzki's ring, small esophageal\ndiverticuli at the thoracic inlet and above the GE junction.\nPatient has since continued a regular diet. Per medical records\nhe was noted with coughing and an EGD was performed on .\nWe were consulted to evaluate patient's oral and pharyngeal\nswallowing function and r/o aspiration while eating and drinking.\nPatient had just finished lunch tray and was coughing upon my\narrival. Patient ate a bowl of soup, pudding, and tried macaroni\nand cheese but said it was \"too heavy\".\nPMH:\nDementia\nCAD s/p NSTEMI \nChronic Systolic CHF, EF 45%\nChronic LE edema\nBenign prostatic hypertrophy\nstage IIIA NSCLC daignosed , offered chemo and refused\nCellulitis\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on the MICU.\nCognition, language, speech, voice: Patient was awake and alert,\nhard of hearing and oriented to self. Patient was able to follow\ncommands and participate in PO trials. Speech was fluent and\nvoice wfl.\nTeeth: dentures present\nSecretions: normal oral secretions\nORAL MOTOR EXAM:\nTongue protruded midline. Functional labial and lingual strength,\nROM, and buccal tone. Palatal elevation was symmetrical. Gag\ndeferred.\nSWALLOWING ASSESSMENT:\nPO trials included ice chips, thin liquids (tsp/straw), nectar\nthick liquids and honey thick liquids via straw and cup, bites of\npuree. Oral phase grossly wfl. Laryngeal elevation felt adequate\nto palpation. Patient had overt wet coughing on ice chips and\nthin liquids. He had consistent delayed repetitive throat\nclearing on both nectar thick liquids and honey thick liquids. O2\nsats remained stable at 98%, however patient was noted with\nappearance of SOB or increased WOB. Patient denied difficulty\nswallowing when asked, however did appear to concentrate and\nprepare to swallow each time he put food in his mouth. He did\nreport he felt he needed to keep swallowing when trialed with\nhoney thick liquids. A chin tuck intermittently prevented throat\nclearing with nectar thick liquids.\nSUMMARY / IMPRESSION:\nMr. presents with s/sx of aspiration and pharyngeal\nresidue. He appeared with overt coughing on thin liquids and a\ndelayed repetitive throat clear on nectar thick and honey thick\nliquids. His recent dilation, if successful, likely improved\ntoleration of puree and solids, however his known oropharyngeal\ndysphagia with penetration prespill is likely persistent and\nmay be resulting in aspiration currently. A video swallow will be\nperformed to further assess swallowing function and safest PO\ndiet. Please keep patient NPO overnight, except meds crushed with\npuree, pending video swallow. Please encourage patient to swallow\nmeds with puree several times and stay upright for 15-20 minutes\nin case of pharyngeal residue.\nThe Functional Oral Intake Scale (FOIS) rating will be determined\npending video swallow.\nRECOMMENDATIONS:\n1. Video swallow to further assess swallowing function and safest\nPO diet.\n2. NPO except meds crushed with applesauce pending video swallow.\n3. Encourage patient to swallow 2-3 times after meds with\napplesauce and stay upright 15-20 minutes.\n4. Q4 oral care.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 1435-1455\nTotal time: 60 minutes\n" }, { "category": "Nursing", "chartdate": "2126-09-30 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 498136, "text": " yo M with h/o CAD, Systolic CHF (EF 45%), NSCLC, dementia, and\n recurrent LE edema c/b cellulitis who presents with fever, altered\n mental status, and worsening LLE cellulitis. Admitted to MICU for\n hypotension, now resolved with IVF. Of note, patient is DNR/DNI and\n daughter who is HCP is refusing central lines and pressors at this\n time.\n Cellulitis\n Assessment:\n Cellulitis and/ or UTI given incontinence. CXR unremarakble on\n admission, but now may have RLL infiltrate (?aspiration PNA) vs\n atelectasis. CT with b/l basilar atelectasis. Legs are red and\n swollen R>L, but not painful.Has +pulses as per Doppler. Is afebrile.\n Action:\n Rec\ning IV antibx\ns Vanco/Cefpime.\n Response:\n Cellulitis continues.\n Plan:\n Continue abx\n vanc/cefepime, check culture results. Check CXR\n observe aspiration precautions.\n Hypotension (not Shock)\n Assessment:\n BP-90/110/50\ns HR 80\ns SR no ectopy. U/O just 10-15cchr for 2 hrs.\n Action:\n Rec\ning NS 500cc over 1-2hrs for low u/o\n Response:\n BP>90 MAP\ns>55, u/o 30-40cc/hr.\n Plan:\n Continue to assess BP\ns and administer ICF\ns as needed\n Deep Venous Thrombosis (DVT), Upper extremity\n Assessment:\n Left arm not swollen, or painful has + radial pulse\n Action:\n Rec\ning Lovenox sq\n Response:\n +LUE Baslic Vein thrombus.\n Plan:\n Continue to assess L arm and administer Lovenox\n Altered mental status (not Delirium)\n Assessment:\n Is A&Ox3, Pupils are pinpoint but are reactive.\n Action:\n Assess MS.\n Response:\n Increased alertness and oreintation\n Plan:\n Monitor MS.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2125-03-01 00:00:00.000", "description": "Report", "row_id": 1607688, "text": "CSRU Admission Note\n\nMr. is a 71 year old man with known stable CAD x 15 years. Over last 3-4 weeks noted nocturnal CP which was waking him up at night. Cardiac cath yesterday revealed 3 VD, EF 51%. He went to the OR today for CABG x 3 LIMA to LAD, SVG to OM and Diagonal. OR course stable.\n\nPMH: CAD, PVD-left CEA ', Htn, elevated cholesterol, arthritis-neck stiffness, h/o esophageal dilatations d/t strictures.\n\nNKDA\n\nNeuro: Sedated on propofol. PERRL. Propofol weaned tooff. Pt intermittantly aggitated and moving about out in bed but calms down when spoken to.\n\nCV: HR 80's NSR, no ectopy noted. BP labile at times. NTG gtt started and titrated to keep MAP's < 90. Up to max of 1.5 mcg/kg/min of Ntg. Currently with slight decreases in MAP to less than 60's with wakefulness. Neo gtt at 0.25 mcg/kg/min started. Received 1l LR since arrival. PP's initially palpable, currently dopplerable w/ lower BP. Hct 36. CT's w/ minimal dng. Small intermittant airleak noted initially which has resolved. K+ repleted.\n\nResp: Vented on SIMV 750/10. PaO2 137 on initial ABG. PEEP increased to 8, FiO2 down to 80%. PaO2 162 on repeat ABG. FiO2 decreased to 50%. BS slightly diminished at bases. Ambued and suctioned for scant clear secretions. CXR done-not read yet.\n\nGI: Abd soft, no BS. OGT w/ bilious dng.\n\nGU: Large u/o.\n\nEndo: Glucoses stable and not requiring treatment.\n\nID: Slightly cool upon arrival.\n\nSkin: Intact. Dsg to chest and leg dry and intact.\n\nComfort: Med w/ MsO4 and toradol for comfort.\n\nSocial: Daughters into visit and updated on pt's condition.\n\nA: BP labile at times. Attempting to wake. Marginal PaO2's. Lg u/o.\n\nP: Monitor neuro status. Ntg/neo gtts per BP needs. ? more IVF d/t large u/o. Monitor PaZO2's. Wean to 40% FiO2 before decreasing peep. Attempt to wean to extubated. Med for pain.\n" }, { "category": "Nursing/other", "chartdate": "2125-03-02 00:00:00.000", "description": "Report", "row_id": 1607689, "text": "ALERT AND ORIENTED, PLEASANT MAN. EXTUBATED AT 2045. PT. IS A MOUTH BREATHER AND DESATS ON NASAL PRONGS, OFM APPLIED AT 50% WITH SATS 98%. LUNGS CLEAR WITH RALES AT THE RIGHT BASE. CT'S TO SUCTION NO LEAK DRAINING MINIMAL SERO-SANG. COUGHING NOT RAISING. NSR NO ECTOPY, PACERBOX TURNED OFF. A WIRES WORK BUT THEY PACE HIS DIAPHRGM AS WELL. HESPAN GIVEN FOR HYPOTENSION AND LOW FILLING PRESSURES WITH EFFECT. PRESENTLY REQUIRING NEO. AT 0.4MCG/KG/MIN. TOLERATING WATER PO, DENIES NAUSEA, NO BOWEL SOUNDS AS OF YET. URINE OUTPUT IS ADEQUATE. C/O RIGHT SHOULDER \"ARTHRITIC\" PAIN. PT. TAKES MOTRIN 800MG AT HOME FOR THIS. TORADOL AND PERCOCETS GIVEN, PT. SLEEPING. TURNS WELL IN THE BED WITH ASSISTANCE. STERNAL AND RIGHT LEG DRESSINGS CHANGED, NO DRAINAGE NOTED, DSD'S APPLIED. ACE WRAP ON RIGHT LEG. 3DAUGHTERS AND A SON-IN-LAW IN TO VISIT AND ARE PLEASED.\n" }, { "category": "Nursing/other", "chartdate": "2125-03-02 00:00:00.000", "description": "Report", "row_id": 1607690, "text": "CSRU NPN\n\nNeuro: Alert and oriented x 3. Very pleasant. MAE w/ equal strength.\n\nCV: HR 80's NSR, no ectopy noted. Neo weaned to off after 500cc hespan. Off x several hours then resumed for MAP's in high 50's. Hct down to 24 then back up to 27. Palpable PT's, dopplerable DP's. VVI in place. 40 meq po kcl x 2. Central line removed without difficulty.\n\nResp: BS diminished at bases, faint rales at right base early in day. Using IS up to 1200 with good technique. Cough occasionally productive small amts thick, tan slightly pink tinged secretions. No airleak. Small amts CT dng. O2 sats down to 92% on 2l np, returned to 4l np.\n\nGI: Abd soft, ND, + BS. Minimal appetite. Tolerating po liquids.\n\nGU: u/o adequate via foley. BUN/Cr wnl.\n\nID: Afebrile. Vanco cont's.\n\nEndo: Glucoses stable.\n\nSkin: Intact to back/buttocks. Leg incision w/ dermabond intact, no dng. Acewrap/DSD changed.\n\nComfort: Initially w/ right shoulder pain (baseline) and incisional discomfort. Given percocet w/ good effect. Toradol cont's.\n\nActivity: OOB to chair x several hours. Moves well w/ 2 assist.\n\nA: Labile BP requiring low dose neo prn to maintain MAP's > 60. Adequate pain control.\n\nP: Maintain BP w/ neo prn. Cont pulmonary hygiene. Wean O2 as tolerated. Med for pain prn. Increase activity as tolerated. Plan for transfer to 6 tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2125-03-03 00:00:00.000", "description": "Report", "row_id": 1607691, "text": "3-29/3-30 B-SHIFT\n\nNEURO-COMPLETELY INTACT. PLEASANT/COOPERATIVE.\n\nCV-NSR 80's NO ECTOPY.REQUIRED TRANSISENT LOW DOSE NEO X 45MIN, FOR MAP HOVERING IN THE MID 50'S. BP STABLE THEREAFTER. 15 POINT DIFFERANCE BETWEEN ABP/NBP.\n\nRESP-LSC 2L=93% SATS DECREASING TO 88-90% WHEN ASLEEP. NC INCREASED TO 4L, SATS=94-95%. PT TO TAKE DEEP BREATHS. NO COUGH.\n\nABD-SOFT +BS. TAKING SIPS OF H20.\n\nG.U.-FOLEY WITH ADEQ CLEAR YELLOW URINE.\n\nI.D. CONTINUES ON VANCO IV.\n\nA/P-STABLE NOC. ENC.CDB. DC CT/A-LINE IN AM. TRANSFER TO F6 LATER TODAY.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2125-03-03 00:00:00.000", "description": "Report", "row_id": 1607692, "text": "CSRU TRANSFER NOTE:\n\nPT 71YO MALE WITH KNOWN CAD. EXERTIONAL CP PAST 15 YRS, RELIEVED BY 1 NITRO SL. CATH SHOWED DISEASE, EF- 45-50%. INF WALL HK. 1 MONTH AGO, CP WOKE HIM IN MIDDLE OF NOC. ETT POSITIVE IN . ECHO IN SHOWEDEF 40% AND INF BASILAR AND INK APICAL HK. PRESENTED FOR CARDIAC CATH.\n\nPMHX: HTN\n INCREASED CHOLESTEROL\n ARTHRITIS\n BPH\n L CEA (00)\n + FAMILY HX\n\n\nALLG: NKDA\n\nCARDIAC CATH: 3V CAD: 100% CX, 100% RCA, TIGHT LESION ON LAD AND DIAG.\n\nCABG: : CABG X3: LIMA->LAD, SVG->OM, DIAG. EZ TUBE. REC'D BLD PRODUCTS, DEFIB X1 OFF BP. BPPT: 87\", XCT: 50\". ON NEO AND NTG POST-OP.\n\nNEURO: PT ALERT AND ORIENTED. MOVING ALL EXTREMITIES. OOB WITH MIN ASSIST. TOL WELL.\n\nCV: PT DENIES CP, PALP, SOB. TELE: MP NSR-ST. HR 90-100'S. NO ECTOPY NOTED. EPI WIRES INTACT. SET FOR A-DEMAND AT 60. PT UNCOMFORTABLE WHEN PACER ON. 1+ EDEMA. DISTAL PULSES PALPABLE.\n\nRESP: LS CTA. STRONG COUGH. USING IS WITHOUT DIFFICULTY. CT REMOVED THIS AM.\n\nGI: ABD SOFT, NONTENDER. +BS, NO BM. TOL DIET WITHOUT DIFFICULTY.\n\nGU: FOLEY INTACT. RESPONDING WELL TO LASIX.\n\nINTEG: INC C/D/I. NO DRNG NOTED.\n\nPLAN: TX PT TO 6. INCREASE AMBULATION AND ACTIVITY.\n\n\n" }, { "category": "ECG", "chartdate": "2125-03-01 00:00:00.000", "description": "Report", "row_id": 162829, "text": "Sinus rhythm\n Inferior ST-T changes are nonspecific\nSince previous tracing of , less suggestive of left ventricular\nhypertrophy\n\n" }, { "category": "ECG", "chartdate": "2125-02-28 00:00:00.000", "description": "Report", "row_id": 162830, "text": "Sinus bradycardia\nLead(s) unsuitable for analysis: V6\nVoltage criteria for left ventricular hypertrophy\nST-T abnormalities consistent with left ventricular hypertrophy\nSince previous tracing, , no significant change\n\n" }, { "category": "Radiology", "chartdate": "2125-03-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 755719, "text": " 6:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post-op hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p cabg\n REASON FOR THIS EXAMINATION:\n post-op hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST : Compared to \n\n CLINICAL INDICATION: Hypoxia.\n\n An endotracheal tube and central venous catheter are in satisfactory position,\n as well as a nasogastric tube and mediastinal drains.\n\n The patient is status post interval median sternotomy and coronary artery\n bypass surgery. The heart demonstrates left ventricular configuration.\n Slightly widening of the mediastinum likely reflects a combination of patient\n rotation, supine portable technique, and post-operative change.\n\n There is patchy increased opacity in the left retrocardiac region and there is\n likely layering pleural effusion. No pneumothorax is identified.\n\n The right costophrenic angle has been excluded from this study and cannot be\n assessed.\n\n IMPRESSION:\n\n 1) Lines and tubes in satisfactory position.\n 2) Patchy left basilar atelectasis and probable layering left pleural\n effusion.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2176-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 781035, "text": " 12:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK NEW CVL LINE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD pre-op cabg\n\n REASON FOR THIS EXAMINATION:\n CHECK NEW CVL LINE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CABG.\n\n S/P CABG. No evidence for CHF. No pneumothorax. There is atelectasis at the\n left lung base.\n\n" }, { "category": "Radiology", "chartdate": "2176-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 781077, "text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD pre-op cabg\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, : Compared to one day earlier.\n\n CLINICAL INDICATION: S/P coronary artery bypass surgery. Evaluate for\n congestive heart failure.\n\n The patient is s/p median sternotomy and coronary artery bypass surgery. A\n left subclavian central catheter remains in satisfactory position. There is\n persistent deviation of the trachea towards the right, which is unchanged from\n the preoperative radiograph.\n\n The lung volumes are relatively low. This, combined with supine positioning\n of the patient, likely accounts for the prominence of the pulmonary\n vascularity. There has been interval improvement in left retrocardiac opacity\n in the interval. No new or worsening areas of opacification are seen. A\n left-sided chest tube remains in place.\n\n IMPRESSION:\n 1) Improving left lower lobe atelectasis.\n 2) Deviation of the trachea towards the right, unchanged since the\n preoperative study, and possibly due to enlargement of the left lobe of the\n thyroid gland. Correlation with palpation is suggested. If the diagnosis is\n in doubt clinically, CT may be helpful.\n 3) No evidence of congestive heart failure allowing for portable, supine\n technique and low lung volumes.\n\n" }, { "category": "Radiology", "chartdate": "2176-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 780807, "text": " 11:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD pre-op cabg\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op CABG, CAD.\n\n FINDINGS: A single frontal view of the chest. The left costophrenic angle is\n not included in this study. The film was performed in apical lordotic\n positioning. There are no consolidations or pleural effusions. The heart is\n high normal in size. There is no pneumothorax or congestive heart failure.\n\n IMPRESSION: Limited study but no acute cardiothoracic pathology is\n identified.\n\n\n" }, { "category": "Echo", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 66681, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nStatus: Inpatient\nDate/Time: at 13:33\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n0.2 mg of glycopyrrolate given IV as an antisialagogue.\nLEFT ATRIUM: The left atrium is mildly dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage. Left atrial appendage\nejection velocity is good (>20 cm/s). All four pulmonary veins were identified\nand found to enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\nprominent Chiari network is present in the right atrium (normal variant). The\ninteratrial septum is normal. No atrial septal defect is seen by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is mildly\ndepressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque.\n\nAORTIC VALVE: There are three aortic valve leaflets. The aortic valve leaflets\nare mildly thickened. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. The patient is\ntachycardic (HR>100bpm). The rhythm appears to be atrial fibrillation. The\ncardiology fellow involved with the patient's care was notified by telephone.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. Overall left ventricular systolic function is at least mildly\ndepressed secondary to hypokinesis of the inferior and posterior walls. Right\nventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. There are three aortic valve leaflets. The aortic\nvalve leaflets are mildly thickened. No aortic regurgitation is seen. The\nmitral valve leaflets are structurally normal. There is no pericardial\neffusion.\n\nIMPRESSION: No eveidence of LA/LAA thrombus.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-27 00:00:00.000", "description": "Report", "row_id": 1306647, "text": "POST OP CABG X2. ARRIVED CSRU 1600 ON PROPOFOL.\nNEURO: PROP WEANED. LETHARGIC. FOLLOWS COMMANDS. MAE.\nCV: INITIALLY APACED OUT OF OR. PACER OFF. NSR 90'S. BP 140-150'S/80. NTG STARTED. AFTER REVERSALS AND PROP WEANED BP DOWN 90'S HR 50'S. NTG OFF. APACED AT 70. PT W/ OCC RUNS SVT. OCC PAC. LYTES REPLETED. 2A 2V WIRES. A NO SENSE APPROPRIATELY BUT CAPTURE. V WIRES SENSE/CAPTURE. DISTAL PULSES DOPPLERABLE. DEMEROL GIVEN FOR SHIVERS. CT OUTPUT 116 CC UPA TO FLOOR. NO LEAK. DOWN TO 10CC HR. NO PRODUCTS NEEDED ON FLOOR RECIEVED MULTIPLE PRODUCTS IN OR.\nRESP: WEANED TO CPAP. ABG WNL. NO EXTUBATED SECONDARY TOO SLEEPY. SX FOR SCANT THIN WHITE. LSC. TV >600.\nGI/GU: THICK BILIOUS DRNG VIA OGT. SX LARGE AMT ORAL SECRETIONS BLOOD TINGED. URINE OUTPUT EXCELLENT. NO BS. ABD SOFT.\nSKIN: STERNAL DSG INTACT. LT LEG ACED.\nENDO: FS COVERED W/ SS PER PROTOCOL.\nPLAN: WAKE AND WEAN. REPLETE LYTES. CONT ASSESS HEMODYNAMICS.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-28 00:00:00.000", "description": "Report", "row_id": 1306648, "text": "NEURO-PLEASANT,COOPERATIVE. A&O X3. MAE. = STRENGTH.\n\nCV-NSR-ST. NTG TITRATED FORMAP>90. PACER NOT S/C ATRIUM CORRECTLY.PACER SET ON VVI RATE=60 MA=12. RATE TURNED DOWN TO 30 WHEN PACER INAPPROPRIATELY PACED VENTRICLES.EXTREMETIES WARM, PALPABLE PULSES X4.\n\nG.I.- ABD SOFT.+ HYPOACTIVE BS. TOL. CLEAR LIQUIDS FINE.\n\nG.U.- ACCEPTABLE HUO.\n\nENDO- INSULIN GTT FOLOWED PER PROTOCOL. GLUCOSE=115-195.\n\nLABS- K+ + 4.0 REPLACED PARN.\n\nPLAN- PA->CVP OR CORDIS INTRODUCER. OOB TO CHAIR. AMB IN ROOM.\nCONTINUE TO MONITOR HEMODYNAMICS,RESP STATUS.\n" }, { "category": "ECG", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 136210, "text": "Atrial fibrillation with rapid ventricular response\nMarked left axis deviation\nRBBB with left anterior fascicular block\nSince previous tracing, Q's inferiorly no long apparent\n\n" }, { "category": "ECG", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 136211, "text": "Atrial fibrillation\nMarked left axis deviation\nInferior Q waves noted - consider inferior myocardial infarction\nSeptal ST changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing, Q's in lead lll are new\n\n" }, { "category": "ECG", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 136212, "text": "Atrial fibrillation with moderate ventricular response.\nLow frontal plane voltage.\nDiffuse ST-T wave abnormalities.\nSince the previous tracing of no significant change,\n\n" }, { "category": "ECG", "chartdate": "2177-01-09 00:00:00.000", "description": "Report", "row_id": 136206, "text": "Sinus rhythm\nBorderline first degree A-V block\nLeft atrial abnormality\nLeft axis deviation - anterior fascicular block\nPossible RV conduction delay\nPossible old inferior infarct\nAnteroseptal ST-T changes may be due to myocardial ischemia\nSince previous tracing of , the rate has decreased, and the rhythm is\nsinus\n\n" }, { "category": "ECG", "chartdate": "2177-01-08 00:00:00.000", "description": "Report", "row_id": 136207, "text": "Atrial fibrillation with rapid ventricular response\nLead(s) unsuitable for analysis: V2\nLeft axis deviation - anterior fascicular block\nPossible RV conduction delay\nPossible old inferior infarct\nAnterior T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nSince previous tracing of , lead V2 is missing, increase in ventricular\nrate\n\n" }, { "category": "ECG", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 136208, "text": "Atrial fibrillation with moderate ventricular rate\nLong QTc interval\nMarked left axis deviation\nPossible RV conduction delay\nPossible old inferior infarct\nAnt/septal+lateral T wave changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince previous tracing of , more suggestive of inferior myocardial\ninfarction\n\n" }, { "category": "ECG", "chartdate": "2176-12-26 00:00:00.000", "description": "Report", "row_id": 136213, "text": "Atrial fibrillation. Since earlier this date the rate is somewhat slower.\nOtherwise, no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-12-26 00:00:00.000", "description": "Report", "row_id": 136214, "text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of the rate is more rapid. Otherwise, no significant change. The\ntracing continues to voltage in the limb leads and non-specific\nST-T wave abnormalities.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 136209, "text": "Atrial fibrillation with a moderate ventricular response. Left anterior\nfascicular block with left axis deviation. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of the\nanterior T wave inversions are less prominent. Otherwise, no diagnostic interim\nchange.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1306656, "text": "ADDENDUM: CT DC'D BY PA. DSG INTACT. PT W/ PERC 2 TABS W/ GOOD RELIEF. PT CHANGED TO LOPRESSOR 50MG PO TID FOR RATE CONTROL. CONT ON DILT 5MG/MIN TO FINISH PRESENT BAG AND THEN DC. WILL NEED PTT CHECKED AT 2100.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1306657, "text": "NEURO: A+OX3, PLEASANT. FAMILY IN TO VISIT LAST EVENING. TWICE WITH 2 PERCOCETS FOR C/O INCISIONAL PAIN AGGRAVATED BY COUGHING. GOOD EFFECT STATED BY PT. PT SLEPT IN NAPS.\n\nCV: DILT GTT WAS WEANED OFF LAST EVENING BY DAY SHIFT. RESTARTED AS HR INCREASED TO 110-120'S. DR. WAS AWARE OF INCREASED RATE. ORDERED DILT TITRATE TO HR <90. CONT'S WITH AFIB 80'S-90'S. DILT GTT @ 7.5MCG.\n RECIEVED 50MG PO LOPRESSOR @ 2400 AS SCHEDULED. HEP GTT @ 1400U/HR. PTT WAS 49.7. DR. WAS NOTIFIED. NO CHANGE IN RATE MADE.\n\nRESP: C/O OCC. CHEST TIGHTNESS WHEN BREATHING. LUNGS WERE RONCHORUS. ENCOURAGED PT TO COUGH AND DEEP BREATH AND CONTINUE IS QHR. HAS STRONG COUGH AND ABLE TO RAISE THICK TAN SECRETIONS. CLEARS WITH COUGHING.\n\nENDO: GIVEN 3U REG INSULIN FOR BS 130'S.\n\nGU: ADEQUATE URINE OUTPUT.\n\nASSESS: AFIB\n\nPLAN: WEAN DILT GTT AS TOL. RECHECK PTT IN AM. CONT TO MONITOR HEMODYNAMICS. OOB TO CHAIR IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-31 00:00:00.000", "description": "Report", "row_id": 1306658, "text": "UPDATE\nCV: REMAINS IN AF. DILT GTT OFF PER P.A. AFTER GIVING INCREASED PO AND BOLUS OF IV LOPRESSOR. HR STILL ELEVATED(100-140) HOWEVER DESPITE MULTIPLE REPEAT BOLUSES OF IV LOPRESSOR AND FURTHER INCREASE OF PO DOSE TO 100 MG, SO PT W/ DILT AND GTT RESTARTED TO 10MG/HR. BP STABLE AND PT CURRENTLY HAVING PVC'S. K+=4.1.\n\nRESP: LUNGS CLEAR BUT SL DIMINISHED @ L BASE. I.S., C&DB ENC Q 1 HR. COUGH NON-PRODUCTIVE. SPO2 98% ON 2L NCO2; WAS 92% ON RA.\n\nNEURO/ACTIVITY: A&O, PLEASANT, VISITING W/ FAMILY IN EARLY AFTERNOON. ASKED FOR 1 PERCOCET FOR INCISIONAL DISCOMFORT THIS A.M. CURRENTLY STATES HE'S COMFORTABLE. AMB 2 \"LOOPS\" AROUND UNIT W/ P.T.; DID WELL.\n\nG.I.: TOL SM AMTS SOLID MEALS AND PO LIQS W/O PROBLEM. ON COMMODE X 1 BUT NO B.M.\n\nG.U.: ADEQ HUO VIA FOLEY. CONT ON PO LASIX.\n\nA/P: PERSISTENT AF DESPITE ABOVE MEASURES SO BACK ON DILT GTT. CONT CLOSE MONITORING OF HR AND ANTICOAGULATION. REPLETING K+ NOW. ENC PULM TOILET AND ACTIVITY AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1306659, "text": "CV: Pt continues on dilt gtt for afib. Stable bp. Gave .25 mg dig po. Pt also recieved a total of 200mg po lopressor per EP recommendation last pm. Hr down 70-9's afib. Dilt weaned to 7.5mg np. Pt with 6 beat run of VT. Mg 1.7, K+ 3.9. Gave 2 G mgso4 iv and 20 kcl iv.\n\nRESP: Lungs are clear bilat. Spo2 > 95% 1L np.\n\nSKIN: Small pink area noted on well approximated l leg incision. Pt states that it's tender to touch. Notified Dr. .\n\nNEURO: A+Ox3, mae, pleasant.\n\nASSESS: Continues with afib on dilt gtt.\n\nPLAN: Continue to wean dilt as tol. See for Dig orders. Monitor Dig level. Ptt/pt pending, Monitor L leg incision.\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1306653, "text": "NEURO: AWAKE AND OREITNED X3. \" I DON'T FEEL WELL TODAY\" MAE. DEPRESSED REGARDING AFIB.\nCV: CONT RAF MOST OF DAY. EP CONSULTED. MANY DRUG COMBOS ATTEMPTED. SEE FLOWSHEET. LOADED ON PROC W/ ESAMALOL NOT ABLE TO RATE CONTROL. EP SUGGESTED CARDIOVERSION. IF FAIL SWITCH TO DILT/DIG W/ NEO IF NECESSARY. HEPARIN STARTED AT 1000U/HR NO BOLUS GOAL PTT 50-70 PER DR. . DR. AWARE OF CONDITION WANTS TO TRY TO RATE CONTROL FIRST RATER THAN CARDIOVERT. PT CURRENTLY ON ESMOLOL 150MCG AND DILT 20MCG. TITRATING NEO TO KEEP SBP >120. GOAL HR 90-100. PROC DC'D PRIOR TO DOUBLE BLOCKADE. DISTAL PULSES CONT TO BE PALP. CT TO SX MARG OUTPUTL. ON VV1 56 MA 16 1. SENSING APPROPRIATELY. PT NOT AS GOOD AS YESTERDAY SLIGHTLY DIAPOHORETIC. LT SUBCLAVIN CVL PLACED THIS AM SECONDARY TO LIMITED PERIPHERAL ACCESS.\nRESP: SATS IMPROVED THIS AM ON 5L AT 97%. LUNGS DIM AT BASE. PTCOUGHING AND RAISING HICK SPUTUM. AFTER DILT READDED THIS PM SATS DOWN TO 85-88%. OPEN FACE TENT ADDED AT 35% ALONG W/ NC 4L KEEPING SATS GREATER THAN 94%. LUNS CLEAR UPPER BASES. CRACKLES AT BASE THAT CLEAR W/ COUGH.\nGI: PT KEPT NPO FOR ? CARDIOVERSION. PT STATE NO HAVE APPETITE ANYWAY. BS+ ABD SOFT.\nGU: U/O 30-40CC HR. RECIEVED LASIX 20 PO W/ AM MEDS. DARK AMBER.\nENDO: BS CONSISTENTLY OVER 160 TODAY DESPITE SSR. INSULIN GTT STARTED AT 1700 AND TITRATED PER PROTOCOL.\nPLAN: CONT ASSESS HEMODYNAMICS/RESP STATUS. INCREASE NEO TO KEEP BP > 120. CHECK BS HOURLY WHILE ON GTT. CONT ENCOURAGE C&DB. CHECK U/O Q HR. FOLLOW LYTES AND REPEAT PRN.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1306654, "text": "NEURO COMPLETELY INTACT. AFIB WITH RATE CONTROL OF 75-85. DILTIAZEM gTT @20MG/HR,ESMOLOL WEANING 20MCGKGMIN PER/HR AS TOLERATED.BP INCREASING WHILE ESMOLOL WEANING IN PROCESS,THERFORE NEO DECREASED TO 0.5MGKGMIN TO KEEP SBP 110-120.HEPARIN INCREASED TO 1100U/HR FOR A PTT=44.7 (GOAL 50-70).INSULIN GTT DECREASED TO 1.5U/HR FOR GLUCOSE LEVELS 111-115.LSC,DIM AT LEFT BASE. 4LNC &35% FACE TENT. SATS=94%. STRONG NON-PRODUCTIVE COUGH.CT WITH SCANT DRG. DIURESING WELL FROM PO LASIX.NO PERCOCET NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-30 00:00:00.000", "description": "Report", "row_id": 1306655, "text": "NEURO: A&OX3. MAE. PLEASANT BUT MOOD DEPRESSIVE REGARDING PROGRESS AND AF. WIFE AND MOTHER INTO VISIT.\nCV: CONT AF. RATE CONTROLLED 70-90'S. SLOW DILT GTT WEAN. LOPRESSOR INCREASED TO 50MG PO PER EP. VVI 45 OCC PACED BEAT. CONT ON HEPARIN GTT INCREASED TO 1400U/HR FOR PTT 41. GOAL40-60. STARTED ON COUMADIN. REIECVED FIRST DOSE THIS AM OF 5MG. DISTAL PULSES CONT BE PALPABLE. CT->SX MARG OUTPUT. BP MUCH BETTER W/ DILT WEAN NOW 110-130. LYTES REPLETED.\nRESP: O2 WEANED TO NC 3L SATS >95%. USING W/ VOL 1250. COUGHING AND RAISING DARK TANNISH/ SPUTUM. LUNGS DIM AT BASE.\nGI: POOR APPETITE. +BS. ABD SOFT. DENIES NAUSEA.\nGU: IMPROVED DIURESIS ON LASIX 20. AVG>60CC/HR.\nENDO: OFF GTT. BS CONT BE HIGH. NP. ? CONSULT . NEW SLIDING SCALE WRITTEN.\nACT: OOB TO CHAIR MOST OF DAY. AMBULATED X2 AROUND UNIT. TOL OKAY. C/O \"FEELING WEAK\".\nPLAN: WEAN DILT TO OFF. CONT ASSESS HEMODYNAMICS AND RATE. WEAN O2 AS TOL. FOLLOW COAGS. CONT HEPARIN UNTIL THERAPUETIC ON COUMADIN. FOLLOW BS. INCREASE ACT AS TOL. PUSH PO'S. TX F2 AM.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1306667, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \" SOMETIMES I FEEL KIND OF DOWN\"\n\nO: PT. AWAKE AND ALERT. OOB TO COMMODE. MOVING ALL EXTREMITIES WELL. C/O FEELING ANXIOUS THIS AM. GIVEN 1 MG HALDOL PO WITH GOOD EFFECT. PT. NOW FEELING LESS ANXIOUS AND IN GOOD SPIRITS.\n\nCV: HR 84-90 AFIB WITH OCC. PVC'S. BP STABLE. LYTES PENDING THIS AM. HEPARIN OFF. PT 20.6 INR 2.8. DENIES CP. HCT. 32.1 CONT ON DILT. GTT AT 8 MG/HR.\n\nRESP; ON ROOM AIR. O2 SAT 94%-97%. LUNGS CLEAR. DENIES SOB.\n\nGU: VOIDING WELL USING COMMODE. CONT ON LASIX 20 MG .\n\nGI: APPETITE FAIR. ATE TUNA LAST NOC. DRINKING GINGER ALE AND JUICE. I EPISODE OF LIQUID STOOL. COLACE HELD.\n\nSKIN: LEFT LEG INCISION C&D, MODERATE SIZE REDENED AREA OUTLINED, HAS EXTENDED. WARM TO TOUCH. UNCOMFORTABLE WHEN TOUCHED. STERNAL INCISION C&D, GIVEN PERCOCET 2 TABS PO FOR INCISIONAL PAIN WITH GOOD RELIEF FROM PAIN. RIGHT LEG INCISION C&D WITH SMALL ABRASION NEAR INCISION LINE. NO DRAINAGE NOTED.\n\nSPOKE TO WIFE LAST AND UPDATED PT. CONDITION.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-05 00:00:00.000", "description": "Report", "row_id": 1306668, "text": "CCU NPN 7am - 7pm\nS: \" Can I take a walk.\"\nO: CVS: HR 80 - 100's afib. Occasional PVC's noted. Continues on diltiazem at 8 mg/hr. Sotolol 180 mg p.o. given. Coumadin on hold today due to INR of 2.5. Received 2 gm of magnesium and 40 meq of KCL for a Magnesium of 1.9 and potassium of 4.2. Pt. OOB to chair for several hours. Ambulated to the building bridge and back without significant change in HR or BP. Tolerated activity well.\n\nResp.: O2sats on RA are 97 - 99%. Lungs are clear.\n\nG.I.: Appetite is better today. Pt.'s wife brought in pasta and a . No more diarrhea.\n\nG.U.: Pt. voiding via urinal without problems.\n\nMental Status: A&O x3, very pleasant. In better spirits today.\n\nI.D.: Pt. remains afebrile. WBC's - 9.8.\n\nSkin: Left lower leg incision has a reddened area that was outlined and looks slightly improved. All other incision sites are healing well.\n\nA: s/p CABG c/b afib.\n\nP: Plan for cardioversion tomorrow, NPO after MN, continue diltiazem and sotolol as written, activity as tol., replete electrolytes as needed, monitor incision left leg incision site for changes.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1306669, "text": "NSG NOTE\n\nCV: REMAIN IN A-FIB. HR 82-93. CON'T ON DILT. GTT @ 8MG. SOTOLOL INCREASED TO 180MG . MAP'S > 70. PACER V SENSING. NO PACING NEEDED. ARTE SET 45.\n\nRESP: RA SATS 98%. BS CL. APPEARS COMFORTABLE.\n\nSKIN: CHEST SITE INTACT. L LEG HAS TWO AREAS OUTLINED WHICH ARE PINK AND WARM. BUTTOCKS RED BUT INTACT.\n\nGI: ABD SOFT. NO STOOL THIS SHIFT. NPO AFTER MN FOR CARDIOVERSION.\n\nGU: VOIDS IN ADEQAUTE AMTS\n\nNERUO: A&O. FOLLOWS COMMANDS.PLEASANT. MAE\n\nID: AFEBRILE WBC 10.4\n\nLABS: AWAITING AM LABS\n\nCOMFORT: C/O SLIGHT INCISIONAL PAIN. PERCOCET X2 TABS WITH RELIEF.\n\nSOCIAL; NO INQUIERES OVERNOC\n\nA: STABLE/A-FIB ATTEMPTING CHEMICAL CONVERSION\n\nP: NPO FOR CARDIOVERSION\n AWAIT AM LABS\n PER NSG JUDGEMENT\n\n\n" }, { "category": "Nursing/other", "chartdate": "2176-12-28 00:00:00.000", "description": "Report", "row_id": 1306649, "text": "NEURO: AWAKE AND ALERT. MAE. PLEASANT.\nCV: NTG WEANED TO OFF STARTED ON LOPRESSOR 12.5MG. HR 90'S RARE PAC/PVC. WIRES TO BOX OFF. DISTAL PULSES PALBABLE. LYTES REPLETES. /CORDIS DC'D. ANTECUB'S DC'D/ ALINE IN FOR BLOOD DRAWS. PIV LT ARM PATENT. CT-SX NO LEAK. MARG OUTPU.\nRESP: ON AND OFF O2 2-L NC. USING IS W/ VOL 1250 INDEPENDENTLY. LUNGS DIM AT BASE.\nGI: TOL REG DIET. +BS NO N/V\nGU: U/O MARG AMBER. STARTED ON PO LASIX. NO REAL DIURESIS NOTED. DR. AWARE. AVG 40-60CC/HR.\nENDO: INSULIN GTT WEANED TO OFF AFTER BREAKFAST. TX W. SS. BS 140-160'S.\nSKIN: ALL DSG INTACT. NO DRNG NOTED.\nACT: OOB TO CHAIR W/ MIN ASSIST. AMBUALTED AROUND UNIT W/ CONTACT GUARD PUSHING W/C.\nPAIN: GOOD RELIEF W/ PERCOCET.\nPLAN: TX F2 WHEN BED AVAILABLE. CONT ASSESS HEMODYNAMICS. FOLLOW BS. WEAN O2 AS TOL.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1306650, "text": "NEURO'S COMPLETELY INTACT. NSR->SVT->AFIB/FLUTTER AT . TX WITH 10MG IVP LOPRESSOR.20MG IVP DILTIAZEM ( 4 DOSES OF 5MG PUSH )WITH NO CHANGE IN RHYTHM. PT ALERT/ORIENTED WITH STABLE BP.20MG IV DILTIAZEM BOLUS FOLLOWED BY DILTIAZEM GTT AT 5MG/HR. NO CHANGE IN RHYTHM/RATE.\nINTERMITTENTLY BOLUSED WITH 10MG DILTIAZEM BOLUS WITH GTT INCREASED TO 10MG THEN 15MG/HR.REMAINS IN AFIB/FLUTTER WITH RARE PVC.K+/MG REPLETED.ADEQUATE U/O. CT WITH SCANT DRG.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1306651, "text": "MD NOTIFIED OF CONTINUED AFIB/FLUTTER WITH RATE>115. FURTHER INTERVENTION DEFERRED AT THIS TIME. PT REMAINS HEMODYNAMICALLY STABLE WITH THIS RATE/RHYTHM.\n" }, { "category": "Nursing/other", "chartdate": "2176-12-29 00:00:00.000", "description": "Report", "row_id": 1306652, "text": "0630 PT REMAINS IN AFIB RATE 115-150. BP STABLE. ESMOLOL BOLUS WITH GTT STARTED PER PROTOCOL. DILTIAZEM GTT DCD WHEN ESMOLOL STARTED.ESMOLOL TITRATED TO 100MCGKGMIN WITH NO CHANGE IN RHYTHM.PT STATES THAT HE FEELS TIRED WITH NO ENERGY. GLUCOSE=172. TX WITH 6UREG INS.SC. 40%FACE TENT ON FOR INCREASE OXYGENATION.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1306665, "text": "nursing progress note 7p-7a\nPT. ALERT AND AWAKE. OOB TO COMMODE ON EVES. GAIT STEADY. REQUIRING 1 ASSIST TO TRANSFER.\n\nCV: HR 84-86 AFIB NO VEA NOTED. EPI WIRES INTACT. RATE 45. DENIES CP. REMAINS ON DILT GTT AT 8 MG. HEPARIN AT 1300 U/HR. PTT PENDING. STERNAL INCISION C&D WITH STERI-STRIPS. LEFT LEG INCISION C&D WITH STERI-STRIPS INTACT. REDENED, TIGHT AREA NOTED ALONG LEG INCISION. ELEVATED ON PILLOW FOR COMFORT. REQUIRED NO PAIN MED FOR DISCOMFORT LAST NOC.\n\nRESP: ON RA, LUNGS CLEAR. O2 SAT 95%. DENIES SOB.\n\nGI: APPETITE FAIR, OOB TO COMMODE FOR BM. SMALL SOFT STOOL, WITH SOME LIQUID STOOL. DENIES N/V\n\nGU: VOIDING WELL USING URINAL. CONT ON LASIX PO 20 MG .\n\nSKIN INTACT EXCEPT FOR LEFT LEG INCISION AS NOTED ABOVE. SMALL AREA NOTED ON BACK FROM PACING PADS ( CARDIOVERSION)\n\nSTABLE NOC, ? TRANSFER TO FLOOR TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-04 00:00:00.000", "description": "Report", "row_id": 1306666, "text": "CCU NPN 7am - 7pm\nS: \" My leg hurts a little bit when you touch it.\"\nO: Skin: Pt.'s left lower leg incision is reddened and warm to the touch. Team aware and evaluated it. The area is outlined with black marker and has not changed this shift. All other incisions look clean and dry.\n\nCVS: HR 80 - 120 afib. Some VEA noted. Pt. received 180 mg of sotolol at 10 am. Since that time HR has trended down and is more consistently in the 80 - 90 range. Diltiazem continues at 8 mg/hr. Heparin was D/C'd due to therapeutic PT. Coumadin will be held this evening because of INR of 3.5. Pt. received 2 gm of magnesium for a mg++ of 1.8. Pt. was also given 40 meq of KCL for potassium of 4.1. Pt. receiving lasix on a recurring basis and has been having a lot of diarrhea. BP has been stable 90 - 110/60's. .125 mg of digoxin given. Last dig level .6. Pt. tolerated OOB to chair for 2 hours wihtout problems.\n\nResp.: O2sats are 97% on RA. Lungs are clear.\n\nG.U.: Pt. voiding via urinal without problem.\n\nG.I.: Pt. has a poor appetite today. Loose stool x3. Colace held.\nPt. states that he has been having diarrhea for the past few days. Does not like the hospital food and has a homemade in the pt. refridgerator with his name on it.\n\nA: s/p CABG c/b afib that has not resolved with cardioversion and meds.\n\nP: continue dilt, monitor response to increased sotolol, ? stool specs, hold colace, encourage p.o.'s, replete electrolytes as needed.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1306663, "text": "CCU Nursing Progress Note 7p-7a\nS: \"My leg feels a little less achy\"\n\nO: Please see careview for additional data\n\nNeuro: AAOx3. Very pleasant. Cooperative with care, assisting with care. To side of bed to void without difficulty. Received Percocet 1-2 tablets x2 with good effect for incisional pain. Slept comfortably most of the evening with minimal interuption.\n\nCV: Pt remains in AFib. HR 81-102. Initially 115 bpm prior to restart of IV Diltiazem for rate control. Weaned to 12 mg any further and HR>90. Continues po Sotalol. (HR ^ noted with activity). NBP 95-122/56-88. Remains on Heparin 1300u/hr for anticoagulation therapy. AM PTT/INR 58.8/3.1. Called HO> therapeutic. Gtt unchanged. Palpable pulses. Continues CP free. H/H stable. Electrolytes WNL.\n\nResp: LS CTA. RR 13-25. O2 sats 92-95% on RA. Continues incentive spirometry and CDB exercises. Productive cough. Tannish secretions.\n\nGI/GU: NPO after MN. Abd soft/slight distended. Wife brought dinner in from home. Tolerated well. NO N/V. No stool since yesterday am. Voiding 250-300cc cyu x2 overnight via urinal. Continues on Po Lasix . BUN/CR continues gradually increase 25/1.1 (23/0.9 yesterday)\n\nSkin: Incision sites remain CDI. Pt cont c/o lower left leg pain at incisional site. Remains warm to touch and reddened and swollen. Treated with Percocet and some relief stated per pt with elevation of extremety.\n\nSocial: No calls overnight.\n\nA/P: S/P CABG. TEE revealed no thrombus, no significant regurg or stenosis. Unsuccessfully Cardioversion yesterday. AFib ^115. Restarted Dilt gtt. Rate improved but unable to wean less than 12mg/hr overnight. Cont Sotalol po. Npo after midnight for repeat Cardioversion today. Continued to hold BB. PTT therapeutic no change in Heparin. Continue to monitor and adjust as indicated. Cont emotional support for pt and family. Disappointed with yesterday's outcome of unsuccessful cardioversion.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-03 00:00:00.000", "description": "Report", "row_id": 1306664, "text": "CCU Progress Note 7a-7p\n\nS/P CABG x's 2 .\n\nO: CV: Continues in AF with rate 80-120. Early this am Diltiazem drip dc'd with HR in 80's. OOB ambulating tolerated well. CV attempted again today with 200 joules with short period of sinus rhythm and then back to AF. Ventricular rate in 120's after CV and Dilt drip restarted at 8mg/hr. Coninues on Sotolol . BP stable. Coninues on IV Heparin and Coumadin qd.\n\nResp: Lungs clear. O2 sat 99-95% on RA. Coughing and raising tan sputum.\n\nGU/GI: Tolerating po's well after CV. No BM. Good bowel sound. Voiding good amts of clear yellow urine.\n\nSkin: Chest and leg incisions are approximated and clean and dry. Redness still noted in middle part of L leg incision.\n\nA&P: Unsuccessful CV in spite of change to Sotolol. Dose to be increased over the weekend if QT is not prolonged. Encourage ambulation if HR tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1306670, "text": "CCU Progress Note 7a-7p\n\nCV: Pt remains in AF. Rate 90-120's. CV with 200 joules without converting to SR. Started on Diltiazem 60mg po QID. Continues on Sotolol. Coumadin to be restarted today. To return in 4-6weeks as outpt for CV. BP stable.\n\nResp: Lungs clear. O2 sat 99-95%.\n\nGU/GI: Tolerating po's after CV. Abd is soft and distended with good bowel sounds. Episode of loose stool. Voiding good amts of clear yellow urine.\n\nNeuro: Alert and oriented x's 3. MAE. OOB to chair and ambulating well with assistance.\n\nSkin: Abd incision is approximated and clean and dry. L leg incision is C&D, reddness still noted in middle part of incision.\n\nA&P: Stable post CABG. AF continues despite attempt at CV. Cardiazem po QID and wean IV Diltiazem. Check INR for Coumadin dose. Possible transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-06 00:00:00.000", "description": "Report", "row_id": 1306671, "text": "Addendum\n\nCoumadin to be held today. Epicardial wires to be dc'd if INR <2.0, then coumadin to be resumed. Wean IV Diltiazem for HR <100.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-07 00:00:00.000", "description": "Report", "row_id": 1306672, "text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CABG; AFIB\n\nS- \" I FEEL OK...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS IN AFIB - RATE- 64-88 . STARTED ON DILT 60 QID YESTERDAY; SOTALOL 180 MG . DILTIAZEM GTT CONTINUED TO 12 AM AT 8 MG, THEN D/C PER DR .\nCURRENTLY REMAINS WITH HR <100, NO VEA.\nEPI WIRES IN PLACE, ATTACHED TO PACER WITH VVI MODE- RATE OF 45/MA- 15. V SENSING APPROPRIATELY.\nNO NEED FOR PACING THIS SHIFT.\nBP- 90/60- 100/70. NO CHANGE IN CV MEDS CURRENTLY.\nQTC- 0.36 ON SOTALOL PO.\nHOLDING COUMADIN FOR POSSIBLE EPI WIRE D/C TODAY- IF AM INR<2.0.\nPT REMAINS OFF HEPARIN GTT.\n\nSKIN- SITES S/P CABG REMAIN UNCHANGED- STERNAL SITE D/I, LEFT AND RT LEG D/I AND APPROX- LOWER LEFT LEG- PINK, WITH SOME SMALL AMT ERYTHEMA. CONSISTENT WITH START OF SHIFT.\nTEAM AWARE OF PICK/SWELLING AROUND L LEG SITE.\n\n PT WITH CLEAR LUNGS- ENCOURAGED TO USE INCENTIVE SPIROMETRY.\nO2 SATS- 97% ON ROOM AIR.\nNO DISTRESS CURRENTLY.\n\nGU- VOIDING IN URINAL INFREQUENTLY.\nI/O (-) 1 LITER AS OF 12 AM.\n\nGI-MINIMAL PO INTAKE D/T FREQUENT NPO FOR CDV.\nCURRENTLY TAKING LIX WITH PO MEDS WITHOUT PROBLEM.\nNO STOOL THIS SHIFT.\n\nID- SEE ABOVE RE: PINKNESS ON LEG SITE.\nT MAX- 98.2,\nAFEBRILE.\n\nLINES- TLC IN LEFT NECK.\nPERIPHERALS.\n\n PT C/O SOME PAIN AT INCISIONAL SITES- PERCOCET X 2.\nGOOD RELIEF OF PAIN.\nPT ASKED FOR SLEEPER MED 2 AM- UNABLE TO SLEEP\nORDERED FOR AMBIEN - CURRENTLY SLEEPING.\nASKING APPROPRIATE QUESTIONS ABOUT PLAN OF CARE.\n\nA/ PT S/P CABG/RAPID AFIB CURRENTLY APPEARS TO HAVE CV RATE CONTROLED ON CURRENT CV MED REGIMEN.\nTOLERATING IV DILT WEAN OVER TO PO.\n\nCONTINUE TO CLOSELY MONITOR CV STATUS, ANY INCREASE IN HR.\nINCREASE DILT IF NEEDED.\nCONTINUE TO MONITOR QTC ON SOTALOL.\nINCREASE ACTIVITY, OOB- CHAIR AND WALKING AS \nFORMAL PT CONSULT CURRENTLY WORKING WITH PT.\nD/C EPI WIRES PER TEAM\nRESTART COUMADIN AS NEEDED ONCE WIRES D/C .\nKEEP PT COMFORTABLE AND AWARE OF PLAN OF CARE\nC/O TO FLOOR ONCE MEDICALLY STABLE.\n" }, { "category": "Nursing/other", "chartdate": "2177-01-01 00:00:00.000", "description": "Report", "row_id": 1306660, "text": "CCU/CSRU NPN 1100-2200\nS/O: PT ADMITTED FROM CSRU AT 1100.\n\nCV: EPICARDIAL WIRES IN PLACE AND ATTACHED TO PACER. PACER VVI SET AT 45, SENSING APPROPRIATELY. PT IN AF, RATE INITIALLY AS HIGH AS 120'S, THEN REC'D LOPRESSOR AT 1400 AND TO 80'S-90'S. DILT GTT INITIALLY AT 15MG/HR, SLOWLY OVER THE EVENING. HR UP INITIALLY BUT SEEMS TO BE RELATED TO PT'S PAIN LEVEL. HEP AT 1400U/HR, THERAPEUTIC PER TEAM. STERNAL AND MEDIASTINAL WOUND D/I WITH NO DISCHARGE. RIGHT LEG INCISION D/I, LEFT LEG WITH ERYTHEMA MIN INCISION, LEG WARM AND SLIGHTLY SWOLLEN, AWARE. PT STATES LEFT LEG MORE PAINFUL THAN RIGHT. DIG TO BE GIVEN PO TOMORROW.\n\nRESP: PT ON 1LNP, SOME SOB WHILE AMBULATING, OTHERWISE NON-LABORED. LUNGS WITH SOUNDS IN LEFT BASE.\n\nID: AFEB. NO ABX.\n\nGI: TOL DIET WELL, HAD 2 EPISODES LOOSE STOOL, OB NEG. FS 120'S-130'S, REC'D INSULIN X2.\n\nGU: VOIDING CLEAR YELLOW URINE.\n\nREHAB: PT WALKED AROUND UNIT X2, TOL FAIRLY WELL WITH SOME SOB. PT DENIED PAIN UNTIL WHEN ADMITTED HE HAD SOME PAIN, DIDN'T WANT TO SIT IN CHAIR BECAUSE OF PAIN. REC'D PERC X2 WITH GOOD RELIEF.\n\nA/P: SLOWLY TITRATING DILT GTT. PT NEEDS TO BE NPO AFTER MN BECAUSE NEED CV AND TEE IF UNABLE TO WEAN DILT GTT OVERNIGHT. CONT WITH DIG AND LOPRESSOR. ASSESS TOL TO REHAB, PT NEED TO TAKE MEDS MORE FREQ SO CAN REHAB BETTER. CONT TO FOLLOW LEFT LEG INCISION.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1306661, "text": "CCU Nursing Note 11p-7a\nS: \" My leg feels tight\"\n\nO: See careview for additional objective data.\n\nNeuro: AAOx3. Extremely pleasant. Given Percocet x 2 tabs for Mediastinal incision pain with good results.\n\nCV: Epicardial wires intact at bedside to pacer. VVI set @ 45. Sensing appropriately. Pt remains in Afib. Rare PVCs/ Multiform PVCs. Remains on Diltizem gtt. Weaned from 11.0mg to 3.0mg by morning. Tolerated well. HR 82-97(^97 prior to 200mg po dose of Lopressor then decreased to 80s). NBP 96-133/61-66. Heparin dose decreased from 1400u/hr to 1300u/hr per HO when am PTT/INR results were 81.9/2.3. (Has had an issue w/ subtherapeutic PTTs). Am lytes K+ 3.7, Mg 1.9, and Ca 8.3. Repleted w/ 40meq KCL, 2 gm each Ca and Mg. Pt denies any CP. Palpable pulses.\n\nResp: LS cta except slightly diminished in LLL. O2 sats 94-96 on 1L O2 via NC. Regular breathing, unlabored RR 11-17. Per report ^sob w/ activity. Incentive spirometry at bedside. Encouraged to CDB excercises.\n\nGI/GU: NPO after MD for possible TEE this am if unable to tolerate wean from Diltiazem. Abd soft/obese. NTND. +BS. No stool overnight. Tolerating po meds without difficulty. Voiding in urinal. 300cc x2.\nNo diuresis occurred. Remains +1500cc. Bun/Cr 23/0.9\n\nId: Afebrile.\nPO temps 98.1-99.0\n\nEndo: RISS. BS 112-134. Requiring minimal to no coverage.\n\nSkin: Mediastinal wound and right leg incisions approximated, D&I. Left leg incision pt c/o tight feeling> started yesterday. Sm amt of erythma noted, warm to touch/ swollen.\n\nDispo: Full Code\n\nA/P: 63 year old male w/ Hx of HTN, and prior tobacco use presented to OSH w ^ SOB and R AF + NSTEMI . Had transferred to for cath- 1 vessel CAD> TO LAD, unable to PTCA d/t inability to cross lesion w/ coronary guide wire. No changes in TIMI II flow filling distal LAD. CABG X2 LIMA-LAD AND SVG-DIAG. Received 2U PRBCs, 4FFP, PLT x2, crystalloid. Remains in AF overnight. Weaned diltiazem gtt overnight. Plan is to complete TEE and cardiovert this am if dilt was unsuccessfully weaned and HR remained >80s. Remains on high dose BB> 200 mg po. Tolerated well. Dilt gtt 3.0cc/hr as of 0600. Lytes low. Repleted. Heparin decreased for elevated PTT/INR. Continue to monitor and recheck in six hours at 1100. BS stable. Continue to monitor and cover with RISS. Encourage to CDB. Ambulate. OOB to chair as tolerated. Follow right leg incision- swollen and painful. Continue to support pt and family as indicated.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2177-01-02 00:00:00.000", "description": "Report", "row_id": 1306662, "text": "CCU Progress Note 7a-7p\n\nS/P CABG x's 2 .\n\nO: See care view for objective data. Remains in AF. IV Cardiazem off this am restarted for HR > 90. BP stable. TEE done no evidence of clot. CV with 200joules to sinus rhythm then back to AF. Ventricular rate 100-150. IV Diltiazem increased to 15mg/hr Lopressor dc'd and started on Sotalol QID. Better rate control after Dilt increased. Plan is to attempt CV again tomorrow. IV Heparin continues at 1300u/hr PTT 64. Coumadin 5mg given.\n\nResp: Lungs clear. Coughing and raising tan sputum. O2 sat 94-97%. OOB to chair doing incentive spirometry.\n\nNeuro: Alert and oriented. Moving all extremeties.\n\nGU/GI: NPO for procedure. Tolerating small amts of clear liquids post procedure. Abd is soft and distended with good bowel sounds. BM x's1. Voiding small amounts of clear yellow urine. K 4.5.\n\nSkin: Incisions remain approximated & clean and dry. Redness noted in middle part of L leg incision. with Percocet 2 tabs x's 2 for incisional pain.\n\nA&P: Unsucessful CV. Beta blocker changed to Sotolol. NPO after mn for CV . Continue to monitor PTT. Advance actvity as HR tolerates.\n" } ]

[ { "category": "Radiology", "chartdate": "2144-06-30 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1190729, "text": " 1:57 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LT ARM SWELLING ?DVT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with extensive past medical hx. presenting with left upper\n extremity swelling, PICC line in that arm will be removed today.\n REASON FOR THIS EXAMINATION:\n any signs of DVT ?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw TUE 3:34 PM\n Occlusive thrombus within the left cephalic vein at the site of prior PICC\n line placement. No other areas of thrombus in the left arm. PIC catheter\n visualized within the right subclavian vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Extensive past medical history. Presenting with left upper\n extremity swelling with PICC in that arm that was removed.\n\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND:\n\n COMPARISON: None.\n\n FINDINGS:\n\n Color and grayscale son of bilateral subclavian, and left-sided\n axillary, jugular, brachial, basilic, and cephalic veins were evaluated.\n There is occlusive thrombus within an expanded cephalic vein. However, normal\n flow and waveforms were seen within bilateral subclavian veins. There is a\n PIC catheter within the right subclavian vein, with wall-to-wall flow seen\n within this vessel. The axillary, brachial, and basilic veins demonstrated\n normal compressibility and augmentation.\n\n IMPRESSION:\n\n Occlusive thrombus within the left cephalic vein at the site of prior PICC\n line placement. No other areas of thrombus in the left arm. PIC catheter\n visualized within the right subclavian vein.\n\n Findings were discussed via telephone with Dr. at 2:25 p.m.\n on .\n\n" }, { "category": "Radiology", "chartdate": "2144-06-30 00:00:00.000", "description": "L UNILAT UP EXT VEINS US LEFT", "row_id": 1190730, "text": ", B. MED FA2 1:57 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LT ARM SWELLING ?DVT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with extensive past medical hx. presenting with left upper\n extremity swelling, PICC line in that arm will be removed today.\n REASON FOR THIS EXAMINATION:\n any signs of DVT ?\n ______________________________________________________________________________\n PFI REPORT\n Occlusive thrombus within the left cephalic vein at the site of prior PICC\n line placement. No other areas of thrombus in the left arm. PIC catheter\n visualized within the right subclavian vein.\n\n" }, { "category": "Radiology", "chartdate": "2144-06-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1190405, "text": " 2:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Cardiopulm processes, PICC/Midline placement\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 yo W w/ cabg, htn, chf who presents w/ upper GI bleed\n REASON FOR THIS EXAMINATION:\n Cardiopulm processes, PICC/Midline placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: Chest x-ray .\n\n FINDINGS: The patient is status post median sternotomy and aortic graft\n placement. Nasogastric tube terminates below the diaphragm, and right PICC\n terminates in the lower SVC. Widening of cardiomediastinal contours is\n present, accompanied by mild pulmonary vascular congestion. Bilateral pleural\n effusions are present, small on the right and small-to-moderate on the left,\n with improvement on the left compared to the prior radiograph. A cluster of\n calcified granulomas is present in the left upper lobe. A homogeneous opacity\n above this level in the region of the left first anterior rib may reflect\n confluence of structures, but attention to this area on followup radiograph\n would be helpful to exclude a pleural or parenchymal abnormality in this\n region.\n\n\n" }, { "category": "Echo", "chartdate": "2144-06-29 00:00:00.000", "description": "Report", "row_id": 88681, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Coronary artery disease. Left ventricular function.\nHeight: (in) 61\nBP (mm Hg): 112/75\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 10:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). Cannot exclude LV mass/thrombus.\nNo VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views. Suboptimal image\nquality - poor suprasternal views. Suboptimal image quality as the patient was\ndifficult to position. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nPoor image quality. The left atrium is mildly dilated. Overall left\nventricular systolic function is probably preserved (LVEF>50%) however\nregional LV systolic function could not be assessed due to poor image quality\n(in some views the septum and apex appear hypokinetic). A left ventricular\nmass/thrombus cannot be excluded. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The ascending aorta is mildly dilated. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, no definite change. If clinically indicated, a repeat study with\necho contrast (Defnity) is suggested for better assessment of regional\n(apical) LV systolic function and to exclude an LV apical thrombus.\n\n\n" }, { "category": "ECG", "chartdate": "2144-06-28 00:00:00.000", "description": "Report", "row_id": 235246, "text": "Atrial fibrillation with rapid ventricular response. Diffuse T wave changes,\nlikely due to repolarization abnormality, although ischemia cannot be excluded.\nCompared to the previous tracing of atrial fibrillation has replaced\nsinus rhythm. The rate has increased. The anterior ST-T wave changes are not\nseen on the current tracing.\n\n" }, { "category": "ECG", "chartdate": "2144-07-02 00:00:00.000", "description": "Report", "row_id": 235020, "text": "Atrial fibrillation. Modest ST-T wave changes are non-specific. Since the\nprevious tracing of ventricular rate is slower. Otherwise, probably no\nsignificant change.\n\n" } ]